Prosthodontics

Clinical application of a soft denture liner: A case report

Russell T. Williamson* Palienls with thin, nonresilieni mucosa, poor ridge morphology, chronic xerostomia, and acquired or congenital defecis are candidates for soft denliire liners. Soft denture liners may be placed during fabrication of the neiv denture or during relining of the existing dentures. Soft mandibular denture liners are ideal for senior patients with resorbed mandibular ridges who need replacement ofexi.'iling dentures ro correct excessively closed vertical dimension ofocchision and for patients who have maxillaiy complete dentures and mandibuiar natural teeth, severe loss of maxillary ridge, and clenching habits. Soft denture liners should be used only when needed because of their short service life. However, for those patients who cannot tolerate hard denture bases, soft liners are an appropriate alternative treatment- (Quintessence im 1995;26:4I3-4S.)

Introduction

Patients with severe alveolar ridge rsorption, senile atrophy of the mucosa, a history of alveolar surgery, deep anatomic undercuts, bony protuberances, xerostomia, cotnplete dentures opposing natural dentition, and acquired or congenital defects may require soft-lined denture bases. These soft liners distribute stress more evenly than do hard denture bases on the supporting structures under the denture base. Kawano et al' found that when soft denture liners are not used, the area of greatest stress concentration is the mylohyoid ridge because the mandibular denture rotates in that direction. The denture studied was supported on the lingual slope of the residual ridge. When soft denture liners are added to the denture base, the stress distribution in the supporting ridge differs according to the design of the soft denture liner. However, the displacement of the denture increases when soft denture liners are used. The direction and amount of movement are related to the design of the

* Assiscanl Professor, Department of Health Practice, University of Kentucky, Coltege of Dentistry. Chandler Medical Center. Lexington, Kentucky. Reprint requesti: Dr R. T, Williamson, Assislant Professor, Depaiimenl of Heallh Practice, Room D-64K, University of Kentucky, College of Dentistry, Chandier Medical Center, Lexington. Kenlucky 40536-0084.

liner. The four designs Kawano et al ' used were () no soft denture liner, (2) a soft denture liner covering the soft mucosa and extending to the periphery of the denture, (3) a soft denture liner covering the attached mucosa but not extending to the periphery of the denture. (4) a soft denture liner between the denture base and the artificial teeth. The third design results in the most uniform stress distribution on the soft tissue. During fabrication of the new prosthesis with a soft denture liner, a spacer is needed during the trial packing of the flasks to create space for the soft liner. Materials that may be used as the spacer include silicone putty, baseplate wax, spacer paper, tinfoil, or a thermoplastic vacuum-formed sheet. Huband" described a technique of fabricating a spacer from visible light-curing resin. The advantages of a light-curing material are that the thickness of the material can be measured easily with a periodontal probe prior to light curing, the imprint of a denture tooth shows on the light-curing material during flask closure if there is inadequate space, and the cured spacer can be relieved with a bur where the denture base is too thin during trial packing. Kutay^ reported use of a silicone rubber spacer to determine the optimal thickness of both the soft liner and denture base. A minimutn of 2 mm of liner and 3 mm of acrylic base is recommended by the author.

