Preliminary impressions in total prosthesis
PLAN :
Introduction
I- Classification of prints
- Compressive prints
- Non-compressive prints
- Selective pressure prints
II- Fingerprint requirements
III- Preliminary prints
- Definition
- Goals
- Choice of standard impression tray
- Choice of material and impression technique
- Description of preliminary impression techniques
IV- Processing of preliminary prints in the laboratory
1-Decontamination of prints
2- Casting the models
3-Removing the prints from the mold
4-Size of models
5-Individual impression tray: – Creation of the PEI
– Qualities of the PEI
Conclusion
Bibliography
Preliminary impressions in total prosthesis
Introduction :
The treatment of a patient’s edentulism is a medical act. It involves restoring the balance of the masticatory system as a whole by restoring normal conditions for dental occlusion, muscle play, the mechanism of the temporomandibular joints and the entire proprioception of the oral sphere.
And the success of a dental prosthetic treatment depends essentially on compliance with the different stages of its implementation, including taking impressions, which constitutes one of the most important stages of our treatment.
I- Classification of prints:
There are three types of imprints: compressive, non-compressive and selective pressure:
- Compressive impressions: These are made with impression trays (PE) in which no space is provided for taking a secondary impression, or those made with a material whose fluidity is low.
2-Non-compressive impressions: These are made by creating a large space between the PE and the supporting tissues and using a fluid impression material.
3-Selective pressure impressions: When the pressure exerted on the supporting tissues during the impression must be related to their ability to support the support of the intrados of the prosthesis. They are made with PEs that have more space in some places than others for the final impression material.
II- Fingerprint requirements:
The final impression must favorably combine all the elements determining the retention, stability and support of the future prosthesis. It must prefigure the latter, obey the same biological and mechanical conditions, in order to foresee and ensure the triple mission which is incumbent, functional mission, aesthetic mission and phonetic mission.
To simultaneously satisfy all these essential conditions thus defined, it is necessary to respect the following imperatives which can be divided into three groups:
1- Pre-prosthetic requirements:
They are all oriented towards better preservation of tissue integrity, they necessarily involve:
- A perfect knowledge of all general diagnostic elements
- Knowledge and preservation of the anatomical, physiological and biological characteristics of the three parts which are in contact with the base of the prosthesis and with which they must be in harmony and which are:
- A static part (covering fabrics)
- A line of reflection of the mucosa
- Peripheral organs
2- Prosthetic requirements:
They must ensure that the final impression prefiguring the finished prosthesis has the following fundamental qualities, required for the latter to be perfectly integrated within the other structures, namely:
- Mechanical qualities of retention, support, stabilization,
- Functional qualities,
- Aesthetic qualities,
- Phonetic qualities.
3- Post-prosthetic imperatives:
They constitute a synthesis of the preceding imperatives, they are intended to predict and ensure the permanence of the results acquired at the time of the imprint and existing during the first days of insertion.
They require us in particular to exclude all techniques of impressions or distribution of the occlusal load, tending to subject the supporting osteo-mucosal tissues to excessive pressure.
III- Preliminary prints:
- Definition :
It is the first impression reproducing an edentulous maxilla, made with a standard impression tray (PES), filled with a precise but inexpensive material. It is intended for the production of an individual impression tray.
- Goals :
The objectives of preliminary prints are multiple:
- Ensure precise molding of the support surfaces, on which the dental prosthesis will rest. It must allow the intrados of the prosthesis to be produced so that it perfectly matches the contours of the maxillomandibular surfaces and ridges,
- Locate as accurately as possible the optimal situation of the
mucosal reflection line, - Possibly assess the degree of bone resorption and the current position of the paraprosthetic organs,
- Analyze the ideal limits of the future prosthesis,
- Contribute to the clinical study, diagnosis and prosthetic treatment plan for total edentulism,
- Allow the construction in the laboratory of an individual impression tray, roughly prefiguring the finished prosthesis and requiring the minimum of correction in the dental office,
- Minimize the time spent in the office adjusting the individual impression tray.
- She is responsible for the accuracy in making the individual impression tray.
- Choice of standard impression tray:
In the maxilla: The choice of the serial impression tray is determined by the morphology of the alveolar edges, the palatine vault and the tuberosities.
