SUPPORT, RETENTION AND STABILITY – THEIR OUTCOME IN

COMPLETE DENTURE

Introduction

Human teeth play a crucial part in maintenance of an affirmative personality. Our

masticatory system performs the functions like chewing, smiling, yawning, laughing and

talking. Sometimes, a person may have difficulties in performing these functions due to

the malfunctioning of the jaw muscles, jaw joints or the neural system. The human teeth

are also lost with ageing as a result of the cumulative effects of periodontal disease,

trauma, dental caries and dental treatment. With increased awareness among the people,

use of fluoride, better professional and home dental care the prevalence of the complete

tooth loss has reduced. However, the total number of patients requiring complete dentures

is increasing rapidly nowadays. Complete dentures are the most common prescription

which is globally offered to the edentulous patients by the dentists. The most common

reasons for seeking denture therapy by the patients are to improve aesthetics and

masticulation (Mazurat & Mazurat 2003).

In our study we have discussed the importance of dental implant with its

advantages and disadvantages. Support, stability and retention are necessary for the

complete and effective placement of the denture. They are also necessary for the

complete satisfaction of the patient which is more or less absent in most of the patients

who opt for the complete dentures. The factors that influence the retention of the dentures

have also been discussed in brief. We have also explained the effects of ill-fitted dentures

and at the end a brief explanation regarding oral health-related quality of life (OHRQOL)

has been given. As the chewing ability of our natural teeth is much more than the denture,

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one should not deliberately opt for the complete denture therapy until and unless it is

quite necessary to do so.

Complete Denture

A denture in short is the removable replacement for the missing teeth. There are

two types of dentures viz. complete and partial dentures. Complete dentures may be

immediate or conventional. Immediate dentures are made before the removal of the teeth

and are placed as soon as the teeth are removed. The wearer in such case does not have to

remain without teeth during the period of healing. Following the removal of the teeth, the

gums and bones however shrink during this healing period. In case of the conventional

denture teeth are removed but the denture is placed about 8 to 12 weeks after their

removal. The immediate dentures as compared to the conventional dentures require more

adjustments to fit properly during the healing process and are usually considered as a

temporary solution until the conventional dentures are ready.

Many factors are involved in the designing of the complete dentures and not even

a single factor can be overlooked as it can lead to a complete failure of the denture. The

denture should fit comfortably as soon as it is inserted in the mouth and placed in the oral

cavity. Normally the upper appliance is easier to design and remains stable without

slipping. The lower one however, is a bit difficult to design because there is no suction to

hold it in its place. Therefore, in order to support the lower denture, dentists recommend

2-4 implants in the lower jaw to provide support to the denture. A removable denture that

fits over a small number of remaining natural teeth or implants is an overdenture.

Overdenture is to provide stability and support to the natural teeth.

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Dental Implant

The placement of an artificial tooth root in the jaw for supporting and stabilizing a

crown, denture or bridge is known as dental implant. It is an artificial tooth root placed in

the jaw to hold a replacement tooth or bridge.

Dental implant

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It also maintains the surrounding bone that helps in maintaining the long-term facial

appearance.

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 Dental implant

Courtesy: www.eatanapple.com/whyimplants.html

Dental implant usually depends upon the number of missing teeth. It is used to

restore all missing teeth from the age of 18 years or after the jawbones have stopped

growing. It provides stability to the complete denture and hence eliminates unsightly

moving and clicking linked with the dentures. The benefits of the dental implant are as

follows:

1. Improvement in the appearance

2. Improvement in the speech

3. Improvement in masticulation

4. Convenient

5. Better self-esteem

One of the main oral problems in the edentulous persons is the poor retention of

complete denture. Poor retention is quite often related with the loss of complete dentures’

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bone support. The ridges on which the appliance rest begins to deteriorates after years of

wearing dentures. The insertion of implants into the bone below can help to keep it in

place and prevent from deterioration. When the implants are integrated into the dental

treatment, it is referred as implant supported overdenture and the implant itself is referred

to as overdenture abutments.

