Introduction
In an individual's life, teeth play an indispensable role. Complete loss of teeth results in loss of both aesthetics and function. Thus, replacing teeth with artificial dentures is an important requirement. A mucosa-borne complete denture is the most commonly adopted treatment modality for edentulous patients. The patient’s acceptance of the finished prosthesis depends on various factors, among which the retention and stability of the complete denture play a significant role. The loose and unstable denture is a persistent source of annoyance to the patient and the dentist.
The mandibular denture is usually more problematic than the maxillary denture owing to the smaller surface area coverage of the foundation tissues. The problem of retention and stability is more pronounced with mandibular dentures than with maxillary dentures because the covered surface area is approximately half that of the maxillary arch, and the presence of the palate adds to the area against the mobile tongue on the floor of the mouth in the mandibular arch. A complete mandibular denture is considered stable if it is entirely and continuously under the patient’s functional control. The patient should be able to eat comfortably and with minimal movement of the denture relative to its foundation area. Retentive dentures can be fabricated for most patients, regardless of the condition of the ridge. It is mainly the denture's stability that is limited by the ridge conditions. Stability is the quality of a removable prosthesis to be firm, steady, or constant, resisting displacement under functional horizontal or rotational stresses.[1][2]
Function
The dentures move relative to the underlying bone during their functioning. Most principles of denture construction have been formulated to minimize off-vertical forces transmitted to the supporting structure, as vertical forces are better tolerated. The instability has the potential of being traumatic to the supporting tissues. Thus, with complete denture philosophies and techniques, maximum stability and retention appear to be the major objectives throughout the clinical procedure. Stability is usually the distinguishing factor between success and failure. Modifications to the impression surface, occlusal surface, polished surface, and even the compromised mandibular residual ridge have been devised to improve stability and retention in the mandibular denture.[3][4]
Issues of Concern
There are a variety of factors on which the stability of a mandibular denture depends. These appear under the following categories:
The relationship of the denture base to the underlying tissues
The relationship of the polished surface and border to the surrounding orofacial musculature
The relationship of the opposing occlusal surfaces
The Relationship of the Denture Base to the Underlying Tissues
A. Fitting Surface/Intaglio Surface/Impression Surface
The production of a good-fitting surface depends primarily upon the impression. There is general agreement that all complete dentures should cover the maximum area possible, along with close adaptation to the underlying surface, but great care is necessary to confine the area of the impression so that it does not impinge on the zones of muscle attachments.
Various Modifications in the Design of the Denture in Resorbed Ridges
Lingual flange design (sublingual crescent extension): It involves a lingual wing (horizontal extension of the lingual flange) placed in a biologically acceptable fashion by increasing the area of the denture, which enhances retention and stability.[5][6][7]
Posterior lingual extension: The posterior part of the alveolingual sulcus (the retromylohyoid fossa) divides into 2 parts: anteroinferior and posterosuperior. The lingual flange of the mandibular denture should be turned into the anteroinferior part to produce maximum stability for the denture since no muscle lies directly underneath.
B. Residual Ridge Factor
Height and width: Denture stability is directly proportional to the height and width of the ridge. Resorbed ridges have poor stability.
Ridge shape and size: Denture stability is increased in square, parallel-sided, broad ridges than in the small, narrow, tapered ridges. The former provides greater resistance to the functional horizontal dislodging forces.
Interarch space: The appropriate vertical dimension enhances denture stability. If the interridge distance is excessive, stability decreases due to increased leverage. In cases of excessive resorption, the interridge space increases, moving the occlusal surfaces of the teeth farther from the supporting area, resulting in a biomechanical disadvantage for the denture due to increased leverage.
Ridge parallelism: Parallelism of the edentulous ridges favors seating of the denture bases during tooth contact because of favorable directions of forces, thus increasing the stability. Deviation from the ridges' parallelism adversely affects stability.
Ridge relation: Denture stability is a problem in severe prognathic and retrognathic ridge relations.
Ridge quality: Denture stability becomes decreased by the presence of hypermobile or flabby tissue on the ridge surface.
