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Effect of adding impression material to mandibular denture
space in Piezography
K. IKEBE, I. OKUNO & T. NOKUBIDivision of Oromaxillofacial Regeneration, Osaka University Graduate School of
Dentistry, 1\u20138 Yamadaoka Suita Osaka, Japan
SUMMARYThe purpose of the study was to examine

the effect of adding impression material on denture space using a piezographical record. Subjects were ten voluntary edentulous patients, aged from 61 to 84 years old. A maxillary trial denture with anterior arti\ufb01cial teeth and a mandibular base plate with a keel were inserted into the oral cavity. Three ml of tissue-conditioning materials was injected on the base plate for each trial. Afterwards, the patients were instructed to pronounce various phonemes, so that tongue, cheeks and lips conformed to the denture space. The impression complexes were cut at the level of the estimated occlusal plane. Occlusal analogues were made by duplicating the impression complexes. Measurements were performed for \ufb01ve analogues from the \ufb01rst to \ufb01fth additions for each subject. The data were compared using analysis of variance (ANOVA), and a Friedman\u2019s test followed

by a Bonferroni test for multiple comparisons with a level of signi\ufb01cance at 5%. At the molar and premolar positions, the bucco-lingual widths of the occlusal table increased signi\ufb01cantly at incremental injection of impression materials from P1 to P4. The midpoints of the analogues were located at a distance of 1.5 mm buccally at the molar position and at a distance of 1.9 mm buccally at the premolar position from the top of the alveolar crest, independent of the addition of impression material. It was concluded that den- ture space was regulated by volume of material and was located slightly on the buccal side fromthe crest of the residual alveolar ridge.

KEYWORDS: complete denture, denture space, pro-
nunciation, polished surface, arti\ufb01cial teeth arrange-
Accepted for publication 10 September 2005

In the past, most patients became edentulous at a suf\ufb01ciently young age that good adaptation to complete dentures was possible, even when the dentures differed from accepted design standards (1). However, recently patients are experiencing tooth loss later in life, when the ability of the patient to develop the neuromuscular skills necessary to wear dentures successfully has already been physiologically reduced. In particular, wearing dentures is often dif\ufb01cult for cases in which the residual ridge is atrophic.

The arrangement of teeth in complete dentures has been based on mechanical principles. The biology and physiology of the stomatognatic muscles surrounding the prosthetic appliance tend not to be considered during various functions (2, 3). The mandibular complete

denture is usually less stable than the maxillary complete denture (1, 4), and several dentists have proposed different techniques for solving this problem (1, 5\u20137).

The neutral zone philosophy is based on the concept of a speci\ufb01c space that is considered to exist for each individual patient, where the tongue forces pressing outward are neutralized by the contraction of lip and cheek muscles pressing inward and where the function of the intra-oral muscles will not dislodge complete dentures (8\u201310).

Piezography, a technique used to record shapes by means of pressure, is a method for recording a patient\u2019s denture space in relation to oral function (11, 12). This method provides a mandibular denture with a piezo- graphically produced lingual surface, which customizes the contour and precludes over-extension (1). This technique involves introduction of a mouldable mater-

\u00aa2006 Blackwell Publishing Ltd
doi: 10.1111/j.1365-2842.2005.01582.x
Journal of Oral Rehabilitation200633; 409\u2013415

ial into the mouth to allow unique shaping by various functional muscle forces. Speech is one function that can be employed as a selected variable using this technique. Heath reported that the recording of denture space morphology varies according to the volume of material used (13).

The purpose of the present study was to examine, through Piezography, the effect of the addition of impression material on the morphology of the man- dibular denture space, as related to both the polished surface and arrangement of arti\ufb01cial teeth of complete dentures.

Materials and methods

Ten volunteer edentulous patients (three males and seven females), ranging in age from 61 to 84 years, were randomly selected from among outpatients of the Osaka University Dental Clinic attached to the Dental School. All patients were free from oral pathologies and compromised medical conditions. Informed consent was obtained from each participant, and the protocol was approved by the Institutional Review Board of the Osaka University Graduate School of Dentistry.

Construction of maxillary complete denture and mandibular
base plate with a keel

One dentist performed all the clinical and laboratory work. Maxillary trial complete dentures were manufac- tured by a conventional method. The maxillary anterior arti\ufb01cial teeth were arranged so as to restore appearance and the ability to produce accurate speech. The appro- priate location and dimensions of the posterior occlusal rims were given to each maxillary trial complete denture beforehand to record the polished surface of mandibular dentures using phonetics. The tentative occlusal plane was made to coincide with the Camper\u2019s plane (14). The palatal form of the denture was obtained by utilizing a palatogram (15). Vertical dimension of occlusion was determined by facial measurement with a Willis Bite Gauge* and use of a vertical dimension of rest and intraocclusal rest space (1, 16).

