REMOVABLE PROSTHODONTICS

SECTION EDITORS
LOUIS BLATTERFEIN S. HOWARD PAYNE
A contemporary review of the factors involved in
complete denture retention, stability, and support.
Part I: Retention
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 Francisco, Calif
lh e recognition, understanding, and incorporation
of certain mechanical, biologic, and physical factors are
necessary to ensure optimal complete denture treat-
ment. These factors are the determinants that promote
the properties of retention, stability, and support in the
finished prosthesis through their influence on the
relationship between the tissue surface of the denture
base and the mucosal surface of the edentulous ridges.
There are varied opinions in the prosthodontic litera-
ture regarding the roles played by these factors, their
relative importance, and their relationship to clinical
procedures. Numerous contradictory and controversial
articles proposing various impression techniques have
been written in an effort to achieve optimal denture
retention, stability, and support.
Bohannan appropriately noted that technique
itself is merely the practical application of principles,
and if the principles are unsound, the most elaborate
and painstaking technique certainly is doomed to
failure. It is necessary, therefore, to understand each
property and its contributing factors separately and to
recognize their interactions to be able to critically
analyze and select procedures and techniques that lead
to the fabrication of successful complete dentures
(Fig. 1).
DEFINITION OF PROPERTIES
Complete denture retention is the resistance to
displacement of the denture base away from the ridge.
Bouche? describes retention as the most spectacular
yet probably the least important of all complete
denture objectives. This property may indeed be least
important; however, it provides psychologic comfort to
the patient. If a denture is easily dislodged during
*Assistant Clinical Professor, Removable Prosthodontics.
**Chief of Dental Services, Removable Prosthodontics.
Psychologic Physiologic
Comfort
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Support
Success
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Longevity
Fig. 1. Retention, stability, and support are important
to success.
Retention
t
Psychologic
Comfort
Stability
t
Physiologic
Comfort
Prosthesis Success *
/
Fig. 2. Certain biologic, physical, and mechanical fac-
tors provide retention, stability, .and support and
thereby contribute to the properties of a successful
prosthesis.
speech or eating, the embarrassment experienced can
be mentally traumatic. A retentive denture contributes
dramatically to patient acceptance of the finished
prosthesis.
Stability is the resistance to horizontal and rotational
THE JOURNAL OF PROSTHETIC DENTISTRY
5
JACOBSON AND KROL
forces. This property prevents lateral or anteroposter-
ior shunting of the denture base. Stability has been
cited as the most significant property in providing for
the physiologic comfort of the patient. Denture insta-
bility adversely affects support and retention and
results in deleterious forces on the edentulous ridges
during function.
Support is the resistance to vertical movement of the
denture base toward the ridge. This property main-
tains the occlusal relationships established on the
articulator. A complete denture may continue to func-
tion ideally only as long as sufficient support is present
to resist tissueward movement under loading. Each of
these properties will be evaluated separately (Fig. 2).
RETENTION
Many published articles deal with the subject of
complete denture retention. Historically prosthodon-
tists have sought to improve the quality of denture
treatment through an understanding and application of
the factors involved in retention. Despite numerous
research efforts devoted to this controversial topic,
disagreements regarding the relative importance of the
various contributing factors still exist.
History
Fish was among the first to discuss the determinants
of retention and differentiate between the tissue, pol-
ished, and occlusal surfaces of a complete denture. He
emphasized that each of the three surfaces plays a role
in retention. The proper design of the tissue, polished,
and occlusal surfaces of complete dentures permits the
dentist to incorporate the mechanical, biologic, and
physical factors of denture retention.
Most