Completeden.

tures

Analysis of pressures produced during maxillary

edentulous impression procedures

Richard P. Frank, D.D.S., M.S.D.*

United, States Public Health Service Hospital, New Orleans, La.

impression pressures have been thought to be a primary cause of tissue displace-

ment and, consequently, to be a factor in denture stability, efficiency, and comfort.
Displacement of ridge and palatal tissues is often said to result in denture loose-
ness and tissue irritation. Hence, numerous modifications of impression techniques
have been suggested for control of impression pressures.
A search of the literature, however, revealed little information about pressures
produced during impression making. No study has been conducted to determine
the effect of tray modifications or materials upon impression pressures.
Therefore, the objective of this investigation was to find a method to measure
the pressures exerted upon the edentulous maxillary residual ridge and the palate
during impression procedures. It was necessary to design and to prove the reliability
of instruments capable of measuring these pressures, and to develop a suitable tech-
nique for their use.
The effects of impression tray modifications, various types of materials, and
dentists upon these pressures were also studied, A review of the literature revealed
that impression tray modifications differed widely, and that all were based upon
empirical observations. Materials were compared on the basis of pressure measure-
ments because it has been suggested that some types of materials result in much
higher pressures against the tissues than do other materials. Finally, the manner in
which a dentist makes a final impression may be more important than either the
type of material or the type of tray design used regarding production or reduction
of pressure.
Tray modifications selected for study were the presence or absence of relief space
and/or escape holes. The impression materials investigated were a zinc oxide and
eugenol paste,+ a light-bodied thiokol rubber,$ and an irreversible hydrocolloids of

Read before The Academy of Denture Prosthetics in Honolulu, Hawaii.

*Assistant Chief and Staff Prosthodontist, United States Public Health Service Hospital.
$Coe-flo, Coe Laboratories, Inc., Chicago, Ill.
$Coe-flex, Coe Laboratories, Inc., Chicago, Ill.
SD-P Elastic Impression Cream, Dental Perfection Co., Glendale, Calif.

400
 Impre.s.sion pressures 401

Fig. 1. The surfac :e of the analogue is a soft silicone denture linrr: Molloplast B. Two hc
have been drilled to receive the pressure gauges.

two different powder/water ratios. One ratio was that recommended by the manu-
facturer; the other ratio had 20 per cent more water. Pressures occurring at the com-
pletion of tray seating and at the time of the initial setting of the materials wt:~
measured in the palate and on the crest of the residual ridge.
Because there would have been several variables during intraoral impression polo-
cedures that would have tended to obscure the influence of the various factors upon
the pressures produced, and in order to measure pressures exerted against the mu-
cosal surface, an oral analogue was constructed so that precise measurements in thrl
appropriate locations could be made in the laboratory. For this an average-&et1
maxillary arch was duplicated in acrylic resin having a covering of a soft siliron~~
rubber denture liner, Molloplast B% (Fig. 1) .

MEASURING APPARATUS
A pressure gauge was constructed of brass tubing with one end covered with a
thin flexible rubber membrane and the other end connected to a polyethylene tube
(Fig. 2). The gauge and connecting tubing were filled with distilled water, and the
free end of the tubing was then connected to an unbonded wire strain gauge+
(Fig. 3) .
Pressure applied to the rubber membrane caused water displacement in the
closed system, and the water displacement was converted to an electrical signal b\
the strain gauge. The signal was amplified and recorded by an oscil1ograph.S Cali-
bration of each strain gauge was done before and after each testing session with ;L
mercury manometer.

“Kostner and Company, Oberursel/Taunus, Germany.

+Model P23AA, Statham Instruments, Inc., Los Angeles, Calif.
$Model 150, Sanborn Company, Waltham, Mass.
 J. Pros. Dent.
402 Frank October, 1969

Fig. 2. The pressure gauge consists of rubber membrane A and watertight plug B adapted
to the ends of brass tube C. Metal disk D enables the gauge to be bolted to the analogue E.
Polyethylene tube F connects the gauge to a pressure transducer.

Fig. 3. The pressure transducer consisted of an unbonded wire strain gauge.

VALIDITY OF THE ANALOGUE

The validity of using an analogue was ascertained by comparing the results ob-
tained clinically with those obtained in the laboratory under simulated clinical con-
ditions. For this part of the study, the pressure gauges were mounted on the impres-
sion tray flush with the internal surface of the tray. The subject, whose maxillary
arch the analogue duplicated, was recalled for this test.
The amount of force applied to the tray by the dentist was monitored by an ap-
paratus consisting of a soft, plastic, water-filled tube placed between the tray and an
acrylic resin plate (Fig. 4). Force applied against the acrylic resin plate caused a
 Imjression fbessures 403

Fig. 4. The apparatus under the tray was used to monitor the force applied to the tram.