- In the horizontal plane: the impression tray will be square, triangular, rectangular or elliptical, but always in close correspondence with the shape of the arch and with its dimension (n° 1, 2, 3, 4)
- In the frontal plane: it will be parallel to the bony relief at all points; a deep vault will correspond to an impression tray with a rounded basin; a flat palate will have a basin with less curvature.
- The height of the edges of the impression tray depends on that of the alveolar edges. In no case should there be any bone, mucosa or fibromucosal interference with the edge of the impression tray. The latter must therefore always be distant from the mucosal reflection line, and slightly larger than the edentulous arch.
- In the sagittal plane: the same spacing principles are necessary. The posterior edge of the impression tray will extend 2 mm beyond the flexure line of the velum. It will therefore extend approximately 4 mm beyond the palatal fossae and will cover the pterygomaxillary grooves without, however, hitting the pterygomaxillary ligaments when the mouth is open.
The gripping system, or “impression tray handle”, must in no case distend the upper lip, push its median frenulum upwards, or force the patient to keep his mouth wide open.
- In the mandible:
- In the horizontal plane: the impression tray will be elliptical, hyperbolic or square in close relation to the shape of the arch. It must cover the entire alveolar rim and retromolar papillae without displacement or crushing.
At its posterior end there should be no interference with the pterygomaxillary ligament, if the horizontal extension of the PE is insufficient, it will be extended using Kerr paste or wax.
- In the frontal plane: the spacing between the impression tray and the support surface must be regular to allow an equal distribution of the impression material.
- In the sagittal plane: its profile must be parallel to that of the alveolar edges.
The gripping system or handle of the impression tray must not move the lower lip.
However, there is no ideal all-purpose impression tray because it must be adapted to the material used. EX: Thus, when the choice of material falls on alginate, the impression tray must be retentive (perforations) or made retentive by the placement of adhesive bandage strips.
- Choice of material and impression technique:
This double choice is guided by:
- The patient’s general condition,
- Anatomical and physiological structures of covering tissues and peripheral organs,
- By the design of the final print and the material that will be used for it.
Preliminary impressions in total prosthesis
- In the maxilla:
1. Non-compressive plaster impression (anatomical impression) Indicated for:
- Class I and II poorly resorbed ridges
- A healthy and adherent fibromucosa
- Absence of exostosis, protruding intermaxillary suture or torus that could compromise the stability of the prosthesis
- The presence of inoperable floating ridges which requires us to avoid any crushing, any compression, and any displacement.
2. Preliminary mucostatic imprint with alginates:
- Any compression is prohibited but the patient’s nervousness, psychological or pathological state prohibits the use of plaster,
- Or a patient refusing the use of plaster.
3. Preliminary anatomical-functional imprint with alginates:
- When you want to assess the exact limits of the PEI and push back the vestibule and the floor
- When the final mucostatic impression is taken with a material that does not compress the covering tissues of the support surface a second time
- When you want to make a temporary tissue conditioning prosthesis directly on the model from this imprint.
4. Preliminary compressive anatomical-functional impression with a thermoplastic material:
- In the presence of irregular bony support surface with marked protrusions and depressions
- In the presence of a torus or a protruding intermaxillary suture between two particularly depressible Schroeder zones which could play the role of a destabilizing balance for the prosthesis
- And especially in the case of a resorbed bone base, an arch without relief or depth
- The mandible:
The choice is subject to the rules which the preliminary impressions of the upper edentulous arch obey.
In addition to all these impressions, there is the non-compressive anatomical and functional impression with thiocols without an impression tray.
- Description of preliminary impression techniques:
- Preliminary plaster impression:
Plaster is always the material, it is perfectly mucostatic because its initial viscosity is very low; it is hydrophilic and therefore allows precise molding of a wet surface. In addition, plaster has excellent dimensional stability and its rigidity after setting prevents any deformation of the impression.
The imprint is made in several stages:
- In the mandible:
- Choice of impression tray:
For this type of impression, non-perforated impression trays will be used. They have a graduation on the gripping element allowing the measurement of the position of the lip, determining the height of the occlusal rim of the individual impression tray.
Adaptation of the impression tray: It can be either:
- Subtractive: by grinding the edges at the level of overextensions and brakes or by punching with pliers.
- Additive: using thermoplastic paste or more simply plastic wax.
Soft wax push-in and repositioning stops can be made to facilitate precise positioning of the impression tray loaded with material.
