Received: 20 July 2023 Accepted: 6 September 2023

DOI: 10.1111/jopr.13766

TECHNIQUE

Preliminary impression for maxillary defect: A two-step

technique

Adrien Naveau DDS, PhD1,2

1
Associate Professor, Prosthodontics Department, Abstract
Faculty of Dental Medicine, Bordeaux University,
Preliminary impressions must record the periphery and height of maxillary defects to
Bordeaux University Hospital, Saint-André
Hospital, Bordeaux, France allow for an eventual extension of the master impression tray. These impressions are
2
Academic Guest, Clinic of General-, Special
usually made with irreversible hydrocolloid. Carrying the impression material into the
Care- and Geriatric Dentistry, Center of Dental defect can be complex, especially in the case of a limited oral opening. Moreover, the
Medicine, University of Zürich, Zürich, patient can be harmed during the removal procedure, and material may be stuck in
Switzerland
anatomical structures. The technique presented in this article avoids these issues in any
maxillary defect with a two-step preliminary impression. An elastomeric material ball
Correspondence
Adrien Naveau, Service de Médecine is first placed in the defect until full setting. Then, this “obturator bulb” is removed and
Bucco-Dentaire, Hôpital Saint-André, 1 rue Jean eventually relined until it is retentive. Retentions are designed on the oral side of the
Burguet, 33000 Bordeaux, France.
bulb and the bulb is placed back into the defect. Finally, an alginate over-impression of
Email: [email protected]
the maxillary is made. The alginate is removed after full setting, and the obturator can
be reassembled on the maxillary impression to provide a full recording of the maxillary.
This protocol can safely be used for defects of any size, despite eventual limitations in
oral opening.

KEYWORDS
impression, maxillectomy, maxillofacial prosthetics

The etiology of maxillary defects is predominantly surgical stuck in anatomical structures or be inhaled during impres-
tumor removal, and more rarely trauma or infection. These sion removal. Indeed, the pressure performed on the stock
anatomical defects can have large functional and psycholog- tray, filled with a large volume of impression material, drives
ical consequences but are often satisfactorily restored with alginate into all cavities. As the alginate may expand in
an obturator prosthesis. The obturator bulb aims to provide larger chambers, the material will tear during removal. These
sealing between oral and nasal compartments, but also reten- remaining pieces will remain stuck in the nasal area until
tion, stability, and support for the prosthesis.1–3 Preliminary they are naturally or surgically eliminated. In the worst-case
impressions are usually made with irreversible hydrocolloid scenario, the lost piece could slip into the nasopharyngeal
and must record the periphery and height of the defect to area and be inhaled. To avoid these situations, blocking out
allow maximum posterior and lateral extensions of the master the defect with gauze lubricated with petrolatum is often
tray.1 recommended, despite limited efficiency.1
To this end, the addition of wax or compound on the stock The technique presented in this article avoids the previ-
tray may be needed to properly support the impression mate- ously mentioned issues with a two-step preliminary impres-
rial in the defect area.1 However, with limited oral opening, sion for maxillary defects. This protocol can safely be used
carrying the impression material into the defect can be com- for defects of any size, despite eventual limitations in oral
plex. Decreased vertical opening is indeed a frequent problem opening.
in maxillofacial patients, as surgery and radiation therapy
lead to fibrosis and scarring of the masticatory muscles. One
solution then is to inject viscous irreversible hydrocolloid TECHNIQUE
(alginate) with a large syringe into the defect.3
However, impression material may harm the patient on Prior to any impression of maxillary defect, dried crusts of
removal due to a vacuum effect.1 Material can even be mucus have to be removed from the surfaces to be recorded.

J. Prosthodont. 2024;33:611–616. wileyonlinelibrary.com/journal/jopr © 2023 by the American College of Prosthodontists. 611

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F I G U R E 1 Illustration of the two-step technique

for small defects. (a) The extraction of tooth 16 left an
oronasal communication, (b) low viscosity polyether
was applied on a gauze for the impression of the
defect, (c) the impression was removed after the
material had fully set, (d) borders were cut with
scissors, with 5 mm margins to provide support, (e)
the defect impression was placed back with adhesive
on the oral side, and (f) alginate over-impression ready
for plaster casting.

