Effects of relief space and escape holes on pressure characteristics of maxillary edentulous impressions

Osamu Komiyama, DDS, PhD,a Hiroyuki Saeki, DDS, PhD,b Misao Kawara, DDS, PhD,c Kihei Kobayashi, DDS, PhD,d and Shigeo Otake, DDS, PhDe Nihon University of Dentistry at Matsudo, Matsudo City, Chiba, Japan Statement of problem. The selective pressure technique has been recommended for making impressions of
maxillary edentulous residual ridges. Although various methods for making impressions have been reported, a denitive procedure has not been clearly elucidated. Purpose. This in vitro study evaluated changes in impression pressure produced by different types of relief space and escape holes in the impression tray for making an impression of a simulated maxillary edentulous arch. Material and methods. Silicone impression material (Exadenture) and a maxillary edentulous acrylic cast were used. A miniature pressure sensor was embedded at the mid-palatal suture (point-P) and at the left rst molar area on the edentulous ridge (point-R). Three types of tray relief were used: no spacer (NS), a 0.36-mmthick sheet of wax (SS), or a 1.40-mm-thick base plate wax (BS). Four types of escape holes were made: no hole (NH), or escape holes of 0.5, 1.0, or 2.0 mm in diameter (05H, 10H, and 20H, respectively) in the area opposing point-P. Twelve trays were formed using these relief space and escape hole combinations. The cast and tray were attached to a rheometer for applying a continuous isotonic force of 5.0 kgf and compressive speed of 120 mm/min. Impressions were made and measurement of pressure (kPa) began immediately prior to compression and continued until the materials had polymerized for 2 minutes, with a sampling time of 5 Hz. Measurements were performed 5 times for each tray. The data were analyzed using 3-way analysis of variance and the Bonferroni test (a=.05). Results. At initial pressure, the data obtained at point-P showed signicantly higher values for NSNH, NS05H, SSNH, and SS05H (range: 22.29 6 1.58 kPa to 29.96 6 1.41 kPa) than those at point-R (range: 18.61 6 1.12 kPa to 22.71 6 2.11 kPa). At end pressure, the data obtained from NSNH at point P showed a signicantly higher value (25.36 6 1.69 kPa) than that of point-R (15.36 6 0.99 kPa) (P\.001), whereas data from NS10H and NS20H at point-P showed a signicantly lower value (6.32 6 0.84 kPa and 4.50 6 0.42 kPa) than at point-R (15.50 6 0.49 kPa and 14.98 6 0.88 kPa) (P\.001). The data obtained from SS05H, SS10H, and NS20H at point-P showed signicantly lower values (range: 3.72 6 0.44 kPa to 9.10 6 0.26 kPa) than those at point-R (range: 13.40 6 1.31 kPa to 14.40 6 0.98 kPa). Moreover, the data obtained from BSNH, BS05H, BS10H, and BS20H at point-P showed signicantly lower values (range: 3.24 6 1.96 kPa to 10.20 6 1.84 kPa) than those of point-R (range: 11.69 6 1.01 kPa to 14.04 6 2.08 kPa). Conclusion. For making impressions of an edentulous maxilla, the data suggest that a tray with an escape hole 1.0 mm or larger or a spacer thickness of base plate wax (1.40 mm) be used. (J Prosthet Dent 2004;91:570-6.)

CLINICAL IMPLICATIONS
The results of this in vitro study suggest that when making an impression of an edentulous maxillary arch using the selective pressure technique, optimal pressure can be obtained using a tray with escape holes 1.0 mm or larger or a 1.40-mm thickness of base plate wax as a spacer.

