A contemporary review of the factors involved in

complete dentures. Part II: Stability

T. E. Jacobson, D.D.S.,* and A. J. Krol, D.D.S.**
University of California, School of Dentistry, San Francisco, Calif., and Veterans Administration Medical Center,
San Frankco, Calif.
C omplete denture stability is the resistance to
horizontal or rotational forces. It differs from retention
in that stability resists forces in the horizontal plane
whereas retention is the resistance to vertical dislodging
forces. As described in Part I, stability ensures the
physiologic comfort of the patient while retention
contributes to psychologic comfort. The lack of stability
often makes ineffective the factors involved in retention
and support. A denture that shifts easily in response to
laterally applied forces can cause a disruption in the
border seal or prevent the denture base from correctly
relating to the supporting tissues. The factors that
contribute to stability include ridge height and confor-
mation, base adaptation, residual ridge relationships,
occlusal harmony, and neuromuscular control. These
factors can be condensed into the following cate-
gories:
1. The relationship of the denture base to the
underlying tissues
2. The relationship of the external surface and
border to the surrounding orofacial musculature
3. The relationship of the opposing occlusal sur-
faces
RELATIONSHIP OF DENTURE BASE
TO TISSUES
The relationship of the intaglio of the denture base
to the underlying tissues is dependent on the impres-
sion procedures of the clinician. The section on support
demonstrates the significance of this relationship as it
pertains to the tissues that provide resistance to vertical
forces directed toward the residual ridge. This relation-
ship also contributes to denture stability.
Friedman describes the contacting of the labial and
buccal flanges with the labial and buccal ridge slopes as
critical factors contributing to stability. Adequate
extension of the denture border as limited by movable
*Assistant Clinical Professor, Removable Prosthodontics.
**Chief of Dental Services, Removable Prosthodontics.
THE JOURNAL OF PROSTHETIC DENTISTRY
tissues not only allows the establishment of border seal
and coverage of maximum supporting area but also
provides maximum contact of the denture base with
facial and lingual ridge slopes.
The nature of the overlying soft tissues determines
the potential of a given region in tolerating stress.
While the tissues of the maxillary palatal inclines are
ideally designed to resist forces of the denture base, thi
maxillary facial and mandibular lingual inclines may
be less effective due to the thin alveolar mucosal
covering.
Optimal denture stability requires that those tissues
that provide resistance to horizontal forces be properly
recorded and related to the denture base. Boucher2
notes that stability is obtained by incorporating the
surfaces of the maxillary and mandibular ridges, which
are at right an.gle to the occlusal plane. He further
states that stability requires maximum use of all bony
foundations where the tissues are firmly and closely
attached to bone.3 Positive and intimate contact of the
denture base with these inclines as limited by the
nature of the overlying soft tissues determines the
degree of stability attained.
MANDIBULAR LINGUAL FLANGE
The most desirable feature of the lingual slope of the
mandible is that it approaches 90 degrees to the
occlusal plane. This enables it to effectively resist
horizontal forces. The posterior lingual flange is usual-
ly able to be extended inferiorly more than the anterior
lingual flange. Although the posterior fibers of the
mylohyoid muscle attach more superiorly on the man-
dible, they descend nearly vertically to attach to the
hyoid bone. Even when contracted, the muscle fibers
extend medioinferiorly, allowing the posterior flange to
extend to or beyond the mylohyoid ridge. Anteriorly,
the mylohyoid muscle fibers are directed more horizon-
tally to communicate with fibers of the opposite side
along a midline tendinous raphe. When cu>ntracted, the
anterior mylohyoid muscle tenses the floor or the
mouth and limits the extension of the more anterior
165
JACOBSON AND KROL
i @ Post. Ant.
/
Fig. 1. Waxed anatomic model, A, and diagram, B, illustrate attachments and fiber
direction of mylohyoid muscle. C, Cross-sectional diagram of a mandibular denture
indicates relationship of lingual flange to underlying mylohyoid muscle. Posteriorly, as
a result of the more vertical fiber direction, flange may be extended more inferiorly than
anteriorly. Dotted lines represent an activated mylohyoid muscle.
Fig. 2. Lingual flange of mandibular denture must
incline medially to allow for contraction of mylohyoid
muscle, which lies beneath mucosa covering lingual
slope of residual ridge. Dotted lines represent an acti-
vated mylohyoid muscle.
lingual flange (Fig. 1). The extent of contact of the
lingual flange with the lingual ridge slope is thereby
dictated by the functional mobility of the floor of the
mouth.