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An acrylic resin baseplate is adapted over a twothickness wax spacer. The baseplate has four finger widths of acryhc resin extending to the top of the land area supporting the acrylic resin base after the wax spacer is removed. The correct-thickness acrylic resin base is then seated over silicone putty, adapted to the master cast, and trimmed. Conventional waxup and try-in are then completed on the trial base with the silicone spacer. Dootz et al'' compared the physical properties of 11 soft denture-lining materials after accelerated aging. They reported that three distinctly different types of soft liners are used. The largest group of materials tested was plasticizer polymers or copolymers: two materials were silicones, and one was a polyphosphazene fluoroelastomer. They concluded that no denture liner proved superior to all others and that accelerated aging dramatically affects the physical properties of many of the elastomers.* The changing of the physical and mechanical properties also affects the color stability of the soft liners. Shotwell et aP reported the effect of accelerated aging of five different soft liners. The critical remarks of color difference range from "slight to very much." The polyphosphazene fluoroelastomer. for example, was rated to exhibit "veiy much" of a color change. Granata and Staffanou* evaluated a new denture hath solution and its effects on 10 different liners treated with oxidizing solutions and inoculated with Candida albicans. The authors concluded that the new denture bath material (Oral Safe. Great Lakes Orthodontics), which controls Candida albican.i and bacteria, seems to preserve the integrity of soft liners.^ As the physicai and chemical properties of the liner change with age. the adhesive strength is also affected. Sinobad et al' tested bond strengths of three soft liners after submersion in 31C water for 7 and 90 days. After saturation in water, acrylic resins exhibit an increase in tear resistance, and silicone materials deteriorate. The results indicated that denture soft liners have variable water sorption rates. Polyzois** reported the shear adhesive strength of three soft liners. His findings showed that all of the lining materials tested were acceptable for clinical use, but that a 4-month water storage reduced their bond strength to visible light-curing resin. The polyphosphazine fluoroelastomer lining material showed the highest values for bonding strengths and had mainly cohesive failures. Clinical useilness and long-term success are the best measures of soft liner materials. Ryan ' reported on 25 years of clinical application of a heat-curing silicone rubber soft lining material (Molloplast-B, Regneri). The author summarized that heat-curing silicone soft liner is an important adjunct to removable prosthodontic treatment modalities. The dentist must follow good prosthodontic principles, provide close technical supervision, and promote good oral hygiene in the patient. Silicone soft liner material will promote the patient's satisfaction with the prosthesis and will provide serviceability over the normal lifetime of the prosthesis. Case report A woman in her mid-60s, who was in good general health and had no contraindications to conventional dental therapy, requested a new set of dentures. Her chief complaints were: "The lower dentures are loose and I must use a liner in the center. My jaws come too close together, it is hard to chew my food, and my chin is too close to my nose." The patient's appearance revealed classic signs of closed vertical dimension of occlusion. The chin appeared close to the nose, the commissures of the lips were turned down, angular cheilitis was apparent, and the lips had no fullness. The muscles of the face appeared flabby instead of firm and full (Fig 1). The patient presented with 30-year-old porcelaintooth maxillary and mandibular complete dentures that were poorly fitting. The dentures were originally fabricated so that the mandibular incisors occluded with the lingual aspect of the maxillary incisors, but, over the years, the rsorption of the alveolar ridges had closed the vertical dimension of occlusion and the mandibular occlusion had moved into an Angle Class III relationship in which the mandibular incisors were positioned labial to the maxillary incisors. The mandible was not in centric relation during maximal intercuspation (Fig 2). The patient was using a self-applied soft liner in the areas of the resorbed ridge (Fig 3). The soft liner solved the knife-edged ridge soreness by more evenly distributing the occlusal load on the ridge. However, as the mandibular alveolar bone continued to resorb, the exposed mental nerve became more and more painful to increased denture base loading. This was confirmed clinically when finger pressure was placed on the sharp ridge and exposed nerve and a painful response was elicited. The same pressure in unaffected areas did not produce a painful response. Compounding the problem was the thinning of the mucosa (as observed in senile atrophie mucosa).

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Fig 1 The palient's appearance reveals classic signs of closed vertical dimension ol occlusion.The chin appears cicse to the nose, the commissures of the lips are turned down, angular ctieilitis is apparent, and the lips have no fullness.

Fig 2 Over the years, the rsorption of the alveolar ridges has closed the vertical dimension of occlusion and the mandibular occlusion has moved into an Angle Class III relationship in which the mandibular incisors are positioned labially to the maxillary incisors.