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treatments/dentures/

Some of the disadvantages of the removable complete or partial dentures are that

it needs to be removed while sleeping, sometimes chewing movements disturb and

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dislodge the denture and sore areas may develop at the place where denture contacts the

gums.

Support

Support describes the manner in which the underlying oral tissues in the oral

cavity keep the appliance from moving. Implants have been suggested for increasing the

stability of the appliances. It is the principle that explains how organized is the

underlying mucosa which includes the oral tissues, gums and the vestibules. Support is

necessary for preventing the denture from moving vertically towards the arch or moving

deeper into the arch. This function is preformed by the gingival for the mandibular arch

and the buccal shelf. The palate joins to further support the denture in the maxillary arch.

The larger the denture flanges the better is the support.

Stability

Stability explains how well the denture base is prevented from moving in the

horizontal plain and from sliding in any direction. The stability of the denture base is

stronger if it runs smoothly and continuously with the edentulous ridge. Similarly, if the

ridges are higher and broader, the stability will be better.

Retention and factors affecting retention

The retention of the dentures is influenced by the factors like cohesion, adhesion,

fluid, viscosity, atmospheric pressure and external factors arising out of oral-facial

musculature (Murray & Darvell 1993; Shay 1997). The most important of these are the

interfacial surface tensions developed due to saliva layer within the denture base the

supporting soft tissues. Retention is accomplished when the saliva layer maximizes

contact with approximating prosthetic and mucosal surfaces. Hence, there is noticeable

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reduction in the complete denture retention due to decreased interfacial surface tension in

case of the xerostomic patients who experience a quantitative and qualitative reduction in

saliva (Edgerton, Tabak & Levine 1987).

Cohesion: The attraction of the like molecules for each other occurring in the saliva layer

is cohesion. The cohesive forces depend directly on the amount of saliva and the area of

the denture base. However, these forces are less than the forces of adhesion. An adhesive

may be applied to enhance satisfaction with a properly constructed denture. They extend

support and enhance retention, stability and provide an individual with a sense of

security.

Surface tension: The resistance to separation possessed by a film of liquid between the

two well-adapted surfaces is the interfacial surface tension and is the outcome of the

cohesive forces acting at the surface of the liquid. The force is similar to the one that

causes liquid to rise in a capillary tube known as capillary attraction or capillarity. Close

adaptation of the denture base to the mucosa is to enhance these forces. Where the shape

of the palate is high and vaulted, it is easy to displace a denture base as compared to the

one which is flat.

Atmospheric pressure: Saliva produces a pressure disparity between the intra-oral air

pressure and its peripheral meniscus.

Peripheral seal: The peripheral seal is more easily obtained in the upper denture than in

the lower one as there are greater movements of the lower border tissues, especially

lingual.

Oral and facial masculature: The natural action of the oral and facial masculature

acting as well as resting provides for some additional forces against the polished surfaces

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of the dentures. These surfaces must be shaped for facilitating the oral and facial

musculatures to fit naturally against the denture for enforcing the peripheral seal. It is

quite important to observe the position of the tongue at the initial examination of the

patient. It would be easier to use a correctly shaped and extended denture where the

tongue naturally maintains a position resting against the ridge or existing denture. In case

where on opening the mouth, the tongue retreats to the back, the denture is likely to get

dislocated.

Occlusion: The retention and stability of the complete denture depends upon the arch

form and position. The artificial teeth are required to be placed on the same positions as

previously occupied by the natural teeth of a person, as it will create harmony with all the

muscular forces acting on them like the tongue on one side and between the lips and

cheeks on the other one.

All these factors contribute to the retention and stability of denture bases and

therefore must be enhanced during the clinical techniques involving the construction of

complete dentures. The prime concern however, has to be correct extension of the

denture bases such as the length, breadth and the overall shape of the dentures.

