THE RETENTION OF COMPLETE DENTURE

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Introduction Factors involved in retention of denture Interfacial force Inter facial viscous tension Adhesion Cohesion Oral and facial musculature Atmospheric pressure Under cuts, rotational insertion paths and parallel walls Gravity Adjunctive retention through the use of denture adhesives Components and mechanism of action Indication and contraindications Patient education Other Aids to retention Springs Suction chamber Rubber suction Magnets Presented by Surinder Kumar
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Factors for relations Physiology factors Physical tone Quality and quality of saliva Ridge retention skip Psycological Empetation of patients. Eprihension and fear of embessment Aigging Mechanical Deelusion Arch form Contour of denture basic Location of occlusal plane Surgical Implants Vestibuloplasty Ridge Augmentation Penetration Use of Hydroxiapits Silicone graft Retention of denture The resistance of denture to dislodgment. Or complete denture retention is resistance to displacement of denture base away from the ridge Primary retension. It directly proportional to over covered. Secondary retensions Is what be active

THE RETENTION OF COMPLETE DENTURE INTRODUCTION: Optimal outcome of complete denture treatment depends on the success integration of the prosthesis with the patients functions plus psychological acceptance of the dentures by the patient. These parameters require that patients receive their dentures as stationary or well retained during function, and that the prostheses and their effects on the face meet the esthetic and psychodynamic requirements of the patients. We will diseases, the factors in achieving retention (the resistance to removal in the direction opposite that of insertion). FACTORS INVOLVED IN THE RETENTION OF DENTURES INTERFACIAL FORCE: Inter facial force is then resistance to separation of two parallel surfaces that is parted by a film of liquid between them. A discussion of interfacial forces is best broken into separate comments on inter facial surface tension and visions tension. INTERFACIAL SURFACE TENSION Results from a thin layer of fluid that is present between two aprallel planes of rigid material. It is dependent on the ability to wet the rigid surrounding material. If the surrounding materials has low surface tension, as oral mucosa does, fluid will maximize its contact with the material, there by wetting is readily and spreading out in the thin film. If the material has high surface tension, fluid will minimize in contact with the material, with the result that it will form beeds on the materials surface. Most denture base material have higher surface tension than oral mucosa, but once coated with salivary pallicle that display low surface tension that promotes maximizing the surface area between liquid and base. The thin fluid film between denture base and the mucosa of basal seat there fore furnishes a retentive force by virture of the tendency of the fluid to maximize the contact with both surfaces. Another way to understand role of surface tension is denture retention is by describing capillary attraction, or capillavity. Capillarity is
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what causes a liquid to rise in the capillary tube, there by rising along the tube wall at the interface between liquid and air when the adaptation of the denture base to the mucosa on whids it rests in sufficiently close, the space filled with a think film of saliva acts like a capillary tube in that the liquid seeks to increase in contact with both the denture and the mucosal surface. In this way capillarity will help to retain the denture. Interfacial surface tension may not play as important role in retaining the mandibular denture as it does in maxillary one. Interfacial surface tension is dependent on the existence of a liquid/air interface at the terminus of the liquid/solid contact: If the two plates with interposed fluid are immersed in the same fluid, there will be no resistance to bulling them apart. In many patients there is sufficient saliva to keep the external borders of the mandibular a wash in saliva, thereby eliminating the effect of interfacial surface tension. This is not is maxilla. INTERFACIAL VISCOUS TENSION: Refers to the force holding two parallel plates together that is due to the viseosity of the interposed liquid. Viscous tension is described by stefans law for two parallel, circular plates of radius and that are separated by a newtonian (incompressible) liquid of viseosity k and thickness h, this principle states that the force(F) necessary to pull the plates apart of a velocity V in a direction perpendicular to the radius will be: 3/2II k x 4 F = V h3 The relationship expressed by stefans low makes it clear tht eh viscous force increases proportionally to ncrease in the viscosity of the interposed fluid. The viscous force drops of readily as the distance between the plates (i.e, the thickness of the interposed medium) increases. The force increases proportionally to the square of the area of opposing surfaces. When applied to denture retention, the equation demonstrates the essential importance of an optimal adaptation, between denture and basal seat (a minimal h), the advantage of maximizing the surface area covered by the denture (a maximum r), and the theoretical improvement
