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Dr. Nikita Kareker et al . / IJRID Volume 4 Issue 5 Sep.-Oct. 2014 Available online at www.ordoneardentistrylibrary.org
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Case – report
INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY
LIQUID SUPPORTED DENTURE …… A KINDER SOLUTION: A CASE REPORT
Dr. Nikita Kareker*. Dr. Ashwin Mysore.
Department of Prosthodontics, Goa Dental College and Hospital, Bambolim - Goa. Received: 5 Aug. 2014; Revised: 6 Sep. 2014; Accepted: 25 Oct. 2014; Available online: 5 Nov 2014 Complete denture prosthesis is unacceptable if it violates the foundation on which it rests. In this case report, a technique for fabrication of a complete denture prosthesis that eliminates the disadvantages of tissue conditioners and soft liners (i.e., poor bond strength to acrylic, candidial colonization, etc.) and preserves the remaining tissues using a liquid-supported denture for maxillary arch and neutral zone concept for fabrication of contour of the polished surfaces of mandibular denture is described. Keywords: Atrophic ridge, flabby tissue,liquid supported denture, neutral zone,

INTRODUCTION
With increase in life expectancy of a completely edentulous patient, the surface area of the denture foundation eventually decreases due to progressive residual ridge resorption leading to atrophic, flabby and unemployed ridges. Jacobsen and Krol[1] stated that the three key factors governing the success of complete dentures, namely retention, stability and support are compromised in a patient with reduced denture-bearing area, reduced neuromuscular control and degenerative mucosal tissue changes. In such a case, the rigid inflexible tissue surface of the conventional complete denture leads to uneven distribution of load and hence needs to be modified according to the individuals need. A liquid supported denture due to its flexible tissue surface allows continuous adaptation of the mucosa and better distribution of stress to the underlying compromised ridge, thereby providing optimal treatment modality. Neutral zone technique is an alternative approach for the construction of mandibular dentures. This technique yields a complete denture that is shaped by functional trimming of cheek and tongue muscle which is in harmony with the surrounding oral structures. It is most effective when there is atrophic ridge and a history of denture instability [2]. This case report presents the use of a liquid supported denture in a patient with completely edentulous maxillary arch with flabby tissue in anterior region and the use of neutral zone technique on atrophic edentulous mandibular arch to gain stability of mandibular denture. 2. Clinical report
A 73 year old male patient reported to Goa Dental College and Hospital (GDCH) for replacement of old dentures. The patient had a history of wearing complete dentures for 15 years. His chief complaint was "the Dr. Nikita Kareker et al. / IJRID Volume 4 Issue 5 Sep.-Oct. 2014