The resistance of the denture to removal along its path of insertion has been termed as

retention, whereas stability is the resistance of the denture towards the forces dealing with

its displacement by acting in the direction other than the path of insertion. There are

different factors that affect the retention and stability of the dentures.

A research revealed that in the US, the number of adults requiring complete

denture therapy is likely to reach 37.9 million mark by the year 2020 from 33.6 million in

the year 1991. It has also been estimated that the number of complete dentures made in

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US will increase from 56.5 million in 2000 to over 61 million dentures in 2020 to fulfill

the requirement of both maxillary and mandibular complete denture by the patients

(Douglass, Shih & Ostry 2002). The process of prosthodontic rehabilitation is

complicated with the marked atrophy of alveolar bone following a tooth loss and is

termed as reduction of residual ridges (Atwood, 1971). Also, the oral soft tissue and

alveolar bone changes observed in dentures wearers may be considered as the inevitable

consequences of the loss of natural teeth, occlusal factors, tissue remodeling and

prolonged denture wear (Tallgren, et al. 1980; Kalk & de Baat 1989; Wyatt 1998). Long-

term edentulism followed by alveolar bone loss may be acute and the procedure may

advance all through life (Bairam & Miller 1994).

Ill-fitted dentures and associated trauma to the oral tissues are the primary causes

of rapid destruction of the structures bearing the dentures. Similarly, excessive occlusal

vertical dimension, inaccurate centric jaw relationships, faulty impressions and occlusal

disharmony are the major contributing factors (Schlosser 1950).

Excessive residual ridge resorption (RRR) is one of the reasons for wearing the

conventional removable complete dentures (RCDs). According to Atwood (1962),

deterioration of edentulous ridges is quite a complex biophysical process which involves

metabolic factors like systemic influences on bone formation and resorption, functional

factors like intensity and duration of applied forces and prosthetic factors like techniques

and materials used in denture construction. For instance, occlusal parafunction may affect

the denture bearing tissues adversely. It is also likely that numerous complete denture

wearers limit both separation of the denture teeth and mandibular movement to avoid

unintentional prosthesis movement. If this clenching habit continues with sufficient force

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for a long time, it is likely to damage the denture bearing soft and hard tissues. Many

others have supported Atwood and believed that aggressive reduction of residual

edentulous ridges may take place despite careful prosthodontic management and apparent

short-term successful outcomes. These may be considered as etiologic factors in alveolar

resorption. An association may also be seen between residual ridge reduction and

osteoporosis although this has not been confirmed yet (Kribbs, Smith & Chesnut 1983;

Razmazzoto, Curro, Gates & Paterson 1986).

People have become more and more conscious regarding their oral health-related

quality of life (OHRQOL), especially after 1980s. OHRQOL is used to assess a person’s

functional, intellectual, social issues, pain and tenderness which are affecting his oral

health (Strassburger, et al. 2004). Results in prosthetic therapy is especially concerned

with the superior results of mandibular overdentures or fixed prosthesis as against the

conventional complete dentures (Heydecke, et al. 2003; Allen & McMillan 2001; Awad

et al. 2000). It has been found that the patients who opt for the replacement of the

complete dentures and partial dentures with implant-retained dentures have a weak

OHRQOL. Some of them even require a treatment later on. On the other hand, the

patients who opt for the complete replacement of their dentures with the new complete

dentures have much better OHRQOL as compared to those seeking for implant-retained

dentures (Allen & McMillan 2001).

Complete denture stability and retention:

In case of the edentulous patients, the success of the denture therapy depends

upon the biomechanical prodigy of support, stability and retention (Jacobson & Krol

1983a; Jacobson & Krol 1983). An ineffective located postpalatal seal may navigate

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denture retention and hence the result may be reduced denture retention (Martone 1962)

with poor denture stability, as a result of decreased vertical alveolar height in severely

atropic edentulous maxilla (Tyson 1967).