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in retention made possible by increasing the viscosity of the medium between the denture and its seat. It also explains why a slow, steady displacing action (small V) may encounter less resistance, and therefore, be more effective at removing a denture than is a sharp attempt at displacement (larger V). In application, interfacial forces are further enhanced through ionic forces development between the fluid and the surrounding surfaces (adhesion) and the forces holding the fluid molecules to each other (cohesion). ADHESION: Adhesion is the physical attraction of unlike molecules for each other. Adhesion of saliva to the mucous membrane and the denture base achieved through ionic forces between charged salivary glycoproteins and surface epithelium or acrylic resin. Both promoting contact of saliva to both oral tissue and denture base, adhesion works to enhance further the retentive force of inter facial surface tension. In xerostomia, the denture base material seem to sticks to the dry mucous membrane of the basal seat and other oral surfaces. Such adhesions are not very effective for retaining dentures, and predisposes to mucosal abrasions ulcerations due to each of salivary lubrications. An athanol free = rinse containing aloe or lanolin, or a water soluble lubricating jelly can be helpful in this situation. For patients whose mouths are dry due to irradiation or an autoimmune disorder such as sjogerns syndrome, salivary stimulation through a prescription of 5 to 10 mg of oval pilocarpine three times a day can be very beneficial if the patient can tolerate the likely side effects of increased perspiration and (occasionally) excess lacrimation. The amount of retention provided by adhesion in proportionate to the are covered by the denture. Mandibular denture cover less surface area than maxillary prostheses and, there fore subject to a lower forces. Similarly, patients with small jaws or very flat alveolar ridges (small basal seats) can not expect retention to be as great as can patients with large jaws or prominent alveoli. Thus dentures should be extended to the limits of health and function of the oral tissues, and efforts functions of the oral tissues, and efforts should at all times be made to preserve the alveolar height to maximize retention.
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COHESION: Cohesion is the physical attraction of like molecules for each other. It is a retentive force because it occurs within the layer of the fluid (usually saliva) that is present between the denture base and the mucosa, and works to maintain the integrity of the interposed fluid. Normal saliva is not very cohesive, so that most of retentive force of denture mucosa interfare comes from adhesive and interfacial factors unless the interposed saliva is modified (as it can be with the use of denture adhesives). Thick, high mucin saliva is more viscous than thin, uretary saliva yet thicks secretions usually do not result in increased retention for following reason watery serous saliva can be interposed in a thinner film then the more cohesive mucin secretions stefens law makes it clear, all other factors being equal, that increase in fluid viscosity can not be accompanied by an equal increase in film thickness if displacement force is to be kept the same. ORAL AND FACIAL MUSCULATURE The oval and fascial musculature supply supplementry retentive forces provided. 1. 2. The teeth are positioned in neutral zone between the cheeks and tonuge. Polished surfaces of dentures are properly shaped so that the buccal and lingual flanges must make it possible for the musculature to fit automatically against the denture and there by to reinforce the border seal. One of the objectives in impression making and arch form design is the harnessing of a patients unconscious tissue behaviour to enhance both retention and stability of the prostheses. If the buccal flanges of the maxillary denture slobes up and out from the occlusal surfaces of the teeth and the buccal flanges of lower (mandibular) denture slobe down and out from occlusal plane, the contraction of the buccinators will tend to seat both dentures on their basal seats.

