CLINICAL RESEARCH

The Dimensions of Mandibular Lingual

Tissues Relative to the Placement of a
Lingual Bar Major Connector
Stephen M. Cameron, DDS,1 Gloria T. Torres, DDS,2 Thomas B. Lefler, DMD,3
and M. Harry Parker, DDS, MS4

Purpose: The purpose of this investigation was to measure and describe the lingual tissues of the
anterior mandible to determine the acceptable boundaries of the zone of nonmovable tissue for
placement of a lingual bar and to compare these to existing numerical guidelines.
Materials and Methods: Eighty subjects, grouped by age and gender, with clinically normal
mandibular lingual gingival tissues from second premolar to second premolar were examined. The
lingual sulcular depths (AB) and the distance from the gingival crest to movable tissue of the floor
of the mouth (AC) were recorded. The zone of lingual nonmovable tissue was calculated (AC ⴚ AB)
for each tooth.
Results: For all subjects, the mean value of the probing depth (AB) ranged from 1.22 mm (ⴞ0.33
mm) for central incisors to 1.66 mm (ⴞ0.43 mm) for second premolars. The mean distance from the
gingival crest to movable tissue of the floor of the mouth (AC) ranged from 7.44 mm (ⴞ1.59 mm) for
central incisors to 10.28 mm (ⴞ2.55 mm) for second premolars. The mean height of the lingual
nonmovable tissue (the zone available for the lingual bar; AC ⴚ AB) ranged from 6.22 mm (ⴞ1.59
mm) for central incisors to 8.63 mm (ⴞ2.57 mm) for second premolars. Most subjects presented with
the minimum zone of nonmovable tissue at the central incisors, but with increasing age more
subjects presented with minimum values at the posterior teeth. The multifactorial analysis of
variance (ANOVA) for males’ available nonmovable tissue shows significance for both tooth (p
<0.001) and age (p <0.001) factors. The multifactorial ANOVA for females’ available nonmovable
tissue shows significance for both tooth (p <0.001) and age (p <0.001) factors. Of all subjects, 85%
(88% of males, 83% of females) had 4 mm or more of nonmovable tissue, sufficient for a lingual bar.
The amount of available room decreased in older females.
Conclusion: Within the limits of this study, the use of actual measurements of lingual tissues
versus existing numerical guidelines increased the percentage of patients for which the lingual bar
can be used from approximately 6% to approximately 85%.
J Prosthodont 2002;11:74-80. This is a US government work. There are no restrictions on its use.

INDEX WORDS: major connector, probing depth, gingival tissue, lingual bar

R EMOVABLE PROSTHODONTICS is a disci-

pline that probably suffers more than most
from a lack of evidence-based research. Removable
partial denture (RPD) design reflects this phenom-
enon in a lack of accepted uniform design criteria as
demonstrated by Frantz in 1975.1 Frantz showed 57
dentists identical casts and photographs of a pa-
tient and received 57 different RPD designs.
1
Director, Prosthodontic Residency Program, U.S. Army Dental Ac- In contrast, the single component of RPD design
tivity, Fort Gordon, GA.
2
Staff Prosthodontist, U.S. Army Dental Activity, Fort Bragg, NC.
that appears to enjoy almost universal acceptance
3
Assistant Director, Prosthodontic Residency Program, U.S. Army for selection criteria is the mandibular lingual bar
Dental Activity, Fort Gordon, GA. major connector. The textbooks and articles re-
4
Associate Professor, Department of Oral Rehabilitation, School of viewed recommend the mandibular lingual bar,
Dentistry, Medical College of Georgia, Augusta, GA.
Accepted February 22, 2002.
when possible, because its design offers advantages
Correspondence to: Stephen M. Cameron, DDS, Director, Prosthodon- in hygiene2,3 and comfort.4,5 A recommended bar
tic Residency Program, U.S. Army Dental Activity, Fort Gordon, GA height is 4 mm.6 Over the years, numerous authors
30905-6500. E-mail: stephen.cameron@se.amedd.army.mil have suggested various criteria for space require-
This is a US government work. There are no restrictions on its use.
1059-941X/02/1102-0003$0.00/0
ments for placement of the lingual bar (Table 1).
doi:10.1053/jpro.2002.124359 These recommendations range from just enough

