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Table of Contents
Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 106-110

Prosthodontic management of Atwood's order V and VI mandibular ridge with cocktail impression technique

1 Post Graduate Student, Department of Prosthodontics and Crown and Bridge, Baba Jaswant Singh Dental College and Hospital, Ludhiana, Punjab, India
2 Professor and Head, Department of Prosthodontics and Crown and Bridge, Baba Jaswant Singh Dental College and Hospital, Ludhiana, Punjab, India
3 Professor, Department of Prosthodontics and Crown and Bridge, Baba Jaswant Singh Dental College and Hospital, Ludhiana, Punjab, India
4 Reader, Department of Prosthodontics and Crown and Bridge, Baba Jaswant Singh Dental College and Hospital, Ludhiana, Punjab, India
5 Senior Lecturer, Department of Prosthodontics and Crown and Bridge, Baba Jaswant Singh Dental College and Hospital, Ludhiana, Punjab, India

Date of Submission24-Oct-2022
Date of Acceptance05-Dec-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. Ravpreet Singh
Department of Prosthodontics and Crown and Bridge, Baba Jaswant Singh Dental College and Hospital, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpcdr.ijpcdr_23_22

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Residual ridge resorption is the reduction in size of the bony ridge under the mucoperiosteum. The resorption occurs faster in the mandibular arch as compared to the maxillary arch. Fabrication of any dental prosthesis over a compromised residual alveolar ridge is really a challenge for prosthodontists. The pattern of bone resorption observed in Atwood's Orders V and VI causes difficulty in providing successful dentures, especially lower denture where stability of denture may get compromised. This clinical case report elicits a combination of different impression techniques to improve mandibular denture stability in severely resorbed ridges preventing their further resorption.

Keywords: Atrophic ridge, cocktail impression technique, residual ridge resorption, severely resorbed ridge

How to cite this article:
Sharma R, Oberoi N, Kaur G, Singh R, Singh J. Prosthodontic management of Atwood's order V and VI mandibular ridge with cocktail impression technique. Int J Prev Clin Dent Res 2022;9:106-10

How to cite this URL:
Sharma R, Oberoi N, Kaur G, Singh R, Singh J. Prosthodontic management of Atwood's order V and VI mandibular ridge with cocktail impression technique. Int J Prev Clin Dent Res [serial online] 2022 [cited 2023 Feb 6];9:106-10. Available from: https://www.ijpcdr.org/text.asp?2022/9/4/106/366146

  Introduction Top

The management of highly resorbed ridges has always posed a challenge to the prosthodontist for years. The resorption of residual ridges is the pathophysiological process and is mostly seen after extraction of teeth.[1] It is also accepted that the rate of resorption varies from person to person. The rate of resorption is most rapid within the first 6 months which decreases moderately to 0.4 mm per year for the mandible.[2] Atwood categorized ridge form into six orders ranging from the preextraction state (Order I) to the atrophic depressed mandibular ridge (Order VI).

Making an impression of an edentulous arch becomes a nightmare when the residual ridges are drastically resorbed.[3] The use of ridge augmentation and implants is generally advocated for such patients. However, treatment option of ridge augmentation and implant procedures may not always be possible. Therefore, conventional dentures can have an equivalent positive impact on the health-related quality of life.

A series of impression techniques such as admixed technique,[4] all green technique,[5] and neutral zone technique have been suggested for the management of severely resorbed ridges. In this clinical case report, a novel impression technique is used to ensure better reproducibility and stability in an atrophied mandibular ridge, which is referred as cocktail impression technique.

  Case Report Top

A 72-year-old female patient reported to the Department of Prosthodontics and Crown and Bridge, Baba Jaswant Singh Dental College, Hospital and Research Institute, Ludhiana (Punjab), with a chief complaint of lost mandibular denture teeth for 20 days. History revealed that she had lost her teeth due to periodontal reasons and had been wearing dentures from 8 years.