Ridge resorption can result in a prominent, sharp mylohyoid ridge, limiting denture extension below the mylohyoid area and potentially affecting denture stability. Mylohyoid ridge reductions can aid in the success of mandibular dentures by permitting the increased surface area coverage by the denture. In highly resorbed ridges with shallow sulcus depth, adequate stability is not achievable through non-surgical procedures. Pre-prosthetic surgery measures, including sulcus deepening and/or ridge augmentation, are to be implemented to ensure the stability of the mandibular denture.
Relationship of the Polished Surface and Periphery to Surrounding Orofacial Musculature
The polished surface of a mandibular denture extends from the denture border in the vestibular depth upwards to the occlusal surface of the teeth. This surface should be shaped to accommodate the musculature contacting it around the denture, which in turn aids the denture's stability. In case the direction of muscle contraction is not respected, and is against the shape of the contacting surface. Muscular force acts as a dislodging factor, resulting in impaired denture stability. Seating action on the mandibular denture occurs if the tongue rests against the lingual flange, inclined away from the mandible medially, and is concave. In general, the labial and buccal flanges of the maxillary and mandibular dentures should be concave to permit positive seating by the musculature of cheeks and lips. Posteriorly, similar conditions govern the shape of the polished surface. When natural teeth are present, they lie in a neutral zone of muscle activity, enclosed by the buccinator and the tongue. Following tooth loss and resorption, the neutral zone area decreases. Accordingly, it is essential to record the neutral zone and use a narrow posterior teeth set over the residual ridge in the premolar region, but deviating a little buccally in the molar region.
Role of Frenum
The frenum, though not a muscular structure, should be permitted adequate space at the denture border. Otherwise, it causes the denture to dislodge.
Role of Modiolus
The modiolus or tendinous node is an anatomic landmark near the corner of the mouth that is formed by the intersection of various muscles (Orbicularis oris, depressor anguli oris, levator anguli oris, quadratus labii superioris, quadratus labii inferioris, buccinators, risorius, and zygomaticus major) of the cheeks and lips. The mandibular denture base must be contoured to permit the modiolus to function freely. This muscle hub contributes to denture stability.
Relationship of Opposing Occlusal Surfaces
A. Occlusal Surface
Although every aspect of denture construction is important, there can be no doubt that establishing the correct occlusal relationship of the opposing teeth is the most important. Even the skilfully made, retentive, and stable mandibular dentures can become unstable and cause irritation due to interfering occlusal contacts. Any tooth interference during function should be removed to achieve occlusal equilibration. The functional range of movements refers to the positions through which the lower jaw moves horizontally during normal speech, swallowing, and mastication. Ideally, the dentures should be fabricated so that all posterior teeth have simultaneous contact in eccentric positions as well as in centric relation, ie, the dentures should have bilateral balanced occlusion. In the monoplane occlusal scheme, positioning zero degrees (cuspless/flat) teeth slightly lingual to the mandibular ridge crest enhances the denture stability. The lingualized occlusion limits the range of excursive balance and direct forces to the lingual side of the mandibular ridge during working side contacts. These contacts may reduce the horizontal stresses, thereby enhancing denture stability by controlling the leverages induced by lateral/protrusive (eccentric) tooth contacts.
B. Tooth Position
Artificial teeth arrangement should be as close as possible to the position previously occupied by the natural teeth. Only slight modifications should be made to improve leverage and aesthetics. Complete stability is often difficult to achieve due to the yielding nature of the supporting structures. The wider and larger the ridge and the closer the teeth are to the ridge, the greater is the lever balance. The more lingual the teeth are placed relative to the ridge crest, the greater the balance. The more buccally placed the teeth, the poorer the balance. More centered is the force of occlusion anteroposteriorly; greater is the stability of the denture base.
C. Occlusal Plane
There is a general tendency to regard the occlusal plane as being related mainly to esthetics and occlusion. However, the occlusal plane is also an important factor of stability. Ideally, the best stability occurs when the occlusal plane is parallel and anatomically oriented to the ridges. An occlusion plane that is too high forces the tongue into a new position. This can disrupt the normal position of the floor of the mouth, resulting in partial loss of the border seal. If the occlusal plane becomes tipped (anteriorly or posteriorly), there is a shunting effect and a loss of stability. If the occlusal plane is lower in the molar area, there is a tendency for the upper denture to be displaced posteriorly and the lower anteriorly. If the occlusal plane is lower in the incisor area, the shunting effect is the opposite.
