See discussions, stats, and author profiles for this publication at: [Link]

net/publication/350845615

A Novel Functional Swallow Method to Establish the Posterior Palatal Seal

Article in The Journal of Contemporary Dental Practice · December 2020

CITATION READS

1 689

6 authors, including:

Ravishankar Krishna Rashmi B Mandokar

21 PUBLICATIONS 35 CITATIONS
Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences
2 PUBLICATIONS 3 CITATIONS
SEE PROFILE
SEE PROFILE

Sweekriti Mishra
M. S. Ramaiah University of Applied Sciences
9 PUBLICATIONS 23 CITATIONS

SEE PROFILE

All content following this page was uploaded by Ravishankar Krishna on 13 April 2021.

The user has requested enhancement of the downloaded file.

A Novel Functional Swallow Method to Establish the

A b s t r ac t​
Aim and objective: To propose an alternate, reliable, and easy-to-use functional swallow method for establishing the posterior palatal seal.
Background: Accurate registration of the posterior palatal seal is crucial to the success of the maxillary complete denture. The conventionally
used functional “Ah” technique may not be reliable at times to record the posterior palatal seal, hence compromising the retention of the
maxillary complete denture.
Case description and technique: A 70-year-old female patient requiring complete dentures presented with an unusually tense soft palate during
the phase of posterior palatal seal development. The soft palate did not relax and remained in a superior position when the “Ah” functional
method was used to record the seal. The posterior palatal seal area could not be compressed sufficiently during border molding, preventing the
formation of an adequate seal. Hence, a new functional technique was devised to relax and displace the soft palate for developing an effective
seal. This case report describes a novel and reliable method of displacing the posterior palatal seal area with a low-fusing compound by utilizing
the patient’s functional swallow position.
Conclusion: The functional swallow method can be used effectively as an alternative and reliable method to obtain a consistent posterior
palatal seal.
Clinical significance: The functional swallow method of developing the posterior palatal seal is simple, less demanding on the clinician, and
can save chairside time. It also helps in an easy transfer of the demarcated posterior palatal seal area to the custom tray. The method lets the
dentist be in charge of developing the seal rather than relying on the arbitrary cast scrapping by the technician. Also, the seal can be achieved
by employing commonly used materials.
Keywords: Clinical technique, Complete dentures, Final impression, Functional swallow method, Maxillary complete denture, Maxillary denture
retention, Posterior palatal seal.
The Journal of Contemporary Dental Practice (2020): 10.5005/jp-journals-10024-2988

I n t r o d u c t i o n​
1–6
One of the primary reasons for lack of maxillary denture retention is Department of Prosthodontics, Faculty of Dental Sciences, Ramaiah
a poor posterior palatal seal (PPS).1 Accurate registration of the PPS University of Applied Sciences, Bengaluru, Karnataka, India
area plays a very critical role in the retention of maxillary complete Corresponding Author: Ravishankar Krishna, Department Of
denture.2 The commonly used approaches to develop the PPS can Prosthodontics, Faculty of Dental Sciences, Ramaiah University
be classified into conventional, arbitrary, and functional methods.3 of Applied Sciences, Bengaluru, Karnataka, India, Phone: +91
9886056303, e-mail: [Link]@[Link]
The conventional and arbitrary techniques are commonly taught
and followed.4,5 Both the techniques involve scoring or scraping How to cite this article: Krishna R, Mandokar RB, Mishra S, et al. A
Novel Functional Swallow Method to Establish the Posterior Palatal
of the maxillary cast to establish the PPS. Scoring methods are
Seal during the Maxillary Edentulous Final Impression: A Case Report.
not recommended as they are considered inaccurate and leave
J Contemp Dent Pract 2020;21(12):1404–1407.
the retention of the denture to chance at the denture insertion
Source of support: Nil
appointment.6 The PPS area may also get over or undercompressed
due to scoring and the seal achieved also may not be reliable. Conflict of interest: None
Techniques that help to develop PPS during the border molding
or final impression stage are favorable to the dentist. This is because
the dentist becomes totally in charge of locating and developing
the seal without relying on the technician.7 Development of PPS of special waxes that need careful heating after its application on
during the impression stage was classified by Hardy and Kapoor the final impression surface,10 extra caution during cast pouring to
into functional and semi-functional methods. They explained that prevent wax distortion,7,10 and a possible overcompression of the
in the semi-functional technique, the molding of the seal area is PPS area due to the hard nature of resins.9
done by the dentist whereas in the functional method, the molding The functional method commonly used to achieve the PPS is
of the PPS is performed by the patient’s functional movements.8 through “Ah” sounds made by the patient to induce soft palate
Recently introduced semi-functional techniques to achieve the PPS elevation during impression making.11 But at the completion of
have employed materials like light polymerized resin9 and specially “Ah” sound, the soft palate returns early to its lower position before
formulated nonfluid waxes10 on the elastomeric final impression the modeling plastic impression compound may have hardened,
surface. The drawbacks of these methods can be the requirement compromising the PPS.9 Occasionally, in some patients the palatal