Fig. 5. The distance water was displaced into the smaller tube indicated the amount of f’o~ce
applied to the tray.

measurable displacement of the water from the tube into a smaller tube lying along-
side a millimeter rule (Fig. 5). The distance the water was displaced into the small
tube indicated the amount of force used. Force was applied to the tray until the sub-
ject indicated that at least one tray stop on each side was completely seated.
Twenty-one irreversible hydrocolloid impressions were made in this mamrer, and
the mean time and amount of force used in seating the tray were computed. The
same procedure was then conducted on the analogue, using the mean time and force
previously determined. The tray stops were found to be seated, and higher forc,es
were recorded in the palatal area than in the ridge crest area when testing both rite,
subject and the analogue. Incomplete seatina of the tray resulted when either the
force or the time of force application was decreased. It was concluded that the ana-
logue was an acceptable substitute for the purposes of this study. The pressure gauges
were then mounted in the analogue flush with the mucosal surface for the remainr!t*r
of the study.
Fig. 6. The motor has been altered by the addition of microswitches A and B, bolt C, nut D,
and keys E.

I Ll ------ u
D

; --;
C
L!i!!L B
A

Fig. 7. The relationship of motor, tray, pressure gauge, and analogue to each other is illus-
trated: A, motor; B, motor shaft; C, threaded shaft extension; D, nut; E, metal tray support;
F, tray seating guide; G, tray; H, analogue; Z, pressure gauge; ,J, analogue support.
Volume 22 Impression p~txures 405
Number 4

Fig. 8. The over-all view of the apparatus.

SEATING THE TRAYS

In order to minimize the variables present during manual seating of an impres-
sion tray, and thus to enable critical comparison of types of trays and materials, a
motor* with an electronic feedback mechanism? added to maintain a constant
speed was used to carry the loaded impression tray to place (Fig. 6) . A nut was
screwed on the threaded shaft, and the nut was prevented from turning with the
shaft by keying the nut in a slot on the motor frame. As the shaft revolved, there-
fore, the nut was raised or lowered, depending on the motor direction. The distance
of travel of the nut was regulated by microswitches so that the degree of seating 01
the tray could be precisely duplicated.
Four brass rods were attached to the periphery of the analogue support parallel
analogue, and a metal plate, centered over the tray by the rods, was attached to
to each other and to the motor shaft. An impression tray was then seated upon the
the outer surface of the tray. The rods thus served as mechanical guides for seating
the tray by the motor. The analogue was then fixed in position above the motor
shaft so that complete seating of the tray coincided with the maximum rise of the
nut on the motor shaft (Fig. 7). A water bath supplied water at body temperature

*Model 4K862, Dayton Electric Manufacturing Company, Chicago, Ill.

tSpeedia1, Lutron Electronics Company, Inc., Emmaus, Pa.
406 Frank J. Pros. Dent.
October, 1969

to soak the analogue prior to making an impression, so that the setting times of the
materials were consistent with those noted intraorally. The entire system is shown
in Fig. 8.

STANDARDIZED TRAYS
A standardized method of construction of individual trays was adopted. A wax
spacer was evenly adapted to a cast of the analogue except in the region of the
posterior palatal seal. An irreversible hydrocolloid impression of the completed
waxed cast was then made, and poured in dental stone. The resultant cast served
as the master cast upon which all trays incorporating relief were constructed. Trays
without relief or stops were all made directly upon a cast of the analogue.

THE IMPRESSIONS
A standard amount of each of the impression materials was used for each impres-
sion. The time used for mixing a material, and for loading a tray, remained constant
during the study.
After pressures had been measured, using trays with and without relief space
and no holes, five escape holes were drilled equidistantly from each other and one
quarter inch from the center of each pressure gauge with a No. 6 round bur. When
testing of these trays was completed, many holes with about the same spacing as
before were drilled throughout the tray.
The final procedure undertaken was manually making impressions of the ana-
logue in a clinical manner to determine the validity of laboratory results. The
analogue was bolted to the roof of a clear plastic box and provided with an environ-
ment similar to that found intraorally regarding temperature and humidity. The
tray design found to be most effective and the one found least effective in reduction
of pressures when seated by the motor were tested. Each of three dentists made four
impressions of the oral analogue with each tray design and with each of the four
impression materials studied. The only instruction for impression making given to
the dentists was to make the impressions in their usual manner.