Other Factors
A. Patient Muscle Control and Coordination
A well-coordinated patient usually manages even if the dentures are not retentive and stable; these patients are called “oral acrobats,” but this situation should not be taken for granted. Conversely, if the patient has poor muscle control, especially if complicated by conditions of senility, Parkinsonism, etc, even an ideal fit may still leave the patient in a situation where he or she cannot manage the dentures. Thus, patient education and training are vital.
B. Tongue Factor
The position of the tongue is also important in denture stability and retention. If the tongue retracts upon opening the mouth, it is virtually impossible to obtain a good lingual border seal of the lower denture. To overcome this, a training groove is made just below the central incisors. The patient is instructed to place the tongue in the groove during denture use, except when eating or speaking. Most patients can learn to keep their tongue in this correct position in a few weeks. Afterward, the groove can be filled in with auto-polymerizing acrylic resin. Adequate tongue support prevents anteroposterior movement of the mandibular denture, thereby enhancing stability.[8]
Clinical Significance
An unstable denture may result in reduced maximum bite forces. Due to disuse atrophy, the jaw muscles may weaken in such cases.[9] This situation is a vicious cycle, as the resultant weakening of the jaw muscles may further reduce maximum bite forces during mastication. This effect is more pronounced in patients with long-term use of conventional dentures and in those with unstable lower dentures.[10] An unstable denture affects not only masticatory efficiency but also the patient's psychology. In patients, particularly those who are more socially active, unstable dentures may lead to social isolation due to embarrassment; this also affects patients' diets and contributes to malnutrition.
Other Issues
In cancer patients undergoing oral cavity and tongue resection, denture stability is difficult to achieve. Resection of the part of the tongue can impair the movements of the tongue musculature required while recording the neutral zone. As a result, the forces of the cheeks and lip musculature are not neutralized, and stability is affected.
Enhancing Healthcare Team Outcomes
Proper geriatric care requires an interprofessional approach involving specialists from different aspects of healthcare. Apart from the regular assessment of other body functions, oral health also requires assessment, and thus, a dental practitioner should be involved. If the patient needs a denture and has inadequate ridge support, which is one reason for denture instability, the dentist may opt for surgical procedures to enhance the rehabilitative outcome. In such cases, teamwork between the dentist and the patient’s general physician is necessary, as geriatric patients may be suffering from some systemic illness or may be on medication that precludes surgery.
In cancer patients in whom mandibular and/or tongue resection has taken place, and the oral surgeon is fabricating a denture, achieving retention and stability can be challenging. These patients may experience psychological issues, with very few returning to presurgical levels of social function. In such cases, since rehabilitation is complex, a well-planned, coordinated effort involving many disciplines, such as the oral surgeon, prosthodontist, speech therapist, psychiatrist, social service workers, and dietician, is required.
Also, before starting treatment for completely edentulous patients, a thorough examination of the oral cavity must be performed, as it can provide crucial information about the dryness of the oral mucosa. The hyposalivation may be due to some medication or an illness. The dentist and family physician should adopt the interprofessional team approach, especially for geriatric patients, although all patients benefit from this paradigm.
Nursing, Allied Health, and Interprofessional Team Interventions
As geriatric patients become more debilitated and dependent on caregivers/nurses, it becomes imperative that nurses are trained to provide daily oral hygiene care to these patients. The nurses must be aware of the precautions to take when performing oral hygiene for patients with dentures. Care is necessary to prevent abraded fitting surfaces on the denture. The patient should use a denture cleanser instead of conventional toothpaste, bleach, and vinegar for denture cleaning. Using methods other than denture cleanser abrades the polished surface, leading to plaque accumulation and denture odor. They should be able to identify when to refer the patient to the dentist.
Nursing, Allied Health, and Interprofessional Team Monitoring
Nurses should monitor oral hygiene daily and explore any problems that may arise with the denture. As unstable dentures may lead to various functional, social, psychological, and nutritional problems, daily monitoring can help in early intervention if required.
