Journal of Oral Rehabilitation 2006 33; 409–415
Effect of adding impression material to mandibular denture
space in Piezography
K. IKEBE, I. OKUNO & T. NOKUBI Division of Oromaxillofacial Regeneration, Osaka University Graduate School of
Dentistry, 1–8 Yamadaoka Suita Osaka, Japan
SUMMARY The 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
artificial 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 five
analogues from the first to fifth additions for each
subject. The data were compared using analysis of
variance (ANOVA), and a Friedman’s test followed
Introduction
In the past, most patients became edentulous at a
sufficiently 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 difficult 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
ª 2006 Blackwell Publishing Ltd
by a Bonferroni test for multiple comparisons with a
level of significance at 5%. At the molar and premolar
positions, the bucco-lingual widths of the occlusal
table increased significantly 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 from the crest
of the residual alveolar ridge.
KEYWORDS: complete denture, denture space, pro-
nunciation, polished surface, artificial teeth arrange-
ment
Accepted for publication 10 September 2005
denture is usually less stable than the maxillary complete
denture (1, 4), and several dentists have proposed
different techniques for solving this problem (1, 5–7).
The neutral zone philosophy is based on the concept
of a specific 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 (8–10).
Piezography, a technique used to record shapes by
means of pressure, is a method for recording a patient’s
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-
doi: 10.1111/j.1365-2842.2005.01582.x
410 K . I K E B E et al.

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 artificial teeth of complete
dentures.
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

Materials and methods

Subjects

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 Keel Base plate Keel
Osaka University Graduate School of Dentistry.

Fig. 1. Maxillary wax denture and mandibular base plate with

Construction of maxillary complete denture and mandibular keels in oral cavity.
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
artificial 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’s 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
Fig. 2. Tissue conditioning material is injected onto mandibular
*SS White Manufacturing Ltd., Gloucester, UK. base plate using a syringe.

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 409–415

 MANDIBULAR DENTURE SPACE IN PIEZOGRAPHY 411

in the oral cavity. Powder and liquid tissue conditioning

material† were mixed and immediately injected onto
the base plate using a dental impression syringe P1
(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 P2
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 P3
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 P4
then removed from the oral cavity. The excessive tissue
conditioning material was trimmed, and the piezo-
graphic record was reinserted into the mouth. Addi-
P5
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 five times for all Fig. 3. A series of the experimental analogues with acrylic resin
patients. The final piezographic records were those (P1–P5).
obtained in the five further procedures.
These five piezographic records per patient were
seated on the working cast, and the investing cores of
the buccal and lingual indexes were manufactured from Anterior borders
of the retromolar pad
a silicone impression material‡ in order to enclose and 10 mm
capture the piezographically generated profile. The core RM2 LM2
5 mm
indexes were guided to replace with acrylic resin in RM1 LM1
5 mm
RP LP
order to make the experimental analogues. The register
complexes were cut at the level of the estimated
occlusal plane. Five experimental analogues (P1–P5)
I
were manufactured for each patient (Fig. 3). Midline
The measured points of the molar area were defined
Fig. 4. Measured points on the occlusal plane. Molar area 2 (M2)
using the anterior borders of the retromolar pad as 10 mm forward from the anterior borders of the retromolar pads.
reference points. The points were 10 mm (RM2, LM2), Molar area 1 (M1) 15 mm forward from the anterior borders of
15 mm (RM1, LM1) and 20 mm (RP, LP) forward from the retromolar pads. Premolar area (P) 20 mm forward from the
the reference points on both the left and right sides anterior borders of the retromolar pads. Incisal points (I) incisive
(Fig. 4). In addition, the reference of the midline was papilla.

determined by a perpendicular line from the incisive

papilla toward the occlusal plane.
In this study, a non-contact three-dimensional digit-
izer§ was 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
†
Tissue Conditioner; Shofu Inc., Kyoto, Japan.
‡
Lab Silicone; Shofu Inc.
§
VIVID 700; Minolta Inc., Osaka, Japan.
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 five analogues from the first to fifth additions for
each subject.

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412 K . I K E B E et al.

(a) (b)
Buccolingual center of the denture space
on the occlusal table

Anatomical crest of
RM2 LM2 residual alveolar ridge
RM1 LM1
RP LP
Fig. 5. Measured items on the
occlusal plane. (a) Bucco-lingual or
labio-lingual width of each point.
Frontal aspects (b) Discrepancy between the
I
midpoint of the bucco-lingual width
of the recorded occlusal table and the
(c) (d)
anatomical crest of the residual
alveolar ridge. (c) Distance between
left and right sides of the midpoint of
RM2 LM2 RM2 LM2 the bucco-lingual width of the
RM1 LM1 RM1 LM1 recorded occlusal table. (d) Distance
RP LP RP LP
between left and right sides of the
lingual edge of the recorded occlusal
table.