On clinical evaluation, resorbed maxillary [Figure 1] and flat mandibular [Figure 2] ridges (Atwood's Order V) were observed. A thorough medical and dental history was elicited from the patient followed by clinical and radiographic examination. Various treatment options were explained to the patient such as ridge augmentation procedures followed by conventional complete dentures, implant-supported prosthesis, and conventional complete dentures. Advantages and disadvantages were also discussed with the patient. Due to patients' compliance, cost factor, and surgical procedure involved, the patient decided conventional complete denture as a treatment option.
Figure 1: Edentulous maxilla

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Figure 2: Edentulous mandible

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Highly resorbed residual mandibular ridge is commonly observed in older patients, along with thin, atrophic mucosa and lower threshold of pain, with diminished resiliency of tissues and muscle tonicity accompanied by poor adaptive capacity. Providing a stable lower denture for such patients has been a more difficult problem encountered by the dentist. The journey toward successful denture fabrication for such patients begins with an accurate impression that will help to ensure that the complete denture is stable and provides physiological comfort to the patient. Therefore, it was decided to use cocktail impression technique for making a definitive impression in this case.


  1. The primary impression of the maxillary arch was made with irreversible hydrocolloid, and for the mandibular arch, admixed impression technique was used
  2. The custom tray was fabricated with autopolymerizing acrylic resin for secondary impression. One-millimeter wax spacer and cylindrical mandibular rests in the molar region were made at a tentative vertical height [Figure 3] and [Figure 4] (impression compound can be added later on to increase the vertical height)
  3. The custom tray was inserted into the patient's mouth and the patient was advised to close her mouth so that the mandibular rests fit on the maxillary alveolar ridge which helps in stabilization of the tray for impression making
  4. The secondary impression was made with all green technique followed by a final wash impression [Figure 5].[5],[6] For recording the impression in functional state, labial, buccal and lingual movements were made, for instance pull-in the lips and swallowing movements with mouth closed [Figure 6]. The impression retrieved from the mouth was inspected for any surface irregularities and then disinfected with 2% glutaraldehyde [Figure 7]
  5. Maxillomandibular relations were recorded and mounted on an articulator
  6. Then, mandibular wax occlusal rim was removed and a new custom tray was fabricated with autopolymerizing acrylic resin on which high-fusing compound stops were placed for maintaining the vertical dimension. Orthodontic wire loops were made and embedded in record base to ensure moldability and support for the impression material used to record neutral zone
  7. To record neutral zone, greenstick compound was used and the patient was asked to perform movements such as swallowing, sucking, speaking, sipping water, protruding the tongue several times which simulated physiological functioning [Figure 8]
  8. Two putty indices were fabricated, one on the buccal side and the other on the lingual side till the level of the occlusal plane. Teeth can then be set up exactly following the index [Figure 9]
  9. The trial denture was verified in the patient's mouth and the denture was processed and finished [Figure 10].
Figure 3: Custom tray fabricated with mandibular rests at increased vertical

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Figure 4: Compound blocks used to adjust mandibular rests

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Figure 5: Border moulding completed with All-green technique

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Figure 6: Functional impression made with All-green technique

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Figure 7: Final impression made

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Figure 8: Neutral zone recorded

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Figure 9: Teeth arrangement done

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Figure 10: Final denture

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  Discussion Top

Following on from the diagnostic and preparatory phases of treatment, the impression visits provide the clinician with the opportunity to confirm the diagnosis of oral conditions and, of equal importance, to determine the likely degree of patient compliance to the treatment.[6] A considerable emphasis is placed on impression techniques, as recent studies indicate that flawed impressions account for the majority of denture problems. Two principal points that must always be taken into consideration are – lower impressions tend to be short of the retromolar pads and do not accurately record the functional forms of the floor of the mouth and the retromylohyoid fossae. These deficiencies tend to result in an unstable denture. The importance of recording the form of the floor of the mouth in relation to the mylohyoid muscle and the retromylohyoid fossae cannot be understood.[7]

The basic function of primary impressions for complete dentures is to outline support. A secondary function is to provide the basis of a primary cast on which a customized or special tray is made. The primary purpose of definitive impressions is to record accurately the tissues of the denture-bearing areas, in addition to recording the functional width and depth of the sulci. There is a need for the clinician to determine what type of impression technique is appropriate for each patient as, clearly, the condition of the tissues of the denture-bearing areas and the peri-denture tissues must influence the impression technique selected.[7],[8]