74 Journal of Prosthodontics, Vol 11, No 2 ( June), 2002: pp 74-80

 June 2002, Volume 11, Number 2 75

Table 1. Recommendations for the Amount of Space Required for the Use of the Lingual Bar Mandibular
Major Connector
Author Recommended Distance From Free Gingival Margin (mm)
Davenport7 Adequate space from the gingival crest to the floor of the mouth for height of the bar
Dykema8 At least 1 mm
Miller9 A minimum of 2 to 3 mm
Rudd6 3 mm
Stewart10 3 mm
Bolender11 At least 3 mm
Krol12 At least 3 mm
Stratton13 3 to 4 mm
Renner14 At least 3 to 4 mm
McGivney15 At least 4 mm
Henderson16 4 to 5 mm
Graber17 5 mm optimal but will accept 3 mm
Weinberg18 At least 5 mm
Cecconi19 The bar assumes the shape of the alveololingual fold with the inferior border 9 mm
from the margin
Kratochvil20 Mucogingival junction to the floor of the mouth

room to fit the bar between the gingival crest
and the floor of the mouth7 to at least 5 mm
from the gingival crest to the superior border
of the bar.17,18 Kratochvil20 is unique in sug-
gesting using the mucogingival line as the
guideline for placing the superior border of the
bar. Combining this suggestion with the results
of Voigt et al21 would result in placements in
the 3- to 5-mm range from second premolar to
second premolar, with dramatically increasing
distances in the molar region.
The purpose of this investigation was to measure
and describe the lingual tissues of the anterior
mandible to determine the boundaries of the zone
of nonmovable tissue that are acceptable for place-
ment of a lingual bar and to compare these with
clinical recommendations in the literature.
Material and Methods
Eighty subjects with clinically normal gingival tissues
were examined. These were patients with a Löe’s gingival
index score of 0 or 1 and no history of orthodontics for the
mandibular arch and with a minimum of 8 teeth from
second mandibular premolar to second mandibular pre-
molar. Four age groups were examined: 20 to 29, 30 to 39,
40 to 49, and 50 and older.
The tissues were measured using a UNC-15 peri-
odontal probe (93771; Hu-Friedy, Chicago, IL) with
increments of 1 mm. Two measurements were made
for each tooth from second premolar to second pre-
molar (Fig 1A). The first measurement (AB) was the
depth of the gingival sulcus at the most apical point
of the free gingival margin. The second measure-
ment (AC) was from the most apical point of the free
gingival margin to the highest point of the movable
tissue of the floor of the mouth within the interpap-
illar region (DE) of the tooth (Fig 1B). The amount
of nonmovable tissue present was calculated by sub-
tracting the first measurement from the second
(AC ⫺ AB). The tissue height was scored as x.0 mm
if the tissue touched or nearly touched the mm
marker line on the probe and as x.5 mm if the tissue
was between the marks. One clinician (G.T.T.) made
all of the measurements. To evaluate intraoperator
consistency, the clinician first measured 10 subjects
and then 1 week later blindly remeasured the same
subjects. Consistency was demonstrated with a ␬
value of 0.89.
The data were analyzed with a computer statistics
program (SPSS 7.5; SPSS, Chicago, IL). Values are sum-
marized by means and standard deviations (SDs). Multi-
factorial analysis of variance (ANOVA) was used to com-
pare the amount of nonmovable tissue for 3 factors: tooth
location, gender, and age group. If the p value for the F
test for an effect was ⬍0.05, then comparisons were
evaluated using Fisher’s protected least significant differ-
ence (PLSD) test. All calculated p values were 2-sided,
and p values ⬍0.05 were considered statistically signifi-
cant.
Results
The means and SDs of AB, AC, and AC minus AB
for each tooth group are presented in Table 2.
These values are for both genders and all 4 age
groups. Central incisors have the smallest mean
value for available nonmovable tissue.
For each patient, the tooth group with the min-
imum value of available nonmovable tissue was
76 Gingival Tissues and Lingual Bars ● Cameron et al

Figure 1. (A) Two measure-

ments of the lingual tissues
were made clinically: sulcular
depth at the most apical area
of the free gingival margin
(AB) and distance to the
highest point of the movable
tissue of the floor of the
mouth (AC). (B) The mea-
surement AC was made from
the most apical area of the
free gingival margin to the
highest point of the movable
tissue of the floor of the
mouth within the entire in-
terpapillar area (DE).