Finally, the internal face of the impression tray is coated with a specific adhesive and the solvent is left to evaporate completely (5 to 10 minutes) before applying the material.
- Patient preparation:
If necessary, anti-nausea premedication is recommended, namely a tablespoon of Primpéran, 1 hour before the procedure.
Position the patient with their head upright, prevent a nausea accident by advising the patient: only breathe through the nose at a slow, regular pace, shoulders low, possibly head forward.
- Preparation of the plaster:
Prepare a dose of cold water in a plaster bowl which, little by little, saturates with water. When the quantity of powder is correct, only a cone of dry plaster remains. You can then spatulate quickly to obtain a mixture with a creamy consistency, homogeneous and without air bubbles.
- Imprint itself:
The practitioner loads the plaster into the impression tray in a thin layer; he fills it with plaster using a Teflon spatula and a tongue depressor:
- The mirror spreads the tongue at the level of the left flap in order to deposit the plaster with the spatula in this open space, then we overflow onto the trine and the Fish pocket on the same side;
- Then, the spatula loaded with plaster on one side spreads the tongue at the level of the right flap while the mirror spreads the right cheek, the tilting of the spatula causes the plaster to flow into the retromolar niche;
- A third plaster spatula is placed on the right trigone and slid forward into the vestibule to fill the Fish pocket.
He then moves on to the rapid insertion of the impression tray:
- First, the flaps are engaged under the tongue, then the impression tray is tilted forward;
- The patient is asked to stick the tongue out moderately forward and then to the right and left;
- The impression tray is gently pushed in while the patient is asked to close his mouth, and held by the operator, without pressure or movement.
The dehydration of the plaster is complete when a piece of plaster taken from the bowl and crushed between the thumb and index finger pulverizes without any aqueous residue.
Disinsertion first involves a slight tilt by vertical traction of the handle in order to free the vestibule at the labial level, then a translational movement towards the rear to release the lingual flaps and finally an elevation for final disinsertion.
If the print fractures during removal, the fragments are recovered and reunited in the laboratory using cyanoacrylate glue.
Preliminary impressions in total prosthesis
- In the maxilla:
- Choice and adaptation of the impression tray:
As for the mandibular impression.
- Imprint itself:
The practitioner loads the plaster onto the impression tray; a layer of approximately 0.5 cm thick is sufficient;
He fills the vestibule and palate with plaster using a Teflon spatula, a tongue depressor or a pastry syringe; the plaster is carried by the spatula throughout the vestibule and in particular to the level of the paratuberous ampullary areas of Eisenring.
Then he proceeds to quickly insert the impression tray. The manipulation is carried out by positioning himself behind the patient and tilting his head forward, it is the maxilla that enters the plaster. We start with the posterior edge then the tilting of the impression tray allows its anterior placement.
After the material has taken, the impression tray is removed; removal is facilitated by introducing air either using the multi-function syringe or by creating an air intake with the index fingers in the vestibule.
If the impression is generally satisfactory but has bubbles, these can be filled with wax.
- Preliminary alginate impressions:
90% of preliminary impressions are made using alginates and the most used are class A alginates which have the best mechanical properties, precision and dimensional stability.
- In the mandible:
- Choice of impression tray:
Two families of perforated impression trays suitable for the use of alginates:
- The Accu-Trays from frusch: satisfactory because they have lingual flaps whose size allows this region to be recorded well, but they have the disadvantage of being made of plastic.
- Schreinemakers Clean-Trays impression trays: are preferred because they are available in metal and therefore ensure perfect rigidity of the impression, guaranteeing its precision when using elastic materials.
The shape of the impression tray is chosen according to that of the arch; its size can be measured as previously.
- Adaptation of the impression tray:
The Clean-Trays impression trays are not adaptable to the clamp due to their rigidity. However, they can be extended later by adding moyco-type wax.
- Patient preparation:
It is identical to that described for the plaster imprint.
- Preparation of alginate:
Under no circumstances should we attempt to modify the water/powder proportions recommended by the manufacturer, as this could alter the final mechanical properties of the material.
Mixing can be manual, carried out in a bowl using a Teflon alginate spatula, or mechanical in an automatic mixer, possibly under vacuum to improve the homogeneity and quality of the final product.