B
a

Assistant Professor, Department of Comprehensive Clinical Dentistry. b Lecturer, Department of Complete Denture Prosthodontics. c Professor and Chair, Department of Comprehensive Clinical Dentistry. d Professor and Head, Department of Complete Denture Prosthodontics. e Professor and Head, Department of Comprehensive Clinical Dentistry.

oucher recommended the use of the selected pressure technique for impressions of edentulous residual ridges.1 The outer surface of the bone in the region of the crest of the maxillary residual ridge is compact in nature, because it is made up of Haversian systems.2 Histologically, compact bone, in combination with the tightly attached mucous membrane, makes the crest of the maxillary residual ridge most suitable to provide primary support for the maxillary denture.3
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Clinicians should take advantage of the nature of this tissue when making denitive impressions.4-6 The soft tissue covering the hard palate varies significantly in consistency and thickness among different locations.7 Anterolaterally, the submucosa of the hard palate contains adipose tissue, and posterolaterally, the submucosa contains glandular tissue. These tissues should be recorded in a resting condition, because when displaced in the impression procedure, these tissues tend to return to their normal form within the completed denture base, creating an unseating force on the denture or soreness.8,9 The submucosa in the region of the median palatal suture of the maxillary bones is extremely thin, and the mucosal layer is almost in contact with the underlying bone.10 Little or no stress should be placed in this region when making denitive impressions.1 Otherwise, the denture may rock over the center of the palate when vertical forces are applied to the articial teeth. In addition, this part of the mouth is highly sensitive,1 and excess pressure can be painful. Due to these variations, the authors recommend selectively placing pressure on the mucous membrane and bone in amounts that are compatible with the histologic tolerances of the supporting tissues for each patient during impression making.11,12 Although various methods for making selective pressure impressions for edentulous patients have been reported, a denitive procedure has not been clearly elucidated.13-15 Minimal pressure impressions16-18 and selective pressure methods, to obtain the support of occlusal pressure,15 have been reported to control pressure to the edentulous ridge. However, success with these techniques varies according to the clinicians experience using different impression materials and tray designs. The question remains as to the amount of force that should be applied when using the selective pressure technique. Frechette19 reported that the load of a denture on the oral mucosa was 50 to 200 kPa during mastication. In addition, Kydd et al9 reported that it took up to 4 hours for the residual ridge to completely recover from a moderate load, approximately 50 kPa, that lasted for 10 minutes. The authors further stated that a small amount of occlusal force (2 kPa) could compress the denture-bearing mucosa to approximately 20% of its thickness at rest. Lindan20 also found that denture-bearing mucosa might be deformed to 95% of its usual thickness at rest when occlusal force was applied. Frank21 simulated and measured impression pressure using trays with 5 escape holes placed equidistant from each other and 0.25 inches from the center of each pressure gauge with a round bur (number 6), along with relief provided by a base plate wax spacer. That tray produced a pressure of 15 to 16 kPa, compared with approximately 29 kPa in trays without holes and relief.
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Rihani22 measured impression pressure in the edentulous maxilla using zinc oxideeugenol paste and suggested that the primary pressure regions during impression making were near the center of the palate and pressure diminished toward the buccal borders. This in vitro study evaluated changes in impression pressure produced by various designs of relief space and escape holes in the impression tray for making an impression of a simulated maxillary edentulous arch.

MATERIAL AND METHODS

A miniature pressure sensor was embedded into a maxillary acrylic resin cast, and the 12 impression trays were formed for each combination of 3 types of relief space and 4 types of escape hole combinations. The cast and tray were attached to a rheometer for applying a continuous compressive isotonic force. Impressions were made with silicone impression material, and measurement of pressure began immediately prior to compression and concluded when the materials had polymerized for 2 minutes.

Edentulous cast
A standard maxillary edentulous acrylic resin cast (G10-402K; Nissin Dental Products Inc, Kyoto, Japan) was used after eliminating the undercut in the anterior labial region. Two measuring points were selected. The rst was at the sagittal mid-point (pointP) on the mid-palatal suture and the second at the left rst molar point of the crest on the edentulous residual ridge (point-R) (Fig. 1). A miniature pressure sensor (PS-1KD; Kyowa Electronic Instruments Co, Tokyo, Japan) was embedded into the cast at these points, so that the surface of the sensor formed a continuous plane with the cast (Fig. 2).