The lingual surfaces of the lingual flanges should slope towards the center of the mouth so the tongue can got against them and perfect the border seal on the lingual side of the denture. The base of the tongue is guided on the top of the lingual flange by the lingual side of the distal and of the flange, which turns laterally toward the ramus. This part of denture also helps ensure the border seal at the back end of the mandibular denture. The base of the tongue also may serve as an emerging retentive force for some patients. It rises up at the back ad press against the distal border of the maxillary denture during incision of the good by the anterior teeth. This is done without concious effort when the experienced denture wearer bites into an apple or sandwich or other good. It is seldom that the patient need to be taught how to do this for the oral and the facial musculature to be most effective in providing retention for completes dentures, the following conditions must be met. 1. The denture bases must be extended to cover the maximum are possible, with out interfering in health and function of the structures that surround the denture. Occlusal plane must be at correct level. Arch and form of teeth must be in Neutral zone between the tongue and the cheeks. The buccal surfaces of the mandibular dentures in the first bicuspid region, should be shaped carefully so as not to interfare with the action of modiolus connecting the fascial muscles with the orbicularis oris muscle.

2. 3. 4.

ATMOSPHERIC PRESSURE: Atmospheric pressure can act to resist dislodging forces appeared to dentures, if the dentures have an effective seal around their border. This resistance of force is called suction because it is resistance to removal or dentures from their basal seat, but there is no suction, or negative pressure except, when another force is applied (Suction alone

applied to the soft tissues of the oral cavity for then a short time would cause serious damage to the health of soft tissue under negative pressure). A suction cup pressed against a plane of glass stays in place because the rubber of the squeezed cup elastically seeks to return to a large shape, there by causing air pressure within the cup to be less than the pressure outside the cup. A denture can not distorted like a suction cup, but oral mucose can be, when a force is excerted perpandicular to and away from the basal seat of a properly extended and fully seated denture pressure between prosthesis and basal tissue drops below the ambient pressure, resisting displacement. Retension due to atmospheric pressure is directly proportionate to the area covered by the denture base. For atmospheric pressure to be effective, the denture must have a perfect seal around its entire border. Proper border moulding with physiological, selective pressure techniques is essential for taking advantage of this retentive mechanism. Undercuts, rotational insertion paths and parallel walls. The resiliency of the mucosa and submucosa overlying absal bone allows for the existence of modest under cuts that can enhance retention. Although aggregates bony undercuts or less overt ones covered by thin epithelium may compromise denture retention by necessitating extensive internal adjustment of the denture, less severe undercuts of the lateral tuberosities, maxillary premolar areas, distolingual areas and lingual mandibular midbody area can be extremely help-fine to the retention of prosthesis. Some under cuts are only under cut is relationship to the linear path of insertion or relative to a presumed vertical path of insertion. But if the undercut area is seated first (usually in a direction that deviates from the vertical) and the remainder of the denture base can be brought into proximity with the basal seat on rotation of the prosthesis around the under cut part that is already seated this rotational path will provide resistance to vertical displacement. One common example of this is to be found in the area inferior to retromolar pad, into which the distolingual extensions of the mandibular base can be introduced from the superiof and posterior prior to rotating the anterior segment of the denture down over the alveolar process the opposite sequence is common is maxilla, where a prominent or even under cut anterior alveolus may dictate an
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insertion path that begins with eating the anterior in a posterior and superior direction and ends with rotation of the posterior border over the backs of the tuberosities. The concept increases in importance as other retentive mechanism decline is strength for instance patients who has undergone loss of normal anatomic contours due to tumar resection or trauma, surgically created relative under cuts may mean the difference between prosthetic success and failure. Prominent alveolar ridges with parallel buccal and lingual walls may provide significant retention by increasing the surface area between denture and mucosa and there by maximizing interfacial and atmospheric forces. Prominent ridges also resist denture movement by limiting the range of displacive force directions possible. Very flat ridges may bear dentures that display strong resistance to displacement perpendicular to the basal seat, due to atmospheric pressure (forces). Yet susceptible to movement parallel to the basal seat, analogous to sliding a suction cup along a plane of glass, or sliding apart two glass pieces separated by interulnning fluid. GRAVITY: When a person it in upright posture, gravity acts as retentive force for the mandibular denture and displacive force for the mandibular denture and a displacive force for the maxillary denture. In most cases, the weight of prosthesis constitutes a gravitational force that is insignificant in comparison with the after forces acting on the denture. But if maxillary denture is fabricated wholly partially of a material that increases weight appreciable (e.g. a metal base or precious metal posterior occlusal surfaces), the wieght of prosthetics may worth to unseat it if the other retentive forces are themselves suboptimal. Increasing the weight of mandibular denture (throught the addition of a metallic base, insert, or occlusal surfaces) may seem theoretically capable of taking advantage of gravity. Anecdotal evidence suggests that this may indeed prove beneficial in cases where the orthor retentive forces and factors are marginal. Adjunctive retention through the use of denture adhesives Complete denture treatment needs to be customized for each patients particular needs. Successful treatment combines exemplary technique, effective patient rapport and education, and familiarity with all
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possible management options in order to provide highest degree of satisfaction. Commercially available denture adhesive products that have capacity to enhance treatment outcome this reality is compelling underscored by two facts. 1. 2. Consumer survey reveal that approximately 33% of denture patients purchase and use one or more denture adhesive products. Denture adhesive sales in U.S. exceeded $200 million in 1994. Dentist need to know about denture adhesives for two veasons i) ii) To be able to educate all denture patients about advantages and disadvantages. To identify those patients for whom which a product is advisable.