- Imprint itself:
After mixing the alginate, fill the impression tray.
– The mirror spreads the tongue at the level of the left flap in order to deposit the material in this wide open space, then directly above the trine and in the Fish pocket on the same side;
– Then the practitioner fills the area of the right lingual flap then the corresponding Fish pocket while keeping the right cheek apart using the mirror.
- Inserting the loaded impression tray into the mouth:
– First put in place from the back with engagement of the lingual flaps under the tongue, then tilt forward ensuring perfect centering;
– The patient is asked to moderately pull the tongue forward;
– Finally, the impression holder is maintained.
The removal of the impression tray is dry, uniaxial but not abrupt, it is only carried out after the complete gelling of the alginate which occurs 1 minute after the apparent setting.
Any premature removal of the print would result in deformations.
Cleaning the print under running water for 1 minute to remove almost all of the germs contained in the saliva, then disinfecting by soaking or spraying with a sodium hypochlorite solution followed by another rinse.
The impression must be cast within 15 minutes of its removal in order to avoid any deformation.
The possibility of postponing the casting in case of absolute necessity, the impression must be kept in a vacuum sealed plastic bag which ensures a hydrostable enclosure.
- In the maxilla:
- Choice and adaptation of the impression tray:
As with the mandibular impression,
- Patient preparation:
It is identical to that described for the plaster imprint.
- Imprint itself:
– The operator positions himself behind the patient and tilts the head forward to insert the anterior ridge into the alginate, then tilts the impression tray forward, ensuring perfect centering;
– Relaxation and repositioning of the upper lip and cheeks;
– Modeling of the vestibular mucosal reflection areas by gently massaging the external surfaces of the patient’s cheeks and lip, while the impression tray is held pressed against the palate;
– Holding the impression tray without pressure using the index and middle fingers, with the operator always positioned behind the patient.
The removal of the impression tray is dry, uniaxial but not abrupt, it is only carried out after the complete gelling of the alginate which occurs 1 minute after the apparent setting.
Disinsertion is facilitated by creating an air intake by introducing the index fingers into the paratuberous regions.
Cleaning, decontamination and casting of the impression are identical to those of the mandibular impression.
Preliminary impressions in total prosthesisPreliminary impressions in total prosthesis
- Preliminary impression with thermoplastic material:
For taking impressions with thermoplastic paste, impression trays of smaller dimensions and less profiled than those intended for alginate are used. This allows a real individual impression tray to be produced at the same time. The impression material used must have sufficient plasticity properties and remain non-deformable after setting.
For the preliminary impression with a thermoplastic material it is necessary to prepare:
- Thermoplastic material “HM”
- Special adjustable impression trays type “Meist”
- Water at 40°
- Ice water
- Vaseline
- Universal pliers
In a patient who already wears an old prosthesis, this can be used for the preliminary impression with an elastic material.
- Preparation of the thermoplastic material; heated in water at 40°, it is then shaped into a roll slightly wider at the ends, in hands previously coated with Vaseline.
- Preparation of the special impression tray; this receives a thin film of Vaseline.
- First placement; without exerting pressure, the impression tray loaded with material is placed on the patient’s mandibular crest.
- Centering control; the mandibular crest is weakly imprinted in the impression paste. Good centering is recognizable by an equal distribution of the material on each side of the impression tray.
- Second placement; the practitioner asks the patient to gently raise the tongue and lower lip while he presses moderately on the impression tray in place.
- Intermediate check; the entire mandibular crest is now well inscribed in the impression material.
- Final impression; to ensure the proper molding of the vestibular and paralingual sector, the patient also makes lateral movements with his tongue, trying to touch the practitioner’s index fingers which hold the impression tray in place.
- Cooling the impression; in order to avoid deformations of the impression between the different previous times, the impression is immersed in iced water after each of these manipulations.
- Preliminary thiocol imprint: anatomofunctional imprint:
This is a mandibular impression without an impression tray: indicated for levels III and IV of the Klein classification:
We use a metal wire that is roughly adjusted according to the length of the ridge going from one periform eminence to the other and a “regular” thiocol that does not stick to the fingers and whose plasticity depends on the polymerization.
After the introduction of the thiocol-coated wire into the mouth, functional modeling is done by pronouncing “le” repeated several times then by the phonemes “ke, gue, re”, the impression is removed from the mouth after hardening.