Impression trays
Each impression tray was fabricated with autopolymerizing acrylic resin (Ostron 100; GC Co, Tokyo, Japan) using a conventional method.1 The thickness of the tray at the palatal portion was approximately 3 mm, and the border of the tray was in contact with the cast. Three types of tray relief were used: no wax spacer (NS); sheet wax (No. 28 Sheet Wax; GC Co; 0.36 mm thick) (SS), or base plate wax (Base Plate Wax, GC Co; 1.40 mm thick) (BS). Four types of escape holes were tested: no hole (NH) or escape holes of 0.5, 1.0, or 2.0 mm in diameter (05H, 10H, and 20H, respectively) opposite point-P. Twelve trays were fabricated for each relief space and hole-type combinations. Five measurements were made for each tray, resulting in 60 values (Table I) per group.
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Fig. 2. Simulation cast with rheometer. Two pressure sensors at sagittal center point on mid-palatal suture and at rst molar point of crest on edentulous ridge.

Table I. Abbreviations of tray design used in study Fig. 1. Maxillary edentulous cast and tray. Miniature pressure sensor embedded into cast at sagittal mid-point (point-P) on mid-palatal suture and at rst molar point of crest on edentulous ridge (point-R).
Spacer No spacer (NS) Sheet wax spacer (SS) Base plate wax spacer (BS)
Escape Hole No hole (NH) 0.5-mm hole (05H) 1.0-mm hole (10H) 2.0-mm hole (20H)

NSNH SSNH BSNH

NS05H SS05H BS05H

NS10H SS10H BS10H

NS20H SS20H BS20H

Impression material
Light body silicone impression material (Exadenture, 6.0 g; GC Co) was used for making impressions. The manufacturer purports the setting time of the material to be 120 seconds. A cartridge and dispenser were used to evenly mix and distribute the impression material throughout the tray, taking care to avoid trapping air within the materials.

Statistical analysis
The mean values and SD of impression pressure in each tray were calculated. The effects of the spacers, escape holes, and measuring points on impression pressure were analyzed using 3-way analysis of variance (ANOVA). Simple main effect and multiple comparisons (Bonferroni) were used to test the difference between the values by analysis of 3-way interaction effect (a=.05). All analyses were conducted using a computer software package (SPSS 11.0 for Windows; SPSS, Chicago, Ill).

Compression and measurement

The cast and tray were attached to a rheometer (CR200D; SUN Scientic Co. Ltd, Tokyo, Japan) for application of a continuous isotonic force. For equalization of pressure while compressing the impression materials to the tray, the plane formed by connecting the incisive papilla point with the right and left rst molar points was positioned parallel to the oor. The compression force was set at 5.0 kgf and the press speed at 120 mm/min as reported by Frank.21 Measurement began immediately prior to compression and continued for 2 minutes with a sampling time of 5 Hz. Data obtained from the miniature pressure sensor were calculated using a sensor interface (PCD-300A; Kyowa Electronic Instruments Co) and then recorded on a personal computer (VAIO PCG-FX77; Sony Co, Tokyo, Japan) (Fig. 3). The maximum value immediately after the initial pressure and the value after 120 seconds (end pressure), which allowed the impression pressure to settle after compression, were determined.
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RESULTS
Figure 4 indicates the typical pressure changes using the NSNH and BS20H tray. Immediately after the start of compression, impression pressure increased rapidly, and gradually decreased thereafter. The maximum value immediately after compression (initial pressure) and the value after 120 seconds (end pressure), which allowed the impression pressure to settle after compression, were determined by obtaining continuous data.
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Fig. 3. Measuring system. Edentulous cast was isotonically compressed by tray with impression material using rheometer. Impression pressure was detected by pressure sensor embedded into edentulous cast.