Components and medianism of action Denture adhesives augment the same retentive mechanisms already operative when a denture is worn. They enhance retintion through optimizing inter facial forces by: 1. 2. Increasing the adhesive and cohesive properties and viscosity of the medium lying between the denture and its basal seat. Eliminating voids between denture base and its based seat

Denture adhesive materials in use prior to the early 1960 were based on vegetable germs such as Karaya, tragacanth, xanthan, and acacia. Synthetic materials presently dominate the denture adhesive market. The most popular and successful productsconsists of mixtures of satts of short acting (carboxymethyl cellulose or C.M.C.) and long acting (poly vinyl methyl ether maleate) or gantrez polymers.

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Indications and contraindications Scientific evidence favouring the support of routine and safe use of adhesive in lacking yet clinical experience indicates that prudent use of adhesives to enhance the retentive qualities of well made complete denture is sound clinical judgment. Denture adhesives are indicated when were made completes denture do not satisfy a patients perceived retention and stability expectations. Irrespective of underlying reason for a patients reported dissatisfaction psychological, occupational, morphological, function and so on. Specific patient with salivary function or neurological disorders. Patients who suffer from xerostomia, the use of denture adhesive can compensate for the retention that is lecking in the absence of ratliva, and can mitigats the onset of oral ulceration. Xerostomic patients must be educated, however the adhesive bearing denture will need to be deliberately moistened. Several neurological diseases can complicates the use of complete denture, but adhesive may help to overcome the impediments imposed. Patients who have undergone resective surgery for removal of oval neoplasia, or those who have lost intra oral structures and integrity due to trauma may have significant difficulty in functioning with tissue borne prosthesis unless denture adhesive is employed, even if rotational undercuts have been surgically created to resist displacement of the prosthesis.