Extensions: the first outline is completed by successive additions of regular thiocol at the level of the trigones then the alveolo-lingual grooves, this extension is limited by the protraction and laterotraction of the tongue, the labial flap is modeled by a light pronunciation of the bilabials.
At this stage, the print must be very stable, a glaze is carried out to erase the surface irregularities, carried out by a fluid thiocol.
IV- Processing of preliminary prints in the laboratory:
1-Decontamination of prints:
We currently recommend after rinsing with running water:
*For alginates: glutaraldehyde-based solution used as a surface spray (vaporization)
*For plaster: sodium hypochlorite solution (immersion) use of mask and gloves is essential.
This step is always followed by a thorough rinsing in running water before casting the models.
2- Casting the models:
The preservation of an alginate impression must be done in a humid atmosphere in a waterproof packaging. There are some products designed for this waterproof packaging
The impression must be poured within a maximum of 2 hours and ideally 10 minutes after its removal.
*For plaster, it is most stable after setting under normal conditions.
It no longer undergoes deformation provided that it is not left for a long time in a very humid or too dry environment.
Plaster prints should be isolated by immersion in soapy water or 10% soda water for 5 to 10 minutes,
The prints are preferably cast on a vibrator with medium-hard plaster prepared to a creamy consistency.
3-Removing the prints:
*The demolding of plaster impressions is carried out in several stages, first the commercial impression tray is released and placed using a hammer which will fragment the impression plaster, then the rest of the plaster is in turn fragmented until it is completely eliminated.
*On the other hand, removing alginate impressions from the model generally does not pose any problems due to the elasticity of the material.
Regarding the making of the plaster model from an impression taken using thermoplastic paste: the impression is cast using ordinary plaster so that all the vestibular and lingual surfaces are reproduced as much as possible. The base is cut at the same time, then it is cooled in ice water even before the heat is released due to the setting of the plaster (impression and plaster are immersed in ice water). The demoulding is done after the plaster has completely hardened, the model is immersed for a few moments in lukewarm water, which facilitates demoulding.
- Model sizes:
The model thus obtained is ground with a plaster cutter, preserving the vestibular mucosal reflection zone. In order to facilitate easy access to the bottom of the vestibule, the edge of the model is cut with an external bevel.
- Individual impression tray:
The use of a PEI makes it possible to obtain a secondary impression and then a secondary model, and meets a dual purpose.
The imprint also concerns the periphery of the PEI, the limits of which must be defined with extreme precision because it prefigures the prosthesis and must therefore produce its exact template.
The determination of these limits must be done with three objectives:
- Maximum extension of the base which, by increasing the support surface, reduces pressure on the tissues, avoids trauma and limits resorption while improving retention.
- Release of paraprosthetic inserts to avoid discomfort and often injury or mobilization of the prosthesis during functions.
- Peripheral sealing linked to limits located on a depressible fabric and to wide, rounded edges.
Preliminary impressions in total prosthesis
- Implementation of the PEI:
*Construction principles:
In the upper jaw:
*If the model comes from a compressive impression: the non-depressible parts are then anatomically unloaded and the PEI can be adjusted on the model
The extreme limit of the spacing zone is a line drawn on the model approximately 3 mm below the mucosal reflection line materializing the static part of the support surface free of any insertion
*If the model comes from a non-compressive impression: non-depressible areas such as the torus, intermaxillary suture, exostoses are located in the mouth and noted on the model, will be covered with a sheet of calibrated wax or tin foil.
The posterior limit is located behind the flexion line of the veil, at the level of the prolonged pronunciation of “AH” clear, if it was previously identified clinically and marked on the impression. Otherwise, it exceeds the palatal fossae by 4 mm, covering the pterygomaxillary grooves by releasing the pterygomaxillary ligaments.
In the mandible: the construction of the lower PEI must obey the same general principles governing the construction of the upper PEI,
- Boundaries :
It must therefore be decided by the latter and its outline traced by him on the primary model in the presence of the patient. Otherwise the limits of the individual impression tray will be deduced from the anatomical elements recorded by the primary impression and reproduced on the primary model.