The data analyses were performed using SPSS 13Æ0 Right side Left side
for Windows¶. The data were compared using an (mm) (mm)
10 10
analysis of variance (ANOVA), and Friedman’s test
Bucco-lingual width

Bucco-lingual width
8 8
followed by a Bonferroni test for multiple comparisons
6 6
with a level of significance at 5%.
4 4
2 2
Results 0 0
RM2 RM1 RP LP LM1 LM2
Measured points
Bucco-lingual or labio-lingual width of occlusal plane P1 P2 P3 P4 P5

In the molar area (M2 and M1), the mean of the Fig. 6. Bucco-lingual width of molar area (mean and standard
bucco-lingual widths on the occlusal plane was 3Æ2 mm deviation).
for P1. The mean increased significantly with each
impression material addition to reach 7Æ2–8Æ8 mm, (mm)
whereas the width of P5 showed no significant
difference from that of P4 (Fig. 6). In the premolar
4
area (P), the mean of the bucco-lingual widths of the
Labio-lingual width

occlusal plane also increased significantly from P1

(2Æ5 mm) to P4 (7Æ0 mm) with each addition, whereas
that of P5 showed no significant difference from that
2
of P4.
In the incisal area, as six of the ten cases did not
reach the estimated occlusal plane in P1, the labio-
lingual widths from P2 to P5 were measured and
0
compared. Consequently, there was no significant
Measured points
difference in width among the experimental analogues
P2 P3 P4 P5
(Fig. 7).
Fig. 7. Labio-lingual width of incisal area (mean and standard
¶
SPSS Inc., Chicago, IL, USA. deviation).

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 409–415

 MANDIBULAR DENTURE SPACE IN PIEZOGRAPHY 413

Right side Left side

RM2 LM2

Measured points
P1 P1
P2 P2
P3 RM1 LM1 P3
P4 P4
P5 P5

RP LP

Fig. 8. Discrepancy between the 3 2 1 0 0 1 2 3

midpoint of the bucco-lingual width Distance (mm) Anatomical Anatomical Distance (mm)
of the recorded occlusal table and the alveolar ridge alveolar ridge
crest of the alveolar ridge (mean and Buccal Lingual Buccal
standard deviation). side side side

Discrepancy between the midpoint of the bucco-lingual edge (mm)

and the crest of the alveolar ridge on the occlusal plane 60

Compared with the top of the alveolar crest, the 50

midpoints of the bucco-lingual edge on the occlusal 40
Distance

plane were located 1Æ5 mm buccally on average at both

30
M2 and M1 and 1Æ9 mm buccally in all cases at point P
(Fig. 8). However, for the same measurement points, 20
no significant discrepancy was found among the 10
experimental analogues from P1 to P5.
0
M2 M1 P
Measured points
Distance between right and left sides of the midpoints of the P1 P2 P3 P4 P5
bucco-lingual edges of the occlusal plane
Fig. 9. Distance between right and left sides of the midpoints of
At each measurement point, the distances between the the bucco-lingual width of the recorded occlusal table (mean and
left and right sides of the midpoint of the bucco-lingual standard deviation).
edge (Fig. 9) were quite consistent (50 mm at M2,
48 mm at M1, and 40 mm at P) even if the number of (mm)
impression material additions was increased, and no 60
significant difference was found among any of the
50
registers of P1–P5.
40
Distance

Distance between right and left sides of the lingual edge 30

of occlusal plane 20

Distances between the right and left sides of the lingual 10

edge of the occlusal plane (Fig. 10), i.e. the width of 0
tongue space, at M2, M1 and P, decreased significantly M2 M1 P
Measured points
from P1 (42, 40 and 37 mm respectively) to P4 (47, 42
P1 P2 P3 P4 P5
and 39 mm respectively) with the addition of impres-
sion material, whereas that of P5 showed no significant Fig. 10. Distance between right and left sides of the lingual edge
difference from that of P4. of the recorded occlusal table (mean and standard deviation).