For small defects (Fig 1a), proceed as follows: 4. With a blade, decrease the palatal material thickness
exceeding 3 mm and cut the margin to present no
1. Place light elastomeric material on a gauze. undercuts (Fig 2c).
2. Apply the gauze on the defect with gentle pressure 5. Hollow the palatal side with no undercuts (for future
(Fig 1b). repositioning) (Fig 2e).
3. After the material has fully set, remove the impression, 6. Apply alginate adhesive on the oral side and place the
and cut the gauze to keep only the layer embedded with the obturator back into the defect (Fig 2d).
material (Fig 1c). The margins should include the defect 7. Make the maxillary over-impression with alginate.
impression and extend 5 mm around the defect (Fig 1d). 8. After the material has fully set, remove the alginate
4. Apply alginate adhesive on the oral side and place the and if needed, place the defect impression back into the
obturator back into the defect (Fig 1e). maxillary impression (Fig 2f).
5. Make the maxillary over-impression with alginate.
6. After the material has fully set, remove the alginate For large defects (Fig 3a), proceed as follows:
(Fig 1f) and if needed place the defect impression back
into the maxillary impression. 1. Place heavy viscosity elastomeric material that can be
extended with wax or resin matching the size of the defect
For medium defect (Fig 2a), proceed as follows to provide material support (VPS adhesive can be applied
on the mirror or wax support) on the back of a dental
1. Place medium viscosity elastomeric material on the back mirror or tweezers (Fig 3b).
of a dental mirror (Fig 2b). 2. Apply the material in the defect with gentle pressure
2. Apply the material in the defect with gentle pressure. (Fig 3c).
3. After the material has fully set, remove the impression, 3. After the material has fully set, remove the impres-
and detach it from the mirror to keep only the impres- sion, and detach it from the wax tray to keep only the
sion material. The margins should include the defect impression material. The margins should include the
impression and extend 5 mm around the defect (Fig 2b). defect impression and extend 5 mm around the defect.
PRELIMINARY IMPRESSION FOR MAXILLARY DEFECT 613

F I G U R E 2 Illustration of the two-step technique for

medium defects. (a) An oronasal communication was left
after an ancient tumor removal, (b) medium viscosity VPS
was applied on the back of a mirror and applied in the
defect, (c) the impression was removed after the material
had fully set, and the borders were cut with a blade at 45◦
to leave no undercuts areas, with 5 mm margins to provide
support (except on the anterior side because of mobile
tissues), (d) the oral placement was assessed, (e) the oral
side of the bulb was hollowed for repositioning and for
allowing grabbing with tweezers, and (f) alginate
over-impression ready for plaster casting.

If more retention is needed, the bulb can be relined with 2. Remove and digitalize the bulb (with laboratory scanner,
light material (Fig 3d). IOS, or CBCT).
4. With a blade, decrease the palatal material thickness 3. Using professional or open-source software (such as
(exceeding 3 mm) and recreate a palatal contour; then cut Autodesk Meshmixer or Blender), match the arch 3D file
the margins to present no undercuts. with the obturator 3D file, and create a global digital 3D
5. Hollow the palatal side by removing an asymmetric cast.
geometric 3D shape with no undercuts (for future reposi- 4. Using professional or open-source software (such as
tioning) and make sure that some areas facilitate grabbing Gmbh Exocad, 3Shape Dental system, ZirckonZahn
(to carry and pull out the bulb from the defect) (Fig 3e). ZirkonZahn.tray), design the custom tray virtually and 3D
6. Apply alginate adhesive on the oral side and place the print it in a suitable resin.
obturator back into the defect.
7. Make the maxillary over-impression with alginate.
8. After the material has fully set, ask the patient to sit down DISCUSSION
and to look down; remove the alginate and place the defect
impression back into the maxillary impression if needed The technique presented in this article is easy to use and
(Fig 3f). assists with the challenges of maxillary defects. The mate-
rial used for the defect impression can be any elastomeric
For digital recording (Fig 4): material, such as vinyl polysiloxane (VPS) or polyether. As
the defect impression is simple and does not require border
1. Proceed as mentioned above, but instead of making an molding, a fast-setting elastomeric material should be used
over-impression with alginate, make an optical impression to save time. The choice of viscosity is of prime importance
with an intraoral scanner (IOS). to limit the spread of the material in unexpected cavities
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F I G U R E 3 Illustration of the two-step technique

for large defects. (a) Previous maxillectomy had been
performed after fungus infection, (b) a wax plate was
fixed to tweezers to provide a tray for applying a heavy
viscosity VPS ball into the defect, (c) impression of
the defect, (d) the impression was removed after the
material had fully set, and relined with light viscosity
VPS to improve retention, (e) the oral side of the bulb
was hollowed for repositioning and for allowing
grabbing with tweezers, and (f) alginate
over-impression ready for plaster casting.