The mandibular base plate was fabricated from self-
polymerizing resin, and the denture base and bilateral

keels were trimmed. The height of the molar part of the mandibular denture was determined from the estima- ted occlusal plane and occlusal vertical dimension. The keels, made of self-polymerizing resin to hold the impression material, were attached to both the right and left sides of the denture base (Fig. 1). Keels were designed so as not to interfere with oral function.

The shape of the polished surface of dentures was built up as the patients pronounced certain phonemes. Piezography was used to produce the completed man- dibular denture space. First, patients were required to practice the phonemes. Then the maxillary trial denture and the mandibular base plate with keels were inserted

Base plate
Fig. 1.Maxillary wax denture and mandibular base plate with
keels in oral cavity.
Fig. 2.Tissue conditioning material is injected onto mandibular
base plate using a syringe.
*SS White Manufacturing Ltd., Gloucester, UK.
K. IKEBEet al.
\u00aa2006 Blackwell Publishing Ltd,Journal of Oral Rehabilitation33; 409\u2013415

in the oral cavity. Powder and liquid tissue conditioning material\u2020were mixed and immediately injected onto the base plate using a dental impression syringe (Fig. 2). In the present study, the volume of tissue conditioning material injected each time was 3 mL.

The patients were then asked to pronounce various sounds so that tongue, cheeks and lips would conform to the future polished surface of the denture for selected Japanese sounds. The labial sounds [m], [b] and [p], the dental sound [s], and the alveolar sounds [t] and [d] were used in the present study. The patients were instructed to pronounce the sounds repeatedly for 90 s before the material set. The register complex with the base plate, keels and tissue conditioning material was then removed from the oral cavity. The excessive tissue conditioning material was trimmed, and the piezo- graphic record was reinserted into the mouth. Addi- tional tissue conditioning material was injected over the previous register complex, and the patient was asked to repeat the phonemes again in the same way. This further procedure was repeated \ufb01ve times for all patients. The \ufb01nal piezographic records were those obtained in the \ufb01ve further procedures.

These \ufb01ve piezographic records per patient were seated on the working cast, and the investing cores of the buccal and lingual indexes were manufactured from a silicone impression material\u2021in order to enclose and capture the piezographically generated pro\ufb01le. The core indexes were guided to replace with acrylic resin in order to make the experimental analogues. The register complexes were cut at the level of the estimated occlusal plane. Five experimental analogues (P1\u2013P5) were manufactured for each patient (Fig. 3).

The measured points of the molar area were de\ufb01ned using the anterior borders of the retromolar pad as reference points. The points were 10 mm (RM2, LM2), 15 mm (RM1, LM1) and 20 mm (RP, LP) forward from the reference points on both the left and right sides (Fig. 4). In addition, the reference of the midline was determined by a perpendicular line from the incisive papilla toward the occlusal plane.

In this study, a non-contact three-dimensional digit- izer\u00a7was used to measure distances on the occlusal plane of the experimental analogues. The bucco-lingual or labio-lingual width of each point (Fig. 5a) and

discrepancies between the midpoint of the bucco- lingual edge and the anatomical crest of the residual alveolar ridge (Fig. 5b) were measured. In addition, the distance between the left and right sides of the midpoint of the bucco-lingual edge (Fig. 5c) and that between the right and left sides of the lingual edge were measured (Fig. 5d). Measurements were performed for \ufb01ve analogues from the \ufb01rst to \ufb01fth additions for each subject.

Fig. 3.A series of the experimental analogues with acrylic resin
10 mm
5 mm
Anterior borders
of the retromolar pad
5 mm
Fig. 4.Measured points on the occlusal plane. Molar area 2 (M2)

10 mm forward from the anterior borders of the retromolar pads. Molar area 1 (M1) 15 mm forward from the anterior borders of the retromolar pads. Premolar area (P) 20 mm forward from the anterior borders of the retromolar pads. Incisal points (I) incisive papilla.

\u2020Tissue Conditioner; Shofu Inc., Kyoto, Japan.
\u2021Lab Silicone; Shofu Inc.
\u00a7VIVID 700; Minolta Inc., Osaka, Japan.

M A N D I B U L A R D E N T U R E S P A C E I N P I E Z O G R A P H Y 411
\u00aa2006 Blackwell Publishing Ltd,Journal of Oral Rehabilitation33; 409\u2013415

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