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 409–415

414 K . I K E B E et al.
Discussion
Regarding complete denture treatment, several meth-
ods that take physiological function into account have
been developed since the 1930s. These studies have
clarified that the bucco-lingual tooth position and the
contour of the polished surface are important for
denture retention and stability (2, 17). Fahmy and
Kharat reported that artificial teeth were arranged over
the center of the alveolar ridges in conventional
dentures, which was found to be better for mastication.
However, all of the participants in their study expressed
a definite sense of superior comfort and speech ability
with the neutral zone denture and selected the neutral
zone denture over the conventional one (6).
Positioning artificial teeth in the neutral zone has two
objectives. First, the teeth will not interfere with
normal muscle function, and second, the forces exerted
by the musculature against the dentures are more
favourable for stability and retention (8).
In this study, Piezography (1) was used to record
denture space by means of the speech function of each
patient. There are several advantages to using speech
for recording the denture space, e.g. the patients can
practice before the impression is taken; the procedure is
easy to understand, especially for the elderly; it is easy
to inspect for proper oral function while the patients
pronounce the phonemes.
However, it remains unclear exactly when the
procedure for obtaining the piezographic record is
complete. For example, in the flange technique (2, 3),
recording of the denture space is complete when the
resoftened flange wax no longer flows toward the
occlusal surface of the occlusal rims. The recording of
denture space morphology has been reported to vary
according to the volume of the material used (1, 13).
In order to address this volumetric variable, a slowly
setting gel, such as tissue conditioning material, was
used. Tissue conditioner** is a soft material used
originally in the conditioning of denture bearing
tissue and in dynamic impression (18). The use of
Tissue Conditioner** for Piezography is advantageous
because it has a suitable viscoelastic property and
setting time and can be injected gradually over several
applications. With regard to initial flow of Tissue
Conditioner, the widths of the rheometer trace at
**Shofu Inc.
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 409–415
37
C are approximately 70% at 3 min and 20% at
15 min (19).
In this study, the impression material was injected
into the oral cavity several times in order to determine
the suitable denture space. To date, the volume and
number of additions of impression materials have not
been clarified. The present study examined the effect of
incremental injections of impression material on the
resultant denture space. At the molar and premolar
positions, the bucco-lingual widths of the experimental
analogues increased significantly with each impression
material addition of 3 mL from the first to the fourth
trial, 12 mL in total.
In this study, except for the bucco-lingual width of
the occlusal table, which increased significantly with
incremental injections of impression material, the rest
of the resultant morphology of the denture space is
believed to be repeatable despite additional introduc-
tions of impression material.
The bucco-lingual widths of commercially available
acrylic resin teeth of the first molar range from 7Æ7 to
9Æ0 mm, and therefore some of the bucco-lingual
widths are larger than the width of the denture space
determined at point M1 in this study. In these cases,
dentists have to select smaller commercially available
teeth, grind the buccal and/or lingual surface, or make
customized teeth to replace artificial teeth in order not
to disturb the function of the removable dentures.
The bucco-lingual center of the occlusal table
obtained by Piezography in this study was located
slightly to the buccal of the residual alveolar ridge.
Morikawa et al. reported that the centerline of the
neutral zone was located 1Æ9 mm to the buccal side of
the alveolar crest (20). Fahmi stated that the longer the
period of edentulousness, the more buccally located the
neutral zone was from the crest of the alveolar ridge
(21). The present results are in agreement with these
previous reports.
The distance between the left and right sides of the
center of the occlusal surface of the experimental
analogue was approximately the same, independent
of the number of recordings, while the width of the
tongue space decreased gradually. This result indicates
that the recorded denture space was expanded both
buccally and lingually, because muscle pressure might
be recorded equally and the horizontal center of the
recorded space was consistent at the occlusal plane in
the different records compared to the horizontal loca-
tion of the crest of the residual ridge.
 MANDIBULAR DENTURE SPACE IN PIEZOGRAPHY
Conclusions
We examined the effect of the addition of an impression
material on the morphology of the mandibular denture
space by a piezographic technique, as related to both
the polished surface and artificial teeth arrangement
of complete dentures. The denture space was regulated
by volume of material. The horizontal center of the
recorded space at the occlusal plane was located slightly
on the buccal side compared with the horizontal
location of the crest of the residual alveolar ridge,
however, it was consistent in the different records.
Acknowledgments
We greatly appreciate the grammatical correction of the
manuscript by Joanne Madsen, MA. We are especially
grateful to Professor Susumu Nisizaki, Faculty of
Dentistry, University of Uruguay for commenting and
advising on the manuscript. This research was sup-
ported by a Grant-in-Aid for Scientific Research (No.
16390555 and No. 17791388) from Japan Society for
the Promotion of Science.
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Correspondence: Kazunori Ikebe, DDS, PhD, Assistant Professor,
Division of Oromaxillofacial Regeneration, Osaka University Graduate
School of Dentistry, 1-8 Yamadaoka Suita, Osaka, 565-0871, Japan.
E-mail: ikebe@dent.osaka-u.ac.jp