© Jaypee Brothers Medical Publishers. 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
([Link] which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons
Public Domain Dedication waiver ([Link] applies to the data made available in this article, unless otherwise stated.
 Functional Swallow Method to Establish the Posterior Palatal Seal

muscles remain tensed and may not relax when asked to say “Ah” second attempt to record the seal was made. This time, a low-fusing
vigorously during the PPS formation procedure. In such patients, green stick compound was used instead of putty, and the patient
it may be difficult to displace the PPS area by the “Ah” functional was instructed to say “Ah” in vigorous bursts. The obtained PPS was
method, and thereby an effective seal will not be formed. A novel still inadequate despite repeated attempts. It was also recognized
functional technique utilizing the physiologic swallowing forces that the patient had difficulty in repeatedly saying “Ah” in vigorous
can form a consistent and successful PPS for these individuals when bursts as her palatal muscles were in tension and would rarely relax
the head is flexed forward. So this case report aims to describe an during the process. Hence, an alternate method to develop the PPS
alternate method to establish the PPS using the functional swallow was planned by combining the patient’s functional swallow with a
position and low-fusing compound during the phase of complete forward head posture to relax the palatal muscles.
denture final impression.
Technique
T e c h n i q u e​ • The anterior and posterior vibrating lines were located
Background intraorally by asking the patient to say “Ah” and marked with
A 70-year-old completely edentulous female patient reported to an indelible pencil.
the Department of Prosthodontics with a complaint of old and • The maxillary border molded tray was placed intraorally to
ill-fitting removable complete dentures. The patient was using transfer the marked PPS area onto the PVS putty material.
these dentures for the past 6 years and requested a new pair, Transferring the mark onto the putty was easier compared to
after considering the different treatment options given to her. On the resin tray. The tray was removed from the mouth and the
intraoral examination, moderately resorbed completely edentulous transferred mark was highlighted with the indelible pencil
maxillary and mandibular ridges were seen. It was observed that (Fig. 1A).
the PPS area was of class II type based on House’s classification • Putty extending beyond the transferred PPS mark was removed
of the palatal throat form.12 An informed consent was obtained with a sharp B.P blade. Using a round tungsten carbide trimmer
from the patient and her relative before starting the treatment. under slow speed, the putty representing the PPS was made
Primary impressions of both arches were made in alginate and the rough and thinned down almost to the resin tray (Fig. 1B).
casts were poured with plaster. Accurately fitting maxillary and • The patient was trained to lean forward, bend the head down
mandibular resin custom trays were fabricated on the plaster casts. (Fig. 1C), and swallow, with the instruction to keep the tongue
Border molding was performed using the polyvinyl siloxane (PVS) against the palate during the swallow. The angle between the
putty consistency impression material (elite HD+, Zhermack S.p.A. Frankfort plane and the horizontal plane was at least 45° when
Italy) after applying a tray adhesive. During border molding with the head was bent forward.
putty, the PPS formation was attempted using the conventional • A stick of low-fusing compound (DPI Pinnacle Tracing Sticks,
method, by making the patient say “Ah” in vigorous bursts and India) was softened using a flame and applied on the roughened
maintaining finger pressure on the posterior part of the custom polyvinyl siloxane PPS area. The added compound was heated
tray. However, the obtained PPS was found to be inadequate when uniformly using an alcohol torch, tempered in hot water, and
tested by applying tipping finger pressure on the inner side of the placed in the patient’s mouth. The tray was supported with
tray handle. The putty representing the PPS was removed and a fingers on either side and the patient was asked to bend forward

Figs 1A to F: Steps to record the PPS with the novel functional swallow method: (A) Transfer of the PPS mark onto the elastomeric putty; (B)
Roughening and thinning of the elastomeric putty representing the PPS; (C) Patient position for recording the PPS using the functional swallow
method; (D) Low-fusing compound representing the PPS; (E) Low-viscosity elastomeric final impression; (F) Master cast with the functionally
displaced PPS