In addition to determining the inferior extension of
the flange, the musculature of the floor of the mouth
may also influence the degree of intimate contact
allowed. Any flange extension below the mylohyoid
ridge must incline medially away from the mandible to
allow for the mylohyoid muscle contraction (Fig. 2).
The degree of positive contact of firm ridge to flange
may also be compromised by the presence of a thin
mucosa overlying the bony ridge slopes that does not
tolerate stresses effectively and, therefore, may require
relief.
RESIDUAL RIDGE ANATOMY
The development of stability is limited by the
anatomic variations of the patient that determine the
residual ridge height and conformation. Large, square,
broad ridges offer a greater resistance to lateral forces
than do small, narrow, tapered ridges (Fig. 3). Small,
166 FEBRUARY 1983 VOLUME 49 NUMBER 2
COMPLETE DENTURE STABILITY
Fig. 3. Tapered, round, and square ridges diagrammatically in cross section. Potential
for denture stability increases as a residual ridge becomes more square shaped.
Fig. 4. Diagrammatic representation of maxillary and
mandibular complete dentures that have been
designed to enhance seating of prosthesis during
function shown in frontal cross section.
rounded irregularities of the residual ridge also con-
tribute favorably to stability. Therefore, alveoplasty at
the same time as extractions should be limited only to
removal of bone that would prevent fabrication of a
successful prosthesis (for example, sharp spicules,
severe undercuts, and insufficient interarch distance).
Removal of all irregularities to create a smooth, even
ridge would diminish potential stability.
Another factor to be considered in stability is the
arch form. Square or tapered arches tend to resist
rotation of the prosthesis better than ovoid arches.
The shape of the palatal vault contributes to stability
as limited by the length and angulation of the palatal
ridge slopes. A steep palatal vault may enhance stabil-
ity by providing greater surface area of contact and
long inclines approaching a right angle to the direction
of force.
Fig. 5. Inclination and external contour of lingual
flange may be designed to harmonize with muscular
action of tongue.
RELATIONSHIP OF THE EXTERNAL
SURFACE AND PERIPHERY TO
SURROUNDING OROFACIAL
MUSCULATURE
Some important yet easily overlooked determinants
of both denture stability and retention involve the
relationship of the polished surface of the denture base
to the surrounding musculature of the orofacial cap-
sule. Actions of the musculature on the denture base
generally result in lateral and vertical dislodging
forces.
Certain factors involving the musculature and the
polished surface of the denture can facilitate stability in
two ways. First, the action of certain muscle groups
must be permitted to occur without interference by the
denture base so that they will not dislodge the prosthe-
sis during function or compromise stability. Second, the
dentist must recognize that normal functioning of some
muscle groups can be used to enhance stability. Alter-
ations in external denture base contours can lead to a
THE JOURNAL OF PROSTHETIC DENTISTRY
167
JACOBSON AND KROL
Fig. 6. A and B, Concave contours of external surfaces of maxillary and mandibular
denture flanges permit musculature of lips, tongue, and cheeks to effect a seating of
denture during function.
dynamic seating and stabilizing action directed toward
the prosthesis.
The denture border must be extended to contact the
movable tissues. Optimal extension also enhances sta-
bility and support. The actions of the levator anguli
oris (caninus), incisivus, depressor anguli oris (triangu-
laris), mentalis, mylohyoid, and genioglossus muscles
can lead to dislodging forces if the denture base does not
provide freedom for these muscles to function. Proper
border or muscle molding prior to the final impression
ensures optimal border extension.
The external surface should be developed to harmo-
nize with the associated functioning musculature of the
tongue, lips, and cheeks. Fish4 believed that the con-
tours of the polished surface provided the principal
factor governing complete denture stability. In 1933 he
wrote that it is not so widely understood that the
actual shape of the whole of the buccal, labial, and
lingual surfaces can wreck the stability of a den-
ture just as completely as a bad impression or wrong
bite. In order to appreciate this principle, it is
necessary to understand the anatomy and function
of the muscles that comprise the tongue, lips, and
cheeks.
INFLUENCE OF OROFACIAL
MUSCULATURE
The basic geometric design of denture bases should
be triangular. In a frontal cross section, the maxillary
and mandibular dentures should appear as two trian-
gles whose apexes correspond to the occlusal surface
(Fig. 4). The maxillary buccal flange should incline
laterally and superiorly. The mandibular buccal flange
should incline laterally and inferiorly, and its lingual
flange should incline medially and inferiorly. Such
inclinations will provide a favorable vertical component
to any horizontally directed forces.