determined. These values were counted by tooth
location and age group as shown in Table 3. More
incisors than other tooth groups had the least
amount of nonmovable tissue for all age groups, but
with increasing age, more minimum values were
found with posterior teeth. Figure 2 graphically
shows the mean values of the available nonmovable
tissue (AC ⫺ AB), with error bars representing the
95% confidence interval, for both males and fe-
males for each individual tooth for all age groups. A
right–left symmetry is seen in both males and fe-
males.
The effect of 3 factors (tooth, gender, and age)
on the available nonmovable tissue was evaluated
with a multifactorial ANOVA (SPSS 7.5). Because
of a higher-order interaction between gender and
age (p ⬍0.001), males and females were evaluated
separately.

Table 2. Mean Values (in Millimeters) and Standard Deviations (in Parentheses) of the Measurements
Tooth Group AB AC AC-AB
Central incisors 1.22 (0.33) 7.44 (1.59) 6.22 (1.58)
Lateral incisors 1.23 (0.33) 7.67 (1.87) 6.44 (1.88)
Canines 1.28 (0.34) 8.49 (2.28) 7.20 (2.28)
First premolars 1.59 (0.44) 9.75 (2.51) 8.16 (2.54)
Second premolars 1.66 (0.43) 10.28 (2.55) 8.63 (2.57)
 June 2002, Volume 11, Number 2 77

Table 3. Tooth Group With the Minimum Value of Available Attached Tissue Counted by Tooth Location
and Age Group
Age Groups
Number of Teeth for
Each Tooth Group 20s 30s 40s ⱖ50 Total
Centrals 11 8 7 4 30
Laterals 7 7 7 7 28
Canines 2 4 4 5 15
First premolars 1 1 1 3
Second premolars 1 3 4
Number of subjects 20 20 20 20 80

Males (p ⫽ 0.98) and significance for both tooth (p

⬍0.001) and age (p ⬍0.001) factors. The relation is
The multifactorial ANOVA for males’ available
shown graphically in Fig 4, with the available non-
nonmovable tissue shows no significant higher-or-
movable tissue increasing to the posterior for all
der interactions between the tooth and age groups
age groups, but more so for the younger age groups.
(p ⫽ 0.999) and significance for both tooth (p
Central incisors have the least average available
⬍0.001) and age (p ⬍0.001) factors. The relation is
nonmovable tissue. For age, the PLSD post hoc test
shown graphically in Fig 3, with the available non-
showed that all groups were significantly different
movable tissue increasing to the posterior for all
from all other age groups (p ⬍0.001), except for the
age groups, with central incisors having the least. In
30 to 39 and 40 to 49 groups, who showed no
terms of age, the PLSD post hoc test showed that
significant difference from each other (p ⫽ 0.880).
only the 40 to 49 group was significantly different
from all other age groups (p ⬍0.001).
Percent Acceptable
Females
In each subject, the maximum height of the bar is
The multifactorial ANOVA for females’ available limited by the minimum available nonmovable tis-
nonmovable tissue shows no significant higher or- sue space, which is usually found at the central
der interactions between the tooth and age groups incisors. The percentage of subjects that have suf-

Figure 2. The mean values

(in mm) of nonmovable tis-
sues by tooth and gender.
A right-to-left symmetry is
seen.
78 Gingival Tissues and Lingual Bars ●
ficient nonmovable tissue for a 4-mm lingual bar
can be determined from a cumulative frequency
diagram by selecting and looking only at the mini-
mum available space for each subject (Table 4).
Here, 15% of the subjects had less than 4 mm of
available nonmovable tissue, inadequate for a lin-
gual bar. The remaining 85% had 4 mm or more of
nonmovable tissue, sufficient for a lingual bar.
Figure 4. The mean values
(in mm) of nonmovable tis-
sues for females by tooth and
age group.
Cameron et al
Figure 3. The mean values
(in mm) of nonmovable tis-
sues for males by tooth and
age group.
Selecting groups by gender and age group
and repeating the frequency diagram for the
minimum value for each patient allows the
percentage of subjects that have sufficient
room for a lingual bar to be determined for
each combination (Table 5). The results
showed that 88% of the males and 83% of the
females had 4 mm or more of nonmovable
 June 2002, Volume 11, Number 2 79