The Journal of Contemporary Dental Practice, Volume 21 Issue 12 (December 2020) 1405
 Functional Swallow Method to Establish the Posterior Palatal Seal

and swallow at least two times as practiced before. The patient take responsibility for the process, as against the arbitrary and
was instructed to return to the normal posture and swallow once inaccurate cast scraping methods commonly used by technicians.22
again. The efficacy of the PPS was assessed by tucking the tray The novel functional swallow technique described here helps in
handle on its inner side. A single application of the low-fusing developing and estimating the PPS during the final impression
compound was sufficient to achieve the desired seal. The green phase. Today, elastomeric polyvinyl siloxane is commonly used
stick that appeared beyond the boundaries of the PPS was cut as the final impression material for the construction of the tissue-
and finished using a sharp B.P blade (Fig. 1D). supported removable prosthesis. 5 Accordingly, the proposed
• The final impression (Fig. 1E) was made using a light-body PVS functional swallow method was planned with elastomeric materials.
impression material (elite HD+, Zhermack S.p.A. Italy). The Nevertheless, the novel technique is practical even with traditional
impression was poured in type III gypsum to obtain a cast, with border molding techniques that employ the low-fusing green stick
a custom-formed, functionally displaced PPS area (Fig. 1F). compound.
The functional swallow method has the advantages of being
Prosthesis Outcome and Follow-Up simple, efficient, and consistent. Since the proposed technique
does not rely on cast scoring for the development of PPS, it is less
The PPS developed using the novel swallow method gave increased
subjective and hence more consistent than the commonly followed
confidence to the patient for wearing the maxillary complete
cast scoring techniques. Elastomeric putty was used as the first layer
denture. The patient was satisfied with the treatment outcome and
during seal formation in the novel method. This helped in easy
could function adequately in speech and mastication. At 12-month
transfer of the demarcated PPS boundaries from the mouth onto
follow-up, the patient presented with satisfactory retention and
the tray, which otherwise was difficult with the resin tray surface
comfort of the maxillary complete denture. On clinical testing, the
alone. The low-fusing compound (green stick) that is commonly
PPS was found to be consistent and similar to that developed during
used in practice was applied over the initial layer of putty in the
the final impression stage.
present method to complete the seal. The advantage of using a
low-fusing compound is its ease of addition and removal. Further,
D i s c u s s i o n​ a low-fusing compound may not be undercompressive like the fluid
Besides improving maxillary denture retention and stability, waxes10,14 or overcompressive like resins.9 The viscosity of the low-
accurately formed PPS reduces gagging and makes the posterior fusing compound combined with the swallowing pressure was the
border less noticeable to the tongue. It also adds strength to the reason for developing a consistent seal with the novel technique
denture and minimizes food accumulation on the underside.13–15 in the present clinical situation.
It partly compensates for the volumetric shrinkage of the acrylic The fluid wax technique was developed by Millsap,14 whereas
resin and maintains intimate contact between the denture and Wicks10 recently introduced the nonfluid wax technique for the
tissues.16 The Glossary of Prosthodontic terms defines PPS area as development of PPS during the final impression. While fluid waxes
“the soft tissue area limited posteriorly by the distal demarcation are not dimensionally stable, nonfluid waxes contain sticky wax
of the movable and non-movable tissues of the soft palate and and hence may be difficult to soften after its application on the set
anteriorly by the junction of the hard and soft palates on which elastomeric final impression surface. The proposed novel swallow
pressure, within physiologic limits, can be placed; this seal can be method can be considered more accurate as it employs a low-
applied by a removable complete denture to aid in its retention.”17 fusing compound that is dimensionally stable when compared to
This pressure within physiologic limits may probably be simulated waxes. A low-fusing compound (green stick) is easy to soften and
from inherent functional processes that move the soft palate. is also more commonly used in practice when compared to fluid
The commonly used functional method where the patient has or nonfluid waxes. Also, additional precautions are not required to
to say “Ah” vigorously may be awkward and sometimes difficult to protect the PPS developed using a low-fusing compound during
replicate. Also, the muscles of the soft palate are rather taut than cast pouring, which is a necessity with waxes.
relaxed during the pronunciation of “Ah” sounds. Hence, it may be The resin-based provisional material was recently proposed
difficult to displace the PPS area. Bending the head forward and by Batista23 whereas Jeannin9 advocated the light polymerized
downward can make the palatal muscles passive and relaxed.18 It is resin to be used on the elastomeric final impression surface to
also known that the initial phase of swallowing function is voluntary, establish the PPS. Resin materials bond well to elastomeric surfaces
though swallowing reflex is considered involuntary.19 During this but may be difficult to trim and finish especially when applied on
voluntary swallowing phase, the soft palate is elevated by the an elastomeric final impression. Using methods that employ resin
palatal muscles and the tongue comes in intimate contact with can be time-consuming, have the possibility of overcompression
the palate, placing physiologic forces.20 This swallowing position of the PPS area, and may lead to an eventual loss of the seal.23 The
of the soft palate and tongue, along with a forward-downward tendency for overcompression with the proposed swallow method
head posture can be used effectively by the dentist to displace the is very less as the low-fusing compound is not as hard as the resins
PPS area. The current technique incorporates this phenomenon and also easy to trim.
and places functional swallowing pressure on the posterior part Unlike the recently proposed methods,10,23 a major benefit
of the custom tray during PPS recording, which is inherent to the of the novel method is that the PPS is incorporated before the
individual. light body final impression is made. This makes the technique less
The PPS can be established at various stages of denture demanding when compared to contemporary techniques that
construction. It can be incorporated at the final impression require careful heating, cutting, or trimming of the PPS material
stage,7 at the trial base stage,15 or added to an existing denture.21 applied onto the completed final impression surface to develop
Developing the PPS during the final impression stage lets the dentist the posterior seal. Developing a post dam or PPS before the light