Initial pressure
The data obtained at point-P showed signicantly higher values for NSNH, NS05H, SSNH, and SS05H (29.96 6 1.41 kPa , 25.90 6 0.59 kPa , 26.22 6 1.09 kPa, and 22.29 6 1.58 kPa, respectively) than corresponding values at point-R (22.72 6 2.12 kPa, 21.22 6 1.99 kPa, 21.49 6 1.48 kPa, and 18.61 6 1.12 kPa, respectively) (P\.001). However, similar values were obtained for the other conditions. By altering the escape hole at point-P from NH to 05H, and further to 10H, the impression pressure signicantly decreased from 29.96 6 1.41 kPa to 25.90 6 0.59 kPa and 20.10 6 0.69 kPa, respectively, in the NS group, and from 26.22 6 1.09 kPa to 22.29 6 1.58 kPa and 17.31 6 1.28 kPa, respectively, in the SS group (P\.001). However, there was no signicant reduction between 10H and 20H, and no signicant effect of the escape hole in the BS series. In NH, by altering the spacer from NS to SS, and further to BS, the impression pressure was signicantly reduced from 29.96 6 1.41 kPa to 26.22 6 1.09 kPa and 18.76 kPa, respectively (P\.001). A similar tendency was observed in the 05H series; however, in the 10H and 20H series, there was no signicant difference in pressure associated with altering the spacer. At pointR, no signicant reduction in pressure was associated with changes made to the escape hole and spacers.

Fig. 4. Typical pressure changes using the NSNH and BS20H tray. Immediately after start of compression, impression pressure increased rapidly, and gradually decreased thereafter. Maximum value immediately after compression (initial pressure) and value after 120 seconds (end pressure), which allowed the impression pressure to settle after compression, were determined by obtaining continuous data.

Figure 5, Table II, and Table III show the results of data from each tray design and relief combination at point-P and point-R. Tables IV and V show the results of the ANOVA test. There were signicant 3-way interactions between both initial and end pressure, and these data were analyzed by using simple main effect and multiple comparisons (Bonferroni) to test the difference.
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End pressure
The data obtained from NSNH at point P showed a signicantly higher pressure value (25.36 6 1.69 kPa) than that of point-R (15.36 6 0.99 kPa) (P\.001), whereas data from NS10H and NS20H specimens at point-P showed a signicantly lower pressure value (6.32 6 0.84 kPa and 4.50 6 0.42 kPa) than point-R (15.50 6 0.49 kPa and 14.98 6 0.88 kPa) (P\.001).
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Fig. 5. Measurements data in each tray at point-P and point-R: A, initial pressure, B, end pressure. Initially, impression pressure at point-P (mid-palatal) was higher than or similar to that of point-R (ridge crest). However, end pressure at point-P of tray with escape hole 1.0 or 2.0 mm in diameter and without spacer, tray with escape hole 0.5 mm or greater in diameter with sheet wax spacer, and tray with base plate wax spacer were signicantly lower than that at point-R. (*P\.05, ANOVA).

Table II. Mean and 95% condence interval (lower, upper) of initial pressure (kPa) measurements (n=5) from each tray design and relief combination at sagittal mid-point (point-P) of mid-palatal suture and at left rst molar point of crest on edentulous residual ridge (point-R)
Hole Point Spacer NH 05H 10H 20H

NS SS BS NS SS BS

29.96 26.22 18.76 22.72 21.49 18.91

(28.66, (24.93, (17.46, (21.43, (20.20, (17.62,

31.25) 27.52) 20.05) 24.01) 22.79) 20.21)

25.90 22.29 17.72 21.22 18.61 18.79

(24.61, (21.00, (16.43, (19.93, (17.32, (17.50,

27.18) 23.58) 19.02) 22.51) 19.90) 20.08)

20.10 17.31 17.86 18.66 16.54 17.92

(18.81, (16.02, (16.57, (17.37, (15.25, (16.63,

21.39) 18.60) 19.15) 19.95) 17.83) 19.21)