Xerostomia further complicates denture treatment. The lack of saliva creates a situation in which tissue-base friction impedes the displaced denture base from easily reseating. This creates pressure on tender, sharp ridges and exposed nerves during functional loading of the displaced denture. The absence of nonnal salivary antibacterial enzymes also increases susceptibility to oral ulcers. Dry mouth can result from chronic use of drugs (anticholinergics, antidepressants, antihistamins, benzodiazepines. adrenergics. and diuretics), radiation treatment, or diseases {Sjogren's syndrome, acquired immunodeficiency syndrome, rheumatoid arthritis, or lupus). ClinicaUy, dry lips, buccal mucosa, and lack of saliva when glands are palpated are useful signs. Referral ofthe patient to a specialist in oral medicine may be appropriate. The patient agreed that the treatment of choice was a new conventional denture, fabricated at the correct vertical dimension of occlusion, with a polyphosphazene fluoroelastomer soft liner placed in the mandibular denture. The new denture was fabricated conventionally with a vacuum-formed mandibular occlusion base technique to the compression flasking stage (Fig 4), During boil-out, ihe vacuum-formed sheet was saved and used for the polyphosphazene fluoroelastomer soft liner spacer (Fig 5). The spacer should be 1,0 to 1,5 mm at the roll, tapering to 2,5 to 3,0 mm over the crest ofthe ridge. There should be at least 1,0 mm of hard denture base resin for strength. With the spacer in place on the cast, denture resin was packed in the ask. Trial packing was accomplished as needed, all excess resin was removed, and then the flask was closed and pressed with the spacer and the

Fig 3 The patient has been using a sell-applied sofi liner in ihe resorbed ridge bearing areas around the periphery oi ihe hard denture base.

plastic separator sheet still in place. The flask was placed into a 165 F (74 C) water bath (30 to 45 minutes), cooled, and opened (Fig 6). A strip ofthe polyphosphazene fluoroelastomer soft liner (3,0 to 5.0 mm wide) was cut and placed on the crest ofthe ridge of the stone cast. With a sheet of polyethylene between the material and the denture, the flask was closed and placed in the press. Pressure was slowly applied (1,000 to 1,500 psi for 1 to 2 minutes); the flask was then opened and excess was trimmed. The roughened denture surface and liner were painted with the bonding liquid, the flask was clamped, and the denture was slowly cured at 165'' F (74 C) for 8 hours. After curing, conventional divesting, finishing, and

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Fig 4 Ttie new denture has been fabricated conventionally by uing a vacuum-lormed mandibular occiusion base technique to the compression flasking stage.

Fig 5 During boil oui, the vacuum-formed sfieet is saved and used for the polyphosphazene fiuoroelastomer soft liner spacer.

Fig 6 With the spacer in place on the cast, denture resin is paci<ed in the flask and processed.

Fig 7

The final surface will not exhibit a high shine.

polishing were accomplished. Final finishing and adjusting were done with a sharp carbide bur, and a smooth surface was achieved by polishing with a rag wheel and slurry of pumice. The final surface did not have a high shine (Fig 7). The soft liner denture was placed in ice water to cool the material and provide a more solid and easier-to-adjust surface (Fig 8 ). (This is a helpful technique for chairside adjustments. The cooling of the material prevents the pulling of the material when excessively heated by the adjusting instrument. ) The final prosthesis was adequately adjusted to the patient's satisfaction within three appointments and was considered by the patient to be a complete success.

The occlusion was designed to result in end-to-end anterior occlusion and a balanced articulation at the correct vertical dimension of occlusion (Fig 9). The chin was farther from the nose, the commissures of the lips turned up, the muscles of facial expression had more tonicity, and the face was firmer and Riller (Fig 10). The patient was made aware of the need for replacement of the soft liner every 1 to 2 years, as well as the time and the expense involved, before the treatment began.
Discussion

The combination of loss of resiliency of the mucosa,

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Fig 8 The reiined denture is placed in ice water lo cool the material and to provide a more solid and easier-to-adjust surlace

Fig 9 The color change associated wilh aging of the sott iiner is accelerated by the patient's use of bleaching agents to clean the prosthesis. The correct hard and soft liner design, liner thickness, bonding technique, and home care will prevent the tearing of the material that occured in this liner.

Fig 10 The occlusion has been designed to result in end-to-end anterior occlusion and a balanced articulation at the correct vertical dimension of occlusion.