To direct a seating action on the mandibular den-
ture, the tongue should rest against a lingual flange
inclined medially away from the mandible and some-
what concave (Fig. 5). The degree of inclination
depends on the balance of the muscular forces of the
tongue as opposed to the mylohyoid and superior
constrictor muscles.5 Some authors recommend posteri-
or extension of the lingual flange to fill the retromylo-
hyoid space to permit the base of the tongue to
contribute to the neuromuscular control of the prosthe-
sis. Inclination of the lingual flange must be designed
to guide the tongue to rest over the flange and permit
any horizontal forces generated against the denture
base to be transmitted as seating forces.
Generally, the buccal and labial flanges of the
maxillary and mandibular dentures should be concave
to permit positive seating by the cheeks and lips (Fig.
6). The primary muscles of the lips and cheeks are the
orbicularis oris and buccinator muscles, respectively.
These muscles are active during speech, mastication,
and deglutition. The proper contour of the denture
flanges permits the horizontally directed forces that
occur during contraction of these muscles to be
transmitted as vertical forces tending to seat the
prosthesis.
168
FEBRUARY 19.93 VOLUME 49 NUMBER 2
COMPLi?TE DENTURE STABILITY
IMPORTANCE OF THE MODIOLUS AND
ASSOCIATED MUSCULATURE
Fish4 describes the muscles of the musculi cruculi
modioli or modiolus and their actions in detail. The
modiolus or tendinous node is an anatomic landmark
near the corner of the mouth that is formed by the
intersection of several muscles of the cheeks and lips.
These include the orbicularis oris, buccinator, caninus,
triangularis, and zygomaticus muscles (Fig. 7).
Because none of these muscles contains fibers that
have more than one bony attachment, they depend on
fixation of the modiolus to allow isometric contraction.
By studying the diagram of these fan-shaped muscles,
one can understand the various interactions that are
possible. Contraction of the triangularis, caninus, and
zygomaticus muscles fixes the modiolus, allowing the
buccinator muscle to contract isometrically. This causes
the buccinator muscle to tense, allowing it to control the
food bolus on the occlusal table. Isotonic buccinator
muscle contraction in the absence of modiolus fixation
would pull the corner of the mouth posteriorly. A
similar situation can be described for the orbicularis
oris muscle and the remaining musculature of the
modiolus. It can be fixed more anteriorly as when the
word hoe is pronounced or posteriorly as with
he.
The denture base must be contoured to permit the
modiolus to function freely. In the premolar region the
mandibular denture should exhibit both a shortened
and narrowed flange to permit the action that draws
the vestibule superiorly and the modiolus medially
against the dentures. This action is easily demonstrated
by drawing the corners of the mouth inward.
The buccinator muscle may be divided into superior,
middle, and inferior divisions. According to Fish,4 the
superior fibers act to seat the maxillary denture, the
middle fibers control the bolus of food, and the inferior
fibers contribute to mandibular denture stability.
While the middle fibers contract, controlling the bolus,
the inferior fibers relax to form a pouch capable of
storing food until needed to form another bolus.
Extension of a concave denture base into this pouch
allows the cheek to lie over the flange.
A clinical study involving electromyographic analy-
sis of the function of the buccinator muscle by Lund-
quist supports this basic theory by Fish. The study
further showed that the nature of buccinator muscle
contraction was not able to adapt to changes in the
contours of the denture base. Because learning and
adaptation appear to be limited, the denture contours
should be designed to harmonize with existing buccina-
tor muscle function.
Fig. 7. Intersection of muscles of facial expression
that comprise modiolus.
VARIETY OF TECHNIQUES
The idea of establishing harmony between the
polished surface of the denture and the associated
musculature has provided the basis for a number of
techniques for complete denture construction. This
neutral zone (concept has been described with various
modifications by a number of authors.-! The theory
used to develop the denture base contours is based on
the belief that the muscles should functionally mold not
only the border but the entire polished surface. Even
the teeth are placed within the neutral zone, where
facial and lingual forces generated by the musculature
of the lips, tongue, and cheeks are balanced. This
functional rather than anatomic placement of the
artificial teeth is believed to further enhance the
stability of the dentures by minimizing active forces.
The authors do not necessarily recommend such
techniques in all cases, but recognjtion of the
need for a harmonious relationship between den-
ture base and surrounding musculature is cer-
tainly important.