1406 The Journal of Contemporary Dental Practice, Volume 21 Issue 12 (December 2020)
 Functional Swallow Method to Establish the Posterior Palatal Seal

body final impression can reduce the escape of excess material 4. Chen MS, Welker WA, Pulskamp FE, et al. Methods taught in dental
from the posterior tray end and hence prevent gagging. 24 The schools for determining the posterior palatal seal region. J Prosthet
disadvantages of the novel technique when compared with the Dent 1985;53(3):380–383. DOI: 10.1016/0022-3913(85)90517-7.
5. Petrie CS, Walker MP, Williams K. A survey of U.S. prosthodontists
recent techniques can include patient discomfort due to heat from
and dental schools on the current materials and methods for final
the low-fusing compound and a possibility of an inadequate bond impressions for complete denture prosthodontics. J Prosthodont
between the PVS putty impression material and the low-fusing 2005;14(4):253–262. DOI: 10.1111/j.1532-849X.2005.00051.x.
compound. Tempering the compound close to mouth temperature 6. Winkler S. Essentials of complete denture prosthodontics. 3rd ed.,
can prevent patient discomfort. The inadequate bonding can be New Delhi: AITBS Publishers; 2015. p. 160.
improved by creating roughness on putty with a carbide trimmer 7. Ansari IH. Establishing the posterior palatal seal during the final
and also thinning down the putty to expose the resin tray in some impression stage. J Prosthet Dent 1997;78(3):324–326. DOI: 10.1016/
areas so that the low fusing compound can bond with the tray. The s0022-3913(97)70034-9.
8. Hardy IR, Kapur KK. Posterior border seal: its rationale and importance.
other limitation of the swallow method can be inadequately formed
J Prosthet Dent 1958;8(3):386–397. DOI: 10.1016/0022-3913(58)90064-
PPS, especially if the tongue does not contact the palate during the 7.
swallow procedure. Proper communication and training the patient 9. Jeannin C, Millet C. A functional impression technique for
becomes important to prevent the said problem. capturing the superior position of the soft palate. J Prosthet Dent
The purpose of describing this case report was to present a 2006;96(2):145–146. DOI: 10.1016/[Link].2006.05.014.
technique that the clinician can rely on and avoid cast scoring 10. Wicks R, Ahuja S, Jain V. Defining the posterior palatal seal on a
for developing the PPS. A study measured the maxillary denture definitive impression for a maxillary complete denture by using a
retention of eight completely edentulous patients with their PPS nonfluid wax addition technique. J Prosthet Dent 2014;112(6):1597–
established from a cast scraping method. The study involved 1600. DOI: 10.1016/[Link].2014.01.032.
11. Hayakawa I. Principles and practices of complete dentures. Tokyo:
follow-ups to check the retention at various stages that were
Quintessence; 2001. p. 37.
evaluated by three clinicians. The research concluded that the 12. House MM. The relationship of oral examination to dental diagnosis. J
scraping method used to establish the PPS was safe and effective.25 Prosthet Dent 1958;8(2):208–219. DOI: 10.1016/0022-3913(58)90150-1.
But, the study results may not be generalizable as the sample size 13. Ettinger RL, Scandrett FR. The posterior palatal seal. A review. Aust
was small and the retention was measured by subjective means. Dent J 1980;25(4):197–200. DOI: 10.1111/j.1834-7819.1980.tb03863.x.
Hence, a well-designed study comparing the effectiveness of the 14. Millsap CH. The posterior palatal seal area for complete dentures.
conventional cast scoring method and the novel functional swallow Dent Clin North Am 1964;1:663–673.
method in achieving maxillary denture retention would benefit the 15. Chang BM, Wright RF. Accurate location of postpalatal seal area on the