The main objective of the complete denture therapy in case of the patients with

severe reduction of residual ridges is to replace the missing teeth as well as to support the

associated structures. In this procedure, it may occupy a substantial volume. As it is quite

crucial to satisfy mechanical requirements of the prosthesis, the denture base thickness

must be carefully limited in this area. Complete dentures structurally redefine potential

spaces in the oral cavity. However, placing an inappropriate denture tooth or

physiologically unacceptable denture base contour or volume may lead to inefficient

tongue posture and function (Wright, Swartz & Godwin 1961) hyperactive gagging

(Kuebker 1984) and compromised phonetics (Martone & Black 1962). Cautiously

designed external dentures contours like cameo or polished denture surfaces contribute

substantially towards the prosthesis retention and stability. Poorly designed prostheses

that fail to accommodate anticipated muscular function may result in compromised

denture stability and reduced retention. On the other hand, when optimally contoured,

complete dentures occupy space in the oral cavity within the physiologic limits of

acceptable muscular function, stability and retention during phonation, mastication and

deglutition (Beresin & Schiesser 1976).

Denture occlusion also affects complete denture retention. Therefore, most of the

denture wearers intentionally or otherwise perform random, empty-mouth occlusal

contacts throughout the day. These occlusals may result for functional activity like

swallowing, or parafunctional activity like clenching or bruxism. The undesirable

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outcomes of functional and parafunctional loading can be reduced with an adequate

denture occlusion by largely distributing these forces on the denture bearing structures.

Hence, a properly balanced denture occlusion may dampen potentially detrimental

occlusal forces that disrupt denture stability.

For retention and stability of conventional complete dentures it is suitable to

prescribe a denture adhesive. It is usually suggested when appropriately constructed

complete dentures fail to provide adequate stability and retention (Shay 1997; Slaughter,

Katz & Grasso 1999) at the time when some additional retention and stability is required

by the patient especially during public interaction. Denture adhesives decrease food

impaction under the denture base, develop chewing efficiency, enhance functional load

distribution aross the denture-bearing tissues and reduce the mucosal irritation (Grasso,

Rendell & Gay 1994; DeVengencie, Ng, Ford & Iacopino 1997). However, ill-fitting

prostheses cannot provide retention with the use of denture adhesives.

Some people feel that they should get all their teeth replaced with the complete

denture because they give a bad impression or weak presentation. However, researches

reveal that majority of the people who did so regretted afterwards. One of the main

reasons for it is the chewing power of the complete denture. It has been calculated that

the full dentures only have 10% of the chewing power as compared to the chewing power

of the natural teeth. Even the single tooth of a person is enough to provide stability to the

dentures otherwise it is quite difficult task to fit the dentures satisfactorily especially in

the mandibular arch. Therefore, the dentist advises people to keep their natural teeth as

long as possible.

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Patient Assistance

For complete denture care, patient’s assistance is very important. It includes:

Home care: Home care maintenance is quite important and therefore the dentists

encourage the use of denture care products at home in order to take care of complete

denture. The cleansers and fixatives are quite useful adjunct to denture therapy as they

provide patient with confidence, comfort and improves the biting efficacy.

Dental hygiene: It is another important factor in the complete denture service. Care of

the dentures and the mucosal tissues in the edentulous mouth is quite necessary for the

overall health of the person and his mouth.

Conclusion

The complete denture success begins with thorough understanding of the patient’s

oral condition. The condition needs to be carefully recognized, attended to and contented.

Almost 25% of the patients suffering from dental problems are dissatisfied with their

dentures. Even the technical denture quality has not proved to be successful in providing

patient satisfaction (Wolff, Gadre, Begleiter, et al. 2003). One of the reasons for this is

the high failure rate of complete dentures. But practitioners should first explore

emotionally charged issues (acceptance that the natural teeth have gone permanently) and

then providing details regarding the advantages of the complete denture. He should also

explain the disadvantages of the complete dentures and then clarify how advantages can

overcome the disadvantages before proceeding. It should be understood that the denture

success is a process that requires time and patience.

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