RELATIONSHIP OF OPPOSING
OCCLUSAL SURFACES
Harmony developed between the opposing occlusal
surfaces also contributes to stability. Regardless of the
type of posterior tooth form or occlusal scheme used,
the dentures must be free of interferences within the
functional range of movement of the patient The
functional range of movement refers to the positions
through which the lower jaw moves horizontally dur-
ing normal speech, swallowing, and mastication. Dur-
ing both functional and parafunctional movements, the
occlusal surfaces should not strike prematurely in
THE IOURNAL OF PROSTHETIC DENTISTRY
169
JACOBSON AND KROL
Fig. 8. Tendency to lingualize forces transmitted to
mandibular denture to minimize dislodging leverages
during working-side contact in absence of a fully
balanced occlusion.
localized areas. Such contacts cause uneven stresses to
be transmitted to the dentures during function. This
results in lateral and torquing forces that adversely
affect stability. Bilateral, simultaneous, posterior tooth
contact in centric relation is essential. For many
patients the normal range of horizontal movement of
the mandible is limited to centric relation. This is
particularly true for skeletal Class III or mandibular
prognathic patients. Excursive balance may not be
necessary in such situations. Patients who exhibit a
wider functional range of movement, often seen in
skeletal Class II or mandibular retrognathic patients,
require consideration of premature occlusal contacts,
which may occur when the mandible does not close in
centric relation.
THEORIES OF OCCLUSION
Various philosophies have been proposed either to
provide for a fully balanced occlusion throughout
lateral and protrusive excursive movements or to con-
trol the direction of forces experienced during localized
occlusal contact. Setting of anatomic or semianatomic
artificial teeth to provide excursive balance is thought
to minimize localized stress concentration and lateral
dislodging forces by ensuring multiple points of contact
to distribute functional occlusal forces. On closure
through a bolus of food, bilateral posterior tooth
contacts within the range of balance ensure a seating of
the prosthesis. To minimize dislodging forces the
occlusion must be balanced throughout the functional
range of movement of the patient. A balanced occlusion
is limited by the buccolingual and mesiodistal width of
the anatomic cuspal inclines. Patients who exhibit a
functional range of movement beyond the limits of
balance would benefit less from such an arrangement.
An anatomic fully balanced occlusion would, therefore,
not be indicated for a skeletal Class II mandibular
retrognathic patient displaying a functional range of
lateral and protrusive excursions of 4 to 6 mm or
greater.
Some authors recommend occlusal schemes that
direct forces to minimize the unseating of the denture
during unilateral excursive tooth contacts. According to
certain monoplane occlusal schemes, positioning O-
degree teeth slightly lingual to the mandibular ridge
crest may enhance denture stability. Zero-degree teeth
may reduce horizontal forces by eliminating the
inclined planes introduced by the cusp angles of
anatomic teeth.
The theories of lingualized occlusion provide both a
limited range of excursive balance and a directing of
forces to the lingual side of the lower ridge during
working-side contacts (Fig. 8). Such concepts may
minimize horizontal stress and enhance denture stabil-
ity by controlling the leverages induced by eccentric
tooth contacts.4-6
Other philosophies depend on the learned neuro-
muscular skills of the patient. Some patients are
instructed to chew in such a manner that tooth contacts
are limited to centric relation. Horizontal forces can be
minimized when the patient learns to place food
bilaterally to ensure simultaneous posterior contact
without a balanced occlusion.
Woelfel et al. showed that most functional closures
of the complete denture patients occurred in close
proximity to centric relation. A study by Frechettels
demonstrated even force distribution regardless of tooth
position in patients who chewed bilaterally. In another
study he further concluded that bilateral chewing
contributed more to denture stability than balanced
occlusion.18 However, the learning of new neuromuscu-
lar patterns is often limited, and not all complete
denture patients appear to be capable of masticating
bilaterally in centric relation.