The flat (atrophic) mandibular ridge covered with atrophic mucosa (Atwood's ridge Orders V and VI) is complicated by folds of atrophic and/or nonkeratinized tissue lying on the ridge. McCord and Tyson described this technique which is specific for this clinical situation. The philosophy is that a viscous admix of impression compound and tracing compound removes any soft tissue folds and smoothes them over the mandibular bone; this reduces the potential for discomfort arising from the “atrophic sandwich” that is the creased mucosa lying between the denture base and the mandibular bone. The impression medium here is an admix of three parts by weight of (red) impression compound to seven parts by weight of greenstick; the admix is created by placing the constituents into hot water and kneading with vaselined, gloved fingers. Using a standard impression technique, the lower impression is recorded. The working time of this admix is 1–2 min, and this enables the clinician to mold the peri-tray tissues to give good peripheral molding. On removal, this impression is chilled in water and then re-inserted. The operator presses on the stub handles of the tray on the premolar region and reciprocates with his or her thumbs on the inferior body of the mandible; ideally, discomfort will be felt by the patient in the area pressurized by the operator's thumbs. Any discomfort in the denture-bearing area may be treated by adjusting the offending area of the impression with a heated wax knife and re-inserting as required until no further discomfort is felt. Alternatively, the clinician could indicate where relief is required on the master cast. This technique gives the clinician a reliable guide to the load-bearing potential of the patient's denture-bearing area when making the definitive impression.[7],[9],[10],[11]

Functional impression techniques may be used where problems of stability exist, either because of poor muscle adaptation and/or imbalance or because of problems of available denture space. They may also be useful in patients who have recently suffered from a stroke. Two variations are commonly used for functional impressions – (i) local areas of modification and (ii) anthropoidal pouch technique or neutral zone technique.[8]

As the name suggests, “Cocktail” refers to a blend of various impression techniques to obtain a resultant definitive impression. This method combines the use of dynamic impression technique for fabricating custom trays followed by functional impression using all green technique.[6],[9] In low well-rounded or depressed ridges, not only the stability is compromised, but also there is inability of the residual ridges and its overlying tissues to withstand masticatory loads.[10] All the techniques record the primary and secondary load-bearing areas of the mandible without distorting the underlying tissues of the residual ridge.[11] This technique helped in stabilization of the tray while recording the functional impression which resulted in better reproducibility, retention, and stability of the final prosthesis.[3]

  Conclusion Top

To attain the patient's esthetic and physiological needs, the impression techniques must be modified to gain desired outcome. Moreover, it is an economical and effective way of rehabilitation in a patient with compromised ridges, thereby improving the function. This clinical case report exhibited the specialized impression technique that enhanced retention, stability, and support of the final prosthesis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Takeru K, Keiichi K, Hiroshi E, Ichiro N. Current Perspectives of Residual Ridge Resorption: Pathological Activation of Oral Barrier Osteoclasts. Journal of Prosthodontic Research 2022. 10.2186/jpr.JPR_D_21_00333.  Back to cited text no. 1
Johnson K. A study of the dimensional changes occurring in the maxilla after tooth extraction. Part IV. Interseptal alveolectomy and closed face immediate denture treatment. Aust Dent J 1964;9:312-22.  Back to cited text no. 2
Gugale RR, Mittal R, Sran N, Maheshwari R. Management of atwood class V mandibular ridge using “Dynamic impression technique”: A case report. J Dent Panacea 2021;3:88-92.  Back to cited text no. 3
McCord JF, Tyson KW. A conservative prosthodontic option for the treatment of edentulous patients with atrophic (flat) mandibular ridges. Br Dent J 1997;182:469-72.  Back to cited text no. 4
Tunkiwala A, Ram SA. Management of mandibular poor foundation: Conventional complete dentures. Dent Pract 2013;11:34-7.  Back to cited text no. 5
Praveen G, Gupta S, Agarwal S, Agarwal SK. Cocktail impression technique: A new approach to Atwood's order VI mandibular ridge deformity. J Indian Prosthodont Soc 2011;11:32-5.  Back to cited text no. 6
McCord JF, Grant AA. Impression making. Br Dent J 2000;188:484-92.  Back to cited text no. 7
Beria N, Singh R, Rathod AM, Mistry G, Parab S. Neutral zone concept: A distinctive approach to treat the severely resorbed mandibular ridge: Case report. IOSR J Dent Med Sci 2020;19:32-9.  Back to cited text no. 8
Tryde G, Olsson K, Jensen SA, Cantor R, Tarsetano JJ, Brill N. Dynamic impression methods. J Prosthet Dent 1965;15:1023-34.  Back to cited text no. 9
Kapur KK, Soman SD. Masticatory performance and efficiency in denture wearers. J Prosthet Dent 1964;14:687-94.  Back to cited text no. 10
Atwood DA. Some clinical factors related to rate of resorption of residual ridges. 1962. J Prosthet Dent 2001;86:119-25.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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