18.08 15.74 14.95 18.14 16.39 14.75

(16.79, (14.44, (13.66, (16.85, (15.09, (13.46,

19.37) 17.03) 16.24) 19.43) 17.68) 16.05)

The data obtained from SS05H, SS10H, and NS20H specimens at point-P showed signicantly lower values than those at point-R (P\.001). Moreover, the data obtained from BSNH, BS05H, BS10H, and BS20H at point-P showed signicantly lower pressure values than those of point-R (P\.001). By altering the escape hole at point-P from NH, 05H, and further to 10H, impression pressure signicantly decreased from 25.36 6 1.69 kPa to 14.13 6 1.19 kPa and 6.33 6 0.84 kPa, respectively, in the NS groups, and from 13.77 6 1.28 kPa to 9.10 6 0.26 kPa and 5.78 6 1.15 kPa, respectively, in the SS groups (P\.001). However, there was no signicant reduction from 10H to 20H. In the BS groups, a signicant decrease was observed when changed from 05H to 10H (P\.001). Moreover, in NH, by altering the
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spacer from NS to SS, and further to BS, the impression pressure was signicantly reduced from 25.36 6 1.69 kPa to 13.77 6 1.28 kPa and 10.20 6 1.84 kPa, respectively (P\.001). In 05H, a signicant reduction was observed from NS to SS (P\.001); however, in the 10H and 20H series, there was no signicant difference as a result of altering the spacer. As for point-R, no signicant reductions were observed associated with any escape hole and spacer changes.

DISCUSSION
Frank21 simulated and measured impression pressure using trays with 5 escape holes placed equidistant from each other and 0.25 inches from the center of each pressure gauge with a round bur (number 6) along with
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Table III. Mean and 95% condence interval (lower, upper) of end pressure (kPa) measurements (n =5) from each tray design and relief combination at sagittal mid-point (point-P) of mid-palatal suture and at left rst molar point of crest on edentulous residual ridge (point-R)
Hole

Point P

Spacer

NH

05H

10H

20H

NS SS BS NS SS BS

25.36 13.77 10.20 15.36 14.81 13.96

(24.28, 26.45) (12.68, 14.85) (9.12, 11.29) (14.27, 16.45) (13.73, 15.90) (12.88, 15.05)

14.13 9.10 7.94 14.62 14.40 13.95

(13.05, 15.22) (8.02, 10.19) (6.85, 9.02) (13.54, 15.71) (13.31, 15.48) (12.86, 15.03)

6.33 5.78 4.66 15.50 14.40 14.04

(5.24, 7.41) (4.69, 6.86) (3.58, 5.75) (14.42, 16.59) (13.32, 15.49) (12.95, 15.12)

4.50 3.72 3.24 14.98 13.40 11.69

(3.41, 5.58) (2.63, 4.81) (2.15, 4.32) (13.90, 16.07) (12.32, 14.49) (10.60, 12.77)

Table IV. ANOVA table of initial pressure

Type III sum of square Degree of freedom Mean square

Table V. ANOVA table of end pressure

Type III sum of square Degree of freedom Mean square

Source

F value

P value

Source

F value

P value

Point 89.666 Spacer 388.157 Hole 777.773 Point*Spacer 67.244 Point*Hole 74.904 Spacer*Hole 130.928 Point*Spacer*Hole 54.478 Model 1583.151a Error 203.661
a 2

1 2 3 2 3 6 6 23 96

89.666 42.266 194.079 91.483 259.258 122.206 33.622 15.848 24.968 11.769 21.821 10.286 9.080 4.280 68.833 32.446 2.121

.001 .001 .001 .001 .001 .001 .001 .001

R = 0.886.