Dr. Nikita Kareker et al . / IJRID Volume 4 Issue 5 Sep.-Oct. 2014 denture was not fitting well and felt loose while eating". The upper denture had a provision for attachment of a suction cup which had got dislodged. There was no evidence of any palatal defect. He also gave history of use of denture adhesive for past 8 years. The patient gave history of Diabetes Mellitus for which he was taking medications (Glycomet 500) since past 7 years. Intraoral examination revealed maxillary edentulous arch with flabby tissue in the anterior region and highly compressible tissue on the posterolateral slopes of hard palate; and mandibular edentulous arch with atrophic and unemployed ridge in the posterior region. Extraoral examination revealed reduced muscle tone and poor neuromuscular coordination. Orthopanthomogram revealed reduced bone support in the maxilla and a superficially placed mental nerve and the inferior alveolar canal in the mandible. Keeping the various challenges associated with the case, clinical steps and treatment plan was modified to suit the patient's need. The treatment plan included a liquid supported maxillary complete denture and achieving stability for the mandibular complete denture using neutral zone technique. Primary maxillary impression was made with alginate (Alginate, Hydrogum® soft, Zhermack, Clinical, Badia Polesine (Rovigo), Italy) and mandibular impression with impression compound (Y-Dents® Impression composition, MDM Corporation, Lalkuan, Delhi, India). On the maxillary cast, a special tray was made with two posterior handles. Border molding was performed by using low fusing impression compound (Aslate, Asian Acrylates, Mumbai, Maharashtra, India) and medium body addition silicone (Aquasil, Dentsply Detrey gmbH, Konstanz, Germany) wash impression was made. The flabby tissue was recorded using window technique [2] in rest position by injecting light body addition silicone material (Fig 1). Mandibular ridge was recorded using admix technique [3] and a light body addition silicone (Aquasil, Dentsply Detrey gmbH, Konstanz, Germany) wash impression was made (Fig 2). Jaw relations were recorded. The mandibular wax rim was modified to record the neutral zone with swallowing technique [4]. Fig 1 Fig 2
Definitive maxillary impression, using Definitive mandibular impression using Window technique Dr. Nikita Kareker et al. / IJRID Volume 4 Issue 5 Sep.-Oct. 2014 Dr. Nikita Kareker et al . / IJRID Volume 4 Issue 5 Sep.-Oct. 2014
3. Method to record the neutral zone:-
The mandibular wax rim was modified in the following manner: the wax was removed from the wax rim and three auto polymerising acrylic pillars were made each in molar region and in incisor region connected with the help of 21 gauge wire loops (Fig 3). Impression compound (Y-Dents Impression composition, MDM Corporation, Lalkuan, Delhi, India) was kneaded and adapted to the mandibular record base. Maxillary wax record base was placed in the patient's mouth followed by placement of the mandibular record base with softened compound. The patient was asked to carry out different functional movements like sucking, swallowing, smiling, licking the lips, whistling, pronouncing vowels and counting. Excess compound was trimmed away, resoftened and placed back into the mouth asking the patient to repeat the functional movements. Condensation silicone putty index of the moulded compound rims was made and the mandibular teeth were arranged in the neutral zone following the index. Final try-in procedure was carried out. 4. Steps in fabricating maxillary liquid supported denture:-
Vaccum heat pressed polyethylene sheet (Bioplast Scheu-Dental, Iserlohn, Germany) of 1 mm thickness was adapted on the master cast using vaccum heat pressed machine (Biostar Scheu-Dental, Iserlohn, Germany). The sheet was kept 2 mm short of the sulcus and was not extended in the posterior palatal seal area (Fig 4). This sheet was incorporated in the denture at the time of packing. The aim was to provide space for liquid which was to be filled at later date. Fig 3 Modified mandibular record base Fig 4 one mm thick sheet placed on invested master cast prior to packing Upper complete Denture (with 1 mm thick sheet) and lower complete denture were then delivered after making occlusal adjustments. The patient was recalled after two weeks to convert the maxillary denture into a liquid supported one and to check the comfort level of the patient to the polyethylene sheet. Dr. Nikita Kareker et al. / IJRID Volume 4 Issue 5 Sep.-Oct. 2014 Dr. Nikita Kareker et al . / IJRID Volume 4 Issue 5 Sep.-Oct. 2014 At recall appointment, the 1 mm thick sheet was removed from the denture. Due to removal of the sheet crevices were formed all along the denture borders. These crevices were helpful in final placement of 0.5 mm thick sheet. Condensation silicone putty impression was made of the tissue surface of the denture and a cast was obtained (Fig 5). This was done to record the exact junction of the sheet to the denture. On this cast a 0.5 mm thick polyethylene sheet was vacuum pressed, thus creating a 0.5 mm space.  The polyethylene sheet was cut using the putty index as guide. The borders of the 0.5 mm thick sheet were placed in the crevice formed due to removal of 1 mm thick sheet. Cynoacrylate adhesive and autopolymerising acrylic resin were used to seal the borders and prevent escape of the liquid (glycerine).  The space created due to the replacement of a 1 mm thick sheet with a 0.5 mm thick sheet was filled with glycerine. This was done by making two holes in the buccal flange area of the denture and injecting glycerine through these holes and checking the vertical dimensions simultaneously. The holes were sealed using self cure acrylic resin. The maxillary liquid supported denture (Fig 6) was delivered and denture care instructions were given to the patient. The patient was told to clean the tissue surface using soft cloth. Recall appointments were scheduled at one day, one week, one month and three months. At one week appointment, the patient complained of ‘floating' feeling. But, at 3 months recall appointment, patient was comfortably using the dentures. The dentures were well maintained. Fig 5 condensation silicone putty index of tissue surface of denture Fig 6 Liquid supported maxillary complete denture 5. Discussion
Under masticatory load, the polyethene sheet adapts to the modified form of mucosa due to hydrodynamics of the liquid, improving support, retention and stability. There will also be optimal stress distribution of Dr. Nikita Kareker et al. / IJRID Volume 4 Issue 5 Sep.-Oct. 2014 Dr. Nikita Kareker et al . / IJRID Volume 4 Issue 5 Sep.-Oct. 2014 masticatory forces over a larger area which reduces tissue overloading. Prevention of soreness and increased comfort level are other advantages of the liquid supported denture [1]. In this case, polyethylene thermoplastic clear sheet was used because of its softness, flexibility and biocompatibility. Glycerine was used because it is clear, viscous, and biocompatible and also has been used as a vehicle in liquid medications [5]. Recording the neutral zone was essential in this case since the patient presented with impaired neuromuscular coordination and a flat foundation for the mandibular denture base. Neutral zone recording considers the actions of the tongue, lips, cheeks, and floor of the mouth during a specific oral function, to push the soft material into a position where buccolingual forces are neutralized. Many studies have demonstrated that neutral zone dentures are functionally more stable than conventional dentures [2]. 6. Conclusion
Fibrous and atrophic ridges pose a prosthodontic challenge for the achievement of stable and retentive dental prostheses. Surgical removal of the fibrous tissue and implant retained prostheses may not be possible in all cases. Considering conventional prosthodontics, the use of liquid supported denture can improve the patient's acceptance due to more uniform distribution of forces and improved comfort level. 7. References
1. Liquid-supported denture: A gentle option, Brajesh Dammani , Santosh Shingote, Smita Athavale, Dilip Kakade, JIPS 2007: 7(1);35-39. 2. The neutral zone impression revisited, M. J. Gahan1 and A. D. Walmsley; BDJ 2005: 198(5); 269-272. 3. Management of flabby ridges using liquid supported denture: a case report, Nandita Keni, Meena Aras, Vidya Chitre, JOAP 2011:3(1). 4. Morphologic comparison of two neutral zone impression techniques: A pilot study, Makzoumé JE, International Journal of Prosthodontics 2005: 18(3). 5. Management of Compromised Ridges: A Case Report, Smita Sara Manoj, Vidya Chitre , Meena Aras; JIPS 2011: 11(2); 125-129. Dr. Nikita Kareker et al. / IJRID Volume 4 Issue 5 Sep.-Oct. 2014

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