maxillary complete denture cast. J Prosthet Dent 2006;96(6):454–455.
clinician. Devices like the dynamometer may help in measuring
DOI: 10.1016/[Link].2006.10.010.
and comparing the retention values objectively.26 Although, in the 16. Sykora O, Sutow EJ. Posterior palatal seal adaptation: influence of
present case a reliable seal was established, the PPS anatomy can processing technique, palate shape and immersion. J Oral Rehabil
be variable and challenging especially in House’s class III type of 1993;20(1):19–31. DOI: 10.1111/j.1365-2842.1993.tb01511.x.
soft palates. In these patients, the compressible tissues are scanty 17. The glossary of prosthodontic terms: ninth edition. J Prosthet Dent
to develop an effective seal. Further research is needed to prove 2017;117(5S):e1–e105. DOI: 10.1016/[Link].2016.12.001.
the consistency of the novel functional swallow technique in similar 18. Winkler S. Essentials of complete denture prosthodontics. 3rd ed.,
demanding circumstances. New Delhi: AITBS Publishers; 2015. p. 158.
19. Walton J, Silva P. Physiology of swallowing. Basic Science
2 018 ; 3 6 (10 ) : 5 2 9 – 5 3 4 . D O I : h t t p s : //d o i . o r g / 10 .1016 / j .
C o n c lu s i o n​ mpsur.2018.08.010.
Establishing accurate and efficient PPS in a maxillary complete 20. Matsuo K, Palmer JB. Anatomy and physiology of feeding and
swallowing: normal and abnormal. Phys Med Rehabil Clin N Am
denture is crucial for its success. Incorporating PPS during the
2008;19(4):691–707. , vii 10.1016/[Link].2008.06.001.
final impression stage may have many advantages. The functional 21. Carroll EA, Shaffer FW. Redefining the posterior palatal seal on
swallow technique described in this article was efficient and a complete denture. J Prosthet Dent 1980;43(1):105–107. DOI:
consistent for developing the PPS. Materials commonly used in 10.1016/0022-3913(80)90363-7.
practice were employed for developing the PPS. Most importantly, 22. Porter RB. Evaluation of a delegated procedure: posterior border of a
the displacement of the soft palate was brought about by functional maxillary denture. J Am Dent Assoc 1970;81(1):134–136. DOI: 10.14219/
swallowing forces that are inherent to an individual. The functional [Link].1970.0150.
swallow method can be a reliable alternative for the development 23. De Souza Batista VE, Vechiato-Filho AJ, Pellizzer EP, et al. Use of
resin-based provisional material to create the posterior palatal
of PPS.
seal in complete denture definitive impressions. J Prosthodont
2019;28(1):e18–e20. DOI: 10.1111/jopr.12658.
References 24. Weintraub GS. Establishing the posterior palatal seal during the
1. Winland RD, Young JM. Maxillary complete denture posterior final impression procedure: a functional approach. J Am Dent Assoc
palatal seal: variations in size, shape, and location. J Prosthet Dent 1977;94(3):505–510. DOI: 10.14219/[Link].1977.0007.
1973;29(3):256–261. DOI: 10.1016/0022-3913(73)90004-8. 25. Salloum AM. Evaluation of the conventional method for establishing
2. Avant WE. A comparison of the retention of complete denture bases the posterior palatal seal. King Saud Univ J Dent Sci 2012;3(2):61–67.
having different types of posterior palatal seal. J Prosthet Dent DOI: 10.1016/[Link].2012.07.001.
1973;29(5):484–493. DOI: 10.1016/0022-3913(73)90025-5. 26. Jozefowicz W, Mikolajczyk A. Role of the surface and volume of palatal
3. Goyal S. The posterior palatal seal: its rationale and importance: relief chambers in the retention of maxillary complete dentures.
an overview. Eur J Prosthodont 2014;2(2):41–47. DOI: 10.4103/2347- J Prosthet Dent 1989;62(6):651–653. DOI: 10.1016/0022-3913(89)
4610.131972. 90585-4.

The Journal of Contemporary Dental Practice, Volume 21 Issue 12 (December 2020) 1407

View publication stats