Point 810.836 Spacer 316.717 Hole 829.673 Point*Spacer 109.036 Point*Hole 625.464 Spacer*Hole 153.573 Point*Spacer* 207.722 Hole Model 3053.022a Error 143.633
a 2

1 2 3 2 3 6 6 23 96

810.836 158.358 276.558 54.518 208.488 25.596 34.620 132.740 1.496

541.937 105.842 184.842 36.438 139.347 17.107 23.139 88.719

.001 .001 .001 .001 .001 .001 .001 .001

R = 0.955.

relief provided by a base plate wax spacer. That tray design produced a pressure of 15 to 16 kPa, compared with approximately 29 kPa for trays without holes and relief. The values of the present experiment are similar, in that initial pressure ranged from 14 to 30 kPa, and end pressure ranged from 3 to 25 kPa, when similar conditions were used. Therefore, it is the authors opinion that loading force and compression speed used in the present experimental system was reasonable. In the present study, it was found that impression pressure was higher at point-P than at point-R, located on the ridge crest, when the tray was completely tted to the edentulous maxilla. Clinically, attempts to decrease or release the pressure include using a spacer or placing escape holes.1 For the trays without a hole or spacer in the present study, both initial pressure and end pressure at point-P were higher than those recorded at point-R. Accordingly, such a tray may not be recommended for making an impression of the edentulous maxilla. As Boucher1 suggested, if it is necessary to apply pressure to the edentulous ridge crest while applying minimal pressure to the palate, a tray with an escape hole of 1.0 mm or larger, or that with a base plate wax-like spacer in the palatal area, should be used. If it is necessary to apply even less pressure to the palate, the concomitant use of
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a spacer and hole, or an increased number of escape holes, may be solutions. With regard to end pressure, pressure concentration at point-P and point-R was reversed by the effects of escape holes and spacers. When impression material is placed in a tray and the cast is compressed, the highest pressure is located in the central area, and pressure gradually decreases in the direction of the periphery.22 This is due to the rheological properties of the impression material, as the internal pressure of the material decreases in the direction of the peripheral area where pressure escapes. The pressure in the center area was decreased by the use of escape holes in the present experiment because the impression material was able to ow out of the center area, and pressure decreased in the direction of the peripheral area and also at the escape hole. Furthermore, the pressure in the central area also decreased by the use of spacers because the impression material owed in the direction of not only the peripheral area but also the space created by the use of the spacer. In the present study, the impression was simulated using silicone impression materials with a standard edentulous cast. However, clinically, the variability of the condition of the residual ridge and impression
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material should also be considered. Furthermore, a rigid acrylic cast is not movable and is different from compressible moist mucosa. The authors speculate that, intraorally, initial pressure is absorbed by the elasticity of the mucosa, producing lower pressure, whereas end pressure may be higher due to the elastic recovery of the mucosa. Although the impression material was mechanically compressed in this experiment, it is questionable whether clinicians make impressions sensing differences between 20 and 30 kPa. Furthermore, the authors speculate that pressure is sufciently applied in the early stage by the use of the hand and ngers, whereas almost no hand pressure is applied in the nal stage. Only 2 sensors were used in this experiment. By increasing the number of sensors, it would be possible to investigate the distribution of impression pressure inuenced by the use of escape holes and spacers. Nevertheless, it appears that a hole placed in the mid-palatal portion of the tray may signicantly alter impression pressure, with a more ideal result. Future studies are needed to investigate how impression pressures vary in accordance with the height and hardness of the edentulous ridge, as well as to investigate a variety of impression materials and impression-making methods.

CONCLUSIONS
Within the limitations of this in vitro study, it was found that initially, mid-palatal impression pressure using a tray with no spacer, a sheet wax spacer and no hole, or an escape hole 0.5 mm in diameter, was signicantly higher (P\.001) than or similar to the pressure at the ridge crest. However, a tray with an escape hole 1.0 or 2.0 mm in diameter and without a spacer, a tray with an escape hole 0.5 mm in diameter with a sheet wax spacer, or a tray with a base plate wax spacer at each mid-palatal point produced end pressures that were signicantly lower than that at the ridge crest (P\.001). Therefore, it is suggested that an escape hole 1.0 mm or larger, or a spacer with the thickness of a sheet of base plate wax, may be used to selectively reduce palatal impression pressure when making an impression of an edentulous maxilla.
REFERENCES
1. Zarb GA, Bolender CL, Eckert SE, Jacob RF, Fenton AH, Mericske-Stern R. Prosthodontic treatment for edentulous patients. 12th ed. St. Louis: Elsevier Science; 2003. p. 211-31. 2. Nanci A, Cate T. Oral Histology. Development, structure, and fundamentals. 5th ed. St. Louis: Mosby; 1998. p. 104-27.