It must be emphasized that a denture adhesive is not indicated for the retention of improperly fabricated or poorly fitting prosthesis. PATIENT EDUCATION: Obtaining the advantage from the use of an adhesive product is dependent on its proper usage for powder and cream products, the least amount of material that is effective should be used. This approximately
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0.5 6o 1.5 gm per denture unit for powder the prosthesis should be moistened and then, a even coating of the adhesive sprayed onto the tissue surface of the denture the excess is shaken off and the prosthesis inserted and seated firmly. For crams the approaches are possible. First, placement of thin beads of adhesive in depth of dried denture in incisor and molar regions and, in the maxillary unit, and anterio posterior bead along the midpalate. Second, small spots of cream are placed at 5 mm intervals through out the fitting surface of dried denture. Patient must be instructed that daily removal of adhesive product from the tissue surfaces of the denture is an essential requirement for the use of material. Other AIDS to retnention There are certain devices which aid in holding full dentures in place but their permanent use should only be employed as a last resort. Some are discussed here. 1. Springs: Then are made of coiled stainless steel or gold plated base metal and have their ends attached to swivels in the premolar area on both sides of the upper and lower dentures. The dentures are thus permanently attached to each other and are held in occlusion for insertion into the mouth, as soon as they are released the dentures are forced apart by the action of the springs and held in place. Recently nylon springs of continental origin have become available. These have the advantage of being thin and not collecting food. Their life in limited to about six months and the method of their attachment to the denture, which is a nylon ball and socket joint, is not very efficient. If thin were improved they would be very satisfactory.

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Disadvantages: 1. 2. 3. 4. 5. Constant Pressure may cause excessive alveolar absorption. Some cases the mucous membrane will not tolerates the constant pressure. The inner surface of the cheeks frequently become sore from in frictional contact with the springs. Lateral movements are extremely restricted and hence the efficiency of denture is impaired. They are unhygenie. When in the mouth, the cools of springs are separated enough the allow small particles of good to pass between them into the hollow centre: out of mouth the cools are in close contact and so are very difficult to clean.

2. Suction chambers: These often resemble relief areas in shape but differ from them in having a clearly defined outline instead of marging into the surrounding surface. When the denture is inserted the patient creates partial vacum in this chamber by sucking and swallowing and this small area of reduced pressure helps to keep denture in place. The mucous membrane in this area of reduced pressure will proliferate, and in time will got the whole suction chamber, thus limiting the amount of damage (hyperplasia) which can cause Uses: i) ii) iii) To prolong the usefulness of immediate denture. To assist in retention of dentures in difficult cases. Deliberately to raise a stud of hypertrophied tissue in the palate to assist in lateral stability in cases with a very flat palets and very small sulci.

Disadvantages: They only function for few months before they are filled with proliferated tissue.
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3. Rubber suction discs: Although they are still used they are included to condemn them they consist of a rubber disc which is buttoned onto a stud sunk into the fitting surface of a denture. The partial vacum created within the perimeter of this disc holds the upper denture suspended from the hard palats they cause a constant irritation and no operator who has had to misfortune to see a case of epithelioma resulting from the use of one of these discs. Disadvantages: Due to the swelling and spreading of the rubber disc they are not self limiting in action as is the case with a suction chamber cases have been reported where the constant irritation has caused, not only perforation of the hard palates, but in some cases a malignant tumour (epithelioma). They are unhygenic. The soft rubber disc is porous and is soon perishes, swells and becomes very foul. 4. Magnets:

From time to time the use of small steel magnets embedded beneath the molar and premolar teeth and arranged with similar poles opposites each other, has been advocated. In theory the repulsion effect will keep both dentures in place but in practice it will be found that owing to magnetic force being inversely proportional to the square of the distance and also the small size of the magnets which it is possible to girt, that the repulsive are separated by more than one or two millimeters. SUMMARY Establishing optimal complete denture retention requires an understanding of the factors discussed. Incorporation of these determinants into the prosthesis through proper design and technique contributes to the success of complete denture. REFERENCES: 1. 2. Bouchers: Proshtodontic treatment for edentulous patients, 11th ed. Clinical Dental Prosthetics: H.R.B. Fenn, 2nd Edition.
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3. 4. 5.

Complete Denture Prosthesis: Gehl, 4th ed. Syllabus of complete dentures: Charles in Hartwell, 4th ed. Complete Dentures: Marrill G. Swenson, 4th ed.

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