1-1-Maxillary:
- Middle brake: fairly narrow U-shaped notch
- Anterior zone: straight line 2mm beyond the free mucosa
- Side brake: asymmetrical V-shaped notch
- Zygomatic process wide lateral concavity
- Eisering’s paratuberous ampullary zone: go very high
- Posterior palatine area: the boundary is an almost straight line of a groove
pterygomaxillary to another, located on the line of depression always behind the palatine fossae and in front of the hamulus (lower ends of the internal wings of the pterygoid processes of the Sphenoids)
1-2-Mandible:
- Medial and lateral vestibular BRAKES, anterior zone: as in the maxilla
- Lateral vestibular zone: convex trace descending into Fish’s pouch
- Posterior vestibular zone: straight just touching the external oblique line
- Trigone area wide notch avoiding the low insertions of the masseter and posterior insertions of the buccinator
- Lingual frenulum: wide and deep notch
- Sublingual area: seek contact with the sublingual fringe so that a very wide edge occupies the entire sublingual hammock.
- Middle lateral lingual area: perfectly straight line 2mm below the internal oblique line
- Posterior lingual area: whenever possible, a retentive retromylohyoid flap should be created with a vertical limit rising to the upper two-thirds of the trigone.
1-3-Realization:
After preparing the model, by applying the wax to the undercut areas, the PEI can be produced using different possible processes:
a-Individual impression tray in self-polymerizing resin:
After isolating the model with a plaster-resin separator, the limits of the impression tray are traced using an aniline pencil or a soft pencil. The impression tray resin is mixed according to the manufacturer’s instructions. When it reaches its plastic stage, it is calibrated using a carefully vaselined plate and roller, then it is placed on the model and applied manually. Before it hardens, the gross overextensions are removed. After polymerization, the plate is removed from the model and the limits are clearly visible on its intrados. The excesses are ground down to the limits so as to obtain a rounded edge using a resin bur.
The bead can be made of resin or composition, and, in the latter case, retention means must be provided to secure it to the base plate.
Regardless of the material, it must have the same shape and dimensional characteristics as those previously described.
b-Individual impression tray in photopolymerizable resin:
A plate is applied to the model and then it will be photopolymerized in 2 stages: intrados and extrados. This is a quick but expensive technique.
c-Individual spaced or partially spaced impression tray:
- Partially spaced individual impression tray:
The support areas to be unloaded are determined in the clinic. The practitioner delimits them either on the positive working model, but this requires a round trip from the clinic to the laboratory, or these areas are traced on the primary impression itself and then reproduced on the working model. However, simply reading the impression or model can determine the surfaces to be unloaded in the laboratory. This is often a knife-edge edentulous ridge, a pronounced torus, a prominent and fine internal oblique line, a prominent intermaxillary suture, etc.
These precise areas are covered on the working model either with a simple sheet of wax or with a sheet of tin in relation to the desired spacing.
- Fully spaced impression tray:
They are indicated for special techniques using highly compressive materials for heavily resorbed maxillae . The entire surface of the maxilla is then covered with a calibrated wax sheet 4mm thick, cut to the limits of the bottom of the vestibule. This sheet will subsequently remain attached to the individual impression tray, to allow its adjustment in the mouth and the recording of the intermaxillary relationship.
Preliminary impressions in total prosthesis
- Qualities of the PEI:
Whatever the material used to make the individual impression tray, it must have certain essential qualities:
- Must be rigid, non-deformable,
- Its centering must be done without hesitation, it must be inserted and removed easily,
- Its edges must be rounded to compensate for bone resorption,
- It must ensure an even distribution of the impression material,
- The handle must prefigure the position and volume of the alveolo-dental rampart.
Preliminary impressions in total prosthesis
Conclusion :
The primary impression is a very important step for the success of the secondary impression.
BIBLIOGRAPHY:
1- Alfred H GEERING and M.KUNDERT; Atlas of Dental Medicine: Total and Composite Adjunct Prosthesis; Medecine-Science Flammarion.
2- J. LEJOYEUX; Complete prosthesis: volume 01: Clinical examination, Preprosthetic treatment, Materials and impression techniques; 3rd edition; Maloine, SA Publisher; 1979.
3- M. POMPIGNOLI, JY DOUKHAN, D. RAUX; Clinical Guide: Complete Prosthesis Clinic and Laboratory, Volume 01; Edition Cdp, November 2004.
4- Website: 805 Laboratory Stages in Complete Prosthesis.
Preliminary impressions in total prosthesis
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