The selection of anatomic, semianatomic, or nonana-
tomic artificial teeth depends partially on the chosen
occlusal scheme. Still another factor to be considered in
selection of cusp form and occlusal scheme involves the
quality of the residual ridge in terms of height and
conformation. Unfavorable ridges exhibiting severe
resorption patterns may contribute to compromised
stability due to a poor denture base-residual ridge
relationship. Use of anatomic artificial teeth in such
situations may not provide the advantages normally
expected. If balanced occlusion is desired throughout a
limited functional range of movement for patients with
deficient residual ridges, the use of nonanatomic O-
170
FEBRUARY 1983 VOLUME 49 NUMBER 2
COMPLETE DENTURE STABILITY
Fig. 9. A, Mounted casts depict a severe skeletal Class III edentulous patient. B, To
minimize anterosuperior shunting of maxillary denture during function, posterior
occlusion must be developed beyond anteroposterior midline of denture-supporting
area to include line drawn across land area of cast. C, Completed wax-up demonstrates
necessary occlusal contacts.
degree teeth set on a curve may provide the desired
occlusal contacts while eliminating the interlocking of
opposing anatomic teeth.
The subject of occlusion is filled with widely diver-
gent opinions. As concluded by the International
Prosthodontic Workshop of 1972: More long-term
statistical investigations are necessary to compare the
various occlusal designs so that more definable guide-
lines may evolve. Until then, dentists must rely on
clinical experience in selection of posterior tooth form
and appropriate occlusal schemes.
TOOTH POSITION AND OCCLUSAL PLANE
Other considerations relating to the occlusal surface
include the position of the teeth and the level of the
occlusal plane. Anterior and posterior teeth should be
arranged as close as possible to the position once
occupied by the natural teeth, with only slight modifi-
cations made to improve leverages and esthetics.
The superior-inferior position of the occlusal plane
is also a factor to be recognized. A mandibular occlusal
plane that is too high can result in reduced stability.
First, lateral tilting forces directed against the teeth are
magnified as the plane is raised. Second, the mandibu-
lar denture need:s to be controlled by the musculature of
the tongue, lips, and cheeks. An elevated occlusal plane
prevents the tongue from reaching over the food table
into the buccal vestibule. This compromises stability
and makes control of the food bolus and denture more
difficult. A raised mandibular occlusal plane is usually
present when the vertical dimension of occlusion is
increased excessively. Various anatomic landmarks,
such as Stensens duct and retromolar pad, should be
used to determine an acceptable level of the occlusal
plane. Bisecting the interridge distance improves the
mechanical advantage of the mandibular denture; but,
if excessive mandibular ridge resorption has occurred,
the occlusal plane would be too low since less resorp-
tion usually occurs on the maxillae.
RIDGE RELATIONSHIPS
A problem of stability is the offset ridge relations
seen in prognathic and retrognathic patients. Normal
dental relationships of the artificial teeth set on ridges
THE JOURNAL OF PROSTHETIC DENTISTRY
171
that are in severe posterior crossbite can adversely
affect stability. In complete dentures the normal tooth-
to-tooth position may have to be altered to provide a
relationship that can enhance the stability. Weinberg2
recognizes the need to set teeth in crossbite when the
ridges are in a severe crossbite relation.
The Class III patient frequently displays a lower
arch anterior to the upper arch in centric relation.
Sufficient mandibular posterior occlusion must be
developed so that contact against the maxillary denture
extends posteriorly more than half the distance from
the incisive papilla to the hamular notch (Fig. 9).
Without this contact the maxillary denture would tip
anterosuperiorly, traumatizing the maxillary anterior
ridge and loosening the maxillary denture.
The severe retrognathic or prognathous ridge rela-
tionship can be remedied only to a limited extent
through prosthetic treatment. While some compromises
in the ideal tooth-to-ridge and tooth-to-tooth relation-
ships may be made, the range of correction of such
skeletal cosmetic deficiencies without surgical interven-
tions is limited.
CONCLUSION
Both complete denture stability and retention are
essential in providing successful prosthetic treatment.
The factors that contribute to these properties are
highly interrelated, and the constant interaction
between stability and retention often makes them
indistinguishable. The factor of stability involve the
tissue, occlusal, and polished surfaces of the denture.
Care must be taken in the development of all three of
these surfaces to ensure optimal stability of the final
prosthesis.
REFERENCES
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retention and stability. J PR~~THET DENT 214, 1957.
2. Boucher, C.: Complete denture impressions based on anatomy
of the mouth. J Am Dent Assoc 31:124, 1944.
3. Boucher, C. 0.: A critical analysis of mid-century impression
techniques for full dentures. J PROSTHET DENT 1:472, 1951.
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JACOBSON AND KROL
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Reprint requests to:
DR. THEODORE E. JACOBSON
UNIVERSITY OF CALIFORNIA
SCHOOL OF DENTISTRY
SAN FRANCISCO, CA 94143
172
FEBRUARY 1983 VOLUME 49 NUMBER 2