Table 4. Cumulative Frequency Diagram of the Table 6. Cumulative Frequency Diagram of the
Minimum Nonmovable Tissue Height Minimum Available Space From the Gingival Crest to
the Floor of the Mouth for Each Subject
Minimum Available Tissue Cumulative Number of
(AC-AB) per Patient (mm) Percent Subjects Available Tissue
(AC) per Patient Cumulative Number of
1.5 1.25 I (mm) Percent Subjects
2.0 2.50 I
2.5 6.25 III 3.5 1.25 I
3.0 7.50 I 4.0 6.25 IIII
3.5 15.00 IIIIII 4.5 7.50 I
4.0 25.00 IIIIIIII 5.0 22.50 IIIIIIIIIIII
4.5 33.75 IIIIIII 5.5 26.25 III
5.0 46.25 IIIIIIIIII 6.0 43.75 IIIIIIIIIIIIII
5.5 55.00 IIIIIII 6.5 51.25 IIIIII
6.0 66.25 IIIIIIIII 7.0 60.00 IIIIIII
6.5 81.25 IIIIIIIIIIII 7.5 67.50 IIIIII
7.0 86.25 IIII 8.0 82.50 IIIIIIIIIIII
7.5 91.25 IIII 8.5 85.00 II
8.0 93.75 II 9.0 93.75 IIIIIII
8.5 96.25 II 9.5 95.00 I
9.0 98.75 II 10.0 97.50 II
11.0 100.00 I 11.0 98.75 I
12.5 100.00 I
NOTE: The cumulative frequency diagram of the minimum
available space for each subject shows that approximately 15% of
the patients had less than 4 mm of available nonmovable tissue.
The remaining 85% had 4 mm or more of nonmovable tissue,
sufficient for a lingual bar. surgically interfere with a gingival crevice of 3 mm.
Therefore, it seems logical to place the superior
tissue, sufficient for a lingual bar. The amount border of a lingual bar as far below marginal peri-
of available room decreased for the older fe- odontal structures as possible to avoid their im-
males. pingement. Unless an adequate space for a rigid
bar exists between the measured alveolar lingual
sulcus and a line 4 to 5 mm inferior to free gingival
Discussion margins, we must resort to the linguoplate.”16
The average dimensions of gingival tissues have Adding the usual height of a 4 mm lingual bar to
been described previously21,22 but not relative to the Henderson’s required 4 to 5 mm of space from the
use of mandibular major connectors. The data ob- free gingival margin would require his patients to
tained in this study for gingival sulcus depth agrees have a minimum of 8 to 9 mm of space to use a
well with the findings of Gargiulo et al22 and dem- lingual bar. This corresponds to our AC measure-
onstrate that using average figures for sulcular ment. Looking at the cumulative frequency dia-
depth can be misleading. gram (Table 6) of the minimum available space
Of the text books and journal articles reviewed, from the free gingival margin to the floor of the
only Henderson16 gave a rationale for his recom- mouth (AC), we see that based on Henderson’s
mendation to keep the superior border of the lin- 4-mm standard (a total of 8 mm with the bar), only
gual bar 4 to 5 mm from the free gingival crest. He 17.5% of the sample population is capable of using
stated that “the healthy free gingival crevice is said the lingual bar. Using the 5-mm standard (a total of
to be about 2 mm deep. Few periodontists would 9 mm with the lingual bar), only 6.25% of our
sample population is capable of using the lingual
bar. This is in stark contrast to the 85% of our
Table 5. Percentage of Subjects by Age Group With a sample population deemed capable of using a lin-
Sufficient Zone of Tissue for a 4-mm Lingual Bar
gual bar when the actual gingival tissues are mea-
Age Group Males Females sured. The recommendation of Graber17 that 3 mm
of lingual bar height is adequate when chrome
20s 90% 100%
30s 90% 90% alloys are used would allow 93.75% of our sample
40s 70% 90% population to use the lingual bar.
50s 100% 50% Obversely, using the assumption of Davenport7
All 88% 83%
of placing the superior margin of the bar at the
80 Gingival Tissues and Lingual Bars ●
gingival crest would also allow its use 93.75% of the
time. However, this could result in gingival irrita-
tion, as described by Bissada et al2 and Orr et al,3
for a small percentage of these patients.
Conclusion
Within the limits of this study, the use of actual
measurements of the lingual tissues as compared
with clinical recommendations in the literature in-
creased the percentage of patients for which the
lingual bar can be used from approximately 6% to
approximately 85%.
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