3. Mohl ND, Drinnan AJ. Anatomy and physiology of the edentulous mouth. Dent Clin North Am 1977;21:199-217. 4. Tomlin HR, Wilson HJ, Osborne J. The thickness and hardness of soft tissues. A preliminary clinical survey. Br Dent J 1968;124:223-6. 5. Picton DC, Wills DJ. Viscoelastic properties of the periodontal ligament and mucous membrane. J Prosthet Dent 1978;40:263-72. 6. Inoue K, Wilson HJ. Viscoelastic properties of elastomeric impression materials. I. A method of measuring shear modulus and rigidity during setting. J Oral Rehabil 1978;5:89-94. 7. DuBrul EL. Sicher and DuBruls Oral Anatomy. 8th ed. St. Louis: Ishiyaka EuroAmerica; 1988. p. 161-78. 8. Lytle RB. Soft tissue displacement beneath removable partial and complete denture. J Prosthet Dent 1962;12:34-43. 9. Kydd WL, Daly CH, Nansen D. Variation in the response to mechanical stress of human soft tissues as related to age. J Prosthet Dent 1974;32: 493-500. 10. Watson IB, MacDonald DG. Regional variations in the palatal mucosa of the edentulous mouth. J Prosthet Dent 1983;50:853-9. 11. Atwood DA. Some clinical factors related to rate of resorption of residual ridges. J Prosthet Dent 1962;12:441-50. 12. Ortman HR. Factors of born resorption of the residual ridge. J Prosthet Dent 1962;12:429-40. 13. Felton DA, Cooper LF, Scurria MS. Predictable impression procedures for complete dentures. Dent Clin North Am 1996;40:39-51. 14. Klein IE, Broner AS. Complete denture secondary impression technique to minimize distortion of ridge and border tissues. J Prosthet Dent 1985;54: 660-4. 15. Denen HE. Negative pressure impressions for full dentures. J Am Dent Assoc 1944;31:888-94. 16. Newton JP, Quinn DM, Sturrock KC. An impression procedure for the mobile maxillary residual ridge. Int J Prosthodont 1988;1:245-7. 17. Osborne J. Two impression methods for mobile brous ridges. Br Dent J 1964;117:392-4. 18. Tilton GE. Minimum pressure complete denture impression technique. J Prosthet Dent 1956;6:6-23. 19. Frechette AR. Masticatory forces associated with the use of various types of articial teeth. J Prosthet Dent 1955;5:252-67. 20. Lindan O. Etiology of decubitus ulcers: an experimental study. Arch Phys Med Rehabil 1961;42:774-83. 21. Frank RP. Analysis of pressures produced during maxillary edentulous impression procedures. J Prosthet Dent 1969;22:400-13. 22. Rihani A. Pressures involved in making upper edentulous impressions. J Prosthet Dent 1981;46:610-4. Reprint requests to: DR OSAMU KOMIYAMA DEPARTMENT OF COMPREHENSIVE CLINICAL DENTISTRY NIHON UNIVERSITY SCHOOL OF DENTISTRY AT MATSUDO 2-870-1 SAKAECHO-NISHI, MATSUDO CHIBA 271-8587 JAPAN FAX: 81-47-360-9615 E-MAIL: komiyama@mascat.nihon-u.ac.jp 0022-3913/$30.00 Copyright 2004 by The Editorial Council of The Journal of Prosthetic Dentistry

doi:10.1016/j.prosdent.2004.03.020

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