Fig 11 The new denture has improved the tacial appearance. Tie chin is farther from the nose, the commissures of the lips turn up, the muscles ot tacial expression have more tonicity, and the face is firmer and fuller.

exposed mental nerve, and sharp, knife-edged, irregular resorbed ridge creates a very poor prognosis for patients who need their dentures remade. Usually these patients have very little attached gingiva. The soft liner design in which only the attached gingiva is covered would be less desirable than that in which all the mueosa is covered, because of the exposed mental nerve and the prominent mylohyoid ridge. Soft mandibular denture liners are ideal for patients with resorbed mandibular ridges who need replacement of existing dentures. Soft denture iiners should be used only for those patients in need, because soft liners have a short life, and additional expense and time are required for replacement. However, for those

patients who cannot tolerate hard denture bases, soft liners are an appropriate alternative treatment to hard denture bases. The color change associated with aging of soft liners is accelerated by patients' use of bleaching agents for cleaning the prosthesis (Fig 11). Patients are cautioned to use only mild soaps as cleaners. One patient who had a son liner replaced reported that the lifespan of the polyphosphazene fluoroelastomer soft liner was increased by cleaning under cold water only. The patienl thought that the material, which has a thermoplastic quality, was stronger and less affected by the normal abrasion of the cleaning procedure. Use of the correct hard-soft liner design, liner thickness, and

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bonding technique, as well as appropriate home care, will prevent tearing of the material (Fig 3). All of these probably contributed to the liner failure in this instance.

Prosthetic Rehabilitation
Ki'ilh F. Thomas

Acknowledgment
The author would like to thank William P. Cassady for tiis assistance in fabricating the prosthesis and Dr Ldrry C. Breeding for tiis editorial assistance.

References
1. Kawano F, Koran A, Asaoka K, Matsiimoto N. Effect of sofl denture liner on stress distribution in supporting structures under a denture. Int J Prosthoont l993;6;43-49. 2. Huband ML. Spacer made from visible light-cured resin for processing denture soft liners. J Prosthet Dent 1992:68:542-544. 3. Kutay O. A silicone rubber spacer used to delermine the oplimum thickness for hard resilient materials in comptete dentures. J Prosthet Dent 1993:69:329-332. 4. Dootz ER, Koran A, Craig RG. Physical property comparison of i I denture lining materials as a flinctioti of acceterated aging, J Prosthet Dent t993:69:lt4-lt9, 5. Stiotweli JL, Razioog MK, Koran A. Color stability of long-term soft denture liner5 J Prosthet Dem 1993:68=836-838. 6. Cranata JS, Staffanou RS. Evaluation of anew denture bath solution. J PruslbetDent 1991;66:790-791. 7. Sinobad D, Murphy WM, Huggctl G, Brooks S. Botid strength and rupture properties of some sofl tiners, J Oral Retiabil 1992;19:15i160, 8. Polyzois GL. Adhesion properties of resilient litiing materials bonded to iight-cured denture resins. J Prosthet Dent I992;68:854. 9. Ryan JE. Twenty-five years of clinical application of a heat-cured siiicunc rubber. J Prosthet Dent 1991:65:658-661, D

liiij cuiriiJiclicrisivi.' book; presents sl.ep-by-step tecliniques in facial and bodily prosthetic rehabilitation. In addition to technique, theory and materials are discussed, and twenty-eight case histories are featured. This highly practical text will he of interest to not only prosthetic technologists, but to plastic snrgeons and others who sock better technician-clinician COinmutiication in prosthetics.

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Prosthetic Rehabilitation

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Contents include: P^ychlogicai ConsidrtOIIM: Puticiu A>sc^siiiciit; Tidjjression and Facial Materials; Impression Techniques; Ear Prostheses; Nasal Prostheses; Orbiliil Prostheses; Partial Prostheses; Color Matching: Ahi'mativc Methods of Fixation and Reteni ion; Direct Adhesive Fixation Using Adhpsives and Removers: Tissue Conditioning; Fitting the Prosthesis; Osseoiiitegrated Impliints; Remakes; Prohlems; Glossary; Skhi Grafts, Flaps, and Tissue Exparision: and Anatomv.

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