pressure to record enough undercuts and gain some retention

for the bulb. If the bulb is difficult to remove, the challenge
for beginners in maxillofacial prosthodontics will still be less
stressful than dealing with a difficult full-arch impression.
A related technique called the fragmented impression, was
described for very large defects in edentulous patients in 1995
by Pomar and Soulet.4 The concept was to first fill the ante-
rior part of the defect with VPS, leaving no undercuts, and
to wait until the material was fully set. Second, the posterior
part was filled with another VPS ball, leaving no undercuts.
Then, a third ball of VPS was used to fill the central part of the
defect and to record the position of the first two impressions.
Finally, an over-impression of the maxillary was made. In
this article, the four pieces were reassembled extraorally, and
a plaster cast was created to fabricate a removable silicone
F I G U R E 4 Optical impression of the impression bub. To obtain a
cast, the bulb must be digitalized separately and assembled to the arch
obturator providing retention for the prosthesis. Some other
impression. This process requires expertise in three-dimensional modeling techniques have been described for large defect impressions,
software. such as using a stock tray for supporting a first impression
of the defect, followed by the impression of the maxillary
arch using the same tray after the bulb material setting.1
(light material in small defects, regular in medium defects, However these impressions require no limitation in mouth
and heavy in large defects) in association with a gentle opening.
PRELIMINARY IMPRESSION FOR MAXILLARY DEFECT 615

F I G U R E 5 Final impressions with the two-step technique. (a) The two-step technique can be effective for small defects (case from Fig 1, arrow
pointing to the picked-up impression of the defect), (b) and some medium defects (case from Fig 2, arrow pointing to the decent adjustment of the
impressions), (c) however, some gaps may appear in some medium defects and alter the quality of the final impression (arrow pointing to a gap); (d) for large
defects, a regular custom tray is preferred (case from Fig 3).

The use of an IOS for impressions is interesting in max- when pulling the over-impression out of the mouth, the bulb
illofacial prosthetics, especially with a limited oral opening. may be dislodged from the defect without sticking to the
The limitations are identical to any patient scanning, but an alginate. To prevent the bulb from falling towards the oropha-
additional limitation appears in patients with palatal defects, ryngeal area, the patient should be seated with the head
as the dimensions of the probe (in size and angle) and the down.
limited field of depth usually prevent adequately recording
the entire defect.5 Using the described technique, the 3D files
can be matched to obtain a complete cast. However, these dig- SUMMARY
ital transformations require software experience and time that
could dissuade from using it routinely. This two-step preliminary impression for a maxillary defect
This technique may also be used with caution for the final allows easy and safe recording of the maxillary, including
impression of small and some medium defects (Fig 5a,b). the defect. This protocol can be used for defects of any size,
Indeed, an eventual gap may appear between the two despite eventual limitations in oral opening.
reassembled impressions. In a preliminary impression, this
gap will never compromise the fabrication of an effective
AC K N OW L E D G M E N T S
custom tray. However, if this technique is used for the final
The author thanks Valerie Plaire (lab technician, Bordeaux)
impression, this gap might affect the accuracy of the pros-
for the fruitful discussions and Mathieu Carriere (DDS,
thesis (Fig 5c). From the author’s experience, a classical
Bordeaux) for the picture in Fig 4.
single-step technique should be considered when the future
obturator prosthesis is supposed to engage the defect, which
is often needed in medium or large defects (Fig 5d). How- C O N F L I C T O F I N T E R E S T S TAT E M E N T
ever, the two-step technique remains a good option in case of The author reports no conflicts of interest.
a large defect with limited oral opening.
Otherwise, the limitations of this technique are rare. First, REFERENCES
some cyanoacrylate glue may be needed between the two 1. Beumer J III, Marunick MT, Garrett N, Rohner D, Reintsema H,
Abemayor E, et al. Rehabilitation of maxillary defects. In: Beumer
impressions to guarantee immobility during plaster cast-
J, Marunick MT, Esposito SJ, editors. Maxillofacial rehabilitation-
ing. Indeed, despite having applied the suitable adhesive on Prosthodontic and surgical management of cancer related, acquired, and
the oral part of the bulb before over-impression, the bond- congenital defects of the head and neck. 3rd ed. Quintessence, 2011.
ing to alginate may be limited. Second, in large defects, 155–212
616 NAVEAU

2. Carr AB, Brown DT. Removable partial denture considerations 5. Zhang M, Hattori M, Elbashti ME, Sumita YI. Feasibility of intraoral
in maxillofacial prosthetics. In: McCracken’s Removable Partial scanning for data acquisition of maxillectomy defects. Int J Prosthodont
Prosthodontics. 11th ed. New Delhi, Elsevier, 2011. P. 316– 2020;33(4):452–56
37
3. Jacob RF, Chang TL. Maxillofacial prosthodontics for the edentulous
patient. In: George A Zarb, John Hobkirk, Steven Eckert, Rhonda Jacob,
editors. Prosthodontic treatment for edentulous patient—Complete den-
How to cite this article: Naveau A. Preliminary
tures and implant-supported prostheses. 13th ed. St Louis, Elsevier,
2013. 351–75 impression for maxillary defect: A two-step
4. Pomar P, Soulet H. [Fragmented impression making: contribution to the technique. J Prosthodont. 2024;33:611–16.
prosthetic rehabilitation of the full edentulous arch after maxillectomy]. https://doi.org/10.1111/jopr.13766
Actual Odontostomatol Encycl Prat 1995;(191):443–47