RESULTS
Analysis of variance was used to statistically evaluate the effect of the variables
on the pressures recorded. Duncan’s multiple range test1 was used to isolate the fac-
tor (s) responsible for the variation found in the analysis. Figs. 9 through 1% illus-
trate the results of the statistical tests.
Initial pressures, mechanically produced. The highest pressures recorded with
any material occurred when neither escape holes nor relief was used. Addition of
relief to the tray resulted in 70 per cent as much pressure, while use of escape holes
yielded 65 per cent as much pressure. Relief and escape holes together in trays re-
sulted in only 45 per cent as much pressure as an unrelieved tray (Fig. 9).
Differences in the amount of pressure received by the palate and ridge crest
areas were not statistically significant with one exception. When trays with no relief
or holes were used, the ridge crest received much more pressure than did the palate
(Fig. 10).
Major differences in pressure production were noted among the materials. The
 Impression pressures 407

5-

I -

O-
Holes Relief Neither Both
Fig. 9. Initial pressures during mechanical tray seating were reduced by the addition of relief
space and/or escape holes to the tray.

0
Ridge Palate Ridge Palate
NO RELIEF RELIEF
Fig. 10. Initial pressures against the crest of the ridge and the palate were nearly identical
when relieved trays were seated mechanically. The ridge crest received much more pressure
than did the palate when unrelieved trays were used.

more viscous mix of irreversible hydrocolloid caused significantly higher pressures

than any other material. The rubber and the thinner mix of irreversible hydrocol.-
loid were not significantly different from each other in pressure production, but did
result in 66 per cent as much pressure as the thicker irreversible hydrocolloid. The
use of the zinc oxide and eugenol paste caused the least pressure: 43 per cent of tha.t
of the thick irreversible hydrocolloid and 65 per cent of that of either the rubber or
the thinner mix of irreversible hydrocolloid (Fig. 11) .
End pressures, mechanically produced. The highest pressures were recorded
when an unrelieved tray was used. The placement of escape holes or relief in the
 J. Pros. Dent.
408 Frank October, 1969

0
Alginate Rubber Alginate Zn OE
(Regular) (Thin)
Fig. 11. Major differences were noted among the materials relative to initial pressures during
mechanical tray seating.

Fig. 12. Adding relief to the tray resulted in much smaller end pressures during mechanical
tray seating.

tray resulted in 16 per cent as much pressure. Combining escape holes with a relief
space resulted in only 5 per cent of the pressure associated with an unrelieved tray
(Fig. 12).
No statistically significant difference in pressure gauge sites relative to the
amount of pressure recorded was found except when an unrelieved tray was used.
Under that condition twice as much pressure was recorded over the ridge crest as
in the palatal vault (Fig. 13) .
Differences in pressures among the materials tested were not pronounced. The
highest pressures were recorded when using rubber or the thicker mix of irreversible
hydrocolloid in trays with no escape holes or relief space, followed by the zinc oxide
and eugenol paste or thinner mix of irreversible hydrocolloid in the same type of
tray. No statistically significant differences among materials were found relative to
Volume 22
Number 4 Imj!ression pressuwr 409

NO RELIEF RELIEF
Fig. 13. Little difference was found between the ridge crest and palatal end pressures during
mechanical tray seating except when an unrelieved tray was used.

NO RELIEF RELIEF
Fig. 14. Significant differences in end pressures among the materials resulted during mc-
chanical seating only when unrelieved trays were used.

pressure when trays with either escape holes, relief space, or both were used. In no
instance did the pressure fall below zero (Fig. 14) .
Initial pressures, manually produced. The pressures caused by the three dentists
ranged from a little less than one half pound per square inch to 4v4 pounds per
square inch. No two dentists produced the same degree of pressure while making
an impression. The same relationship of mean pressures was found with manual
tray seating as before regarding the presence or absence of tray relief and the type
of material, as shown in Figs. 15 and 16.
One of the dentists also made the specified number of impressions with the vari-
 J. Pros. Dent.
410 Frank October. 1969

NO RELIEF RELIEF
Fig. 15. Initial pressures exerted against the palate and the ridge crest during manual tray
seating were nearly the same except when unrelieved trays were used.

(Regular) (Thin)
Fig. 16. The same order of materials ranked by initial pressures was found with trays seated
manually as that found during mechanical tray seating.

ous materials that resulted in no statistically significant difference attributable to

the type of material used. Differences between pressures with the various materials
were more pronounced when the impressions were made by the other two dentists.
End pressures, manually produced. Pressures ranged from a negative one quarter
pound per square inch to a positive 1 pound per square inch. Negative pressures
were often produced by all of the dentists. The negative pressures occurred almost
exclusively while using the relieved trays, and were evenly divided between the ridge
crest gauge and the palatal gauge. Impressions made with the thick irreversible
hydrocolloid, however, seldom resulted in the occurrence of negative pressure.
 Impression pressures 411

1.5 -

1.0 -

;
4.0.5 -

-0.25’ Ridge Palate Ridge Palate

NO RELIEF RELIEF
Fig. 17. The highest end pressures during manually made impressions were found over the
ridge crest when trays with no relief were used. Negative pressures were often recorded while
using trays with relief space and escape holes.

I .5-

l.O-

;
QL
0.5 -

(15%)
Rubber
(Regular) (Thin )
Fig. 18. Differences in end pressures relative to the type of material used were not statistically
significant except for the thick mix of irreversible hydrocolloid during manual seating.

The highest pressures were recorded over the ridge crest while impressions were
made with an unrelieved tray; 54 per cent as much pressure was recorded in the
palate. The differences in pressures between the ridge and palate were not statisci-
tally significant while impressions were made with relieved trays (Fig. 17) .
Two of the dentists produced higher pressures with the unrelieved trays than
with the relieved ones, but the third dentist produced essentially equal pressures
with either type of tray.
No statistically significant differences were seen in pressures relative to the type
of impression material with any of the dentists with one exception. The use of the
412 Frank .I. Pros. Dent.
October, 1969

thick mix of irreversible hydrocolloid resulted in significantly higher pressures for

two of the dentists than did the use of the other materials (Fig. 18).

DISCUSSION
In 1925 Stansbery2 claimed that higher pressures would be found in the region
of the palatal vault than elsewhere when a maxillary impression was made. His
statement was based upon the results seen when impression compound was compressed
between two blocks of plaster, one of which was perforated: a larger amount of
compound was forced into the central perforations than into the peripheral ones.
Douglas, Bates, and Wilson3 mounted a variable capacitance transducer on an
impression tray and measured the forces occurring while intraoral impressions were
made with various brands of zinc oxide and eugenol paste. Forces arising in the
palatal vault area could not be directly compared with those occurring elsewhere
in the arch since one transducer had been located over the center of the palatal
vault in one subject, and over the palatal slope of the ridge in another subject. They
believed that the higher values of impression pressures found in the first subject may
have been due to the more central location of the gauge.
In the present study, a direct comparison of pressures in the ridge and palatal
areas has been possible, and the results in general do not confirm previous beliefs.
Instances in which trays with relief were used showed no statistically significant dif-
ference in pressure against the palate and the ridge crest. Only when trays with no
relief were used was a significant difference in pressures found.
Negative pressures were recorded during impressions made by the dentists, and
were probably due to the dentist inadequately supporting the tray against gravity
while waiting for the initial set of the impression material to occur. Any change in
pressure near the beginning of the initial set due to tray movement could result in
an inaccurate impression.
That tissues covering an edentulous ridge can be displaced by an impression
procedure has been graphically demonstrated by Woelfel.4 Different tissue contours
resulted when impressions were made of one edentulous maxillary arch with five
different materials. Tissue displacement occurred to a variable extent with all ma-
terials, although the largest displacement occurred over the ridge crest when using
the rubber impression material. That finding is consistent with the results of this
study.
A most important aspect of this study has been the finding that pressure can, in
fact, be selectively applied or reduced. Demonstration of the capability of several
methods to alter impression pressures should encourage the dentist to modify his
technique to be more in accordance with the soft tissue conditions presented by each
patient.
It is reasonable to assume a reduction in pressure would result in less displace-
ment of the soft tissue. Reduced pressure would be most likely achieved with the
use of a zinc oxide and eugenol paste material in a tray constructed with relief space
and escape holes, and gently carried to place.
SUMMARY
A method for measuring pressures produced during edentulous impression pro-
cedures has been described. An oral analogue was constructed, and an electric
 Impression pressures 413

motor was used to carry loaded impression trays to place to minimize variables. Im-
pressions of the analogue were then made by dentists in a clinical manner to estab-
lish the validity of the laboratory results. The influence of several impression ma-
terials and tray modifications upon these pressures was determined.

CONCLUSION
It was concluded from this investigation that impression pressures can be con-
trolled by tray design and material selection.

I wish to thank the Educational and Research Foundation of Prosthodontics and the
United States Public Health Service for the generous support given to this study.

References
1. Li, J. C. R.: Introduction to Statistical Inference, Ann Arbor, 1957, Edwards Brothers,
Inc., p. 238.
2. Stansbery, C. J.: The Negative Pressure Method of Impression Taking, J. A. D. A. 12:
438-445, 1925.
3. Douglas, W. H., Bates, J. F., and Wilson, H. J.: A Study of Zinc Oxide-Eugenol Type
Impression Pastes, Brit. D. J. 116: 34-36, 1964.
4. Woelfel, J. B.: Contour Variations in Impressions of One Edentulous Patient, J. PROS.
DENT. 12: 225-254, 1962.

UNITED STATES PUBLXC HEALTH SERVICE HOSPITAL

210 STATE ST.
NEW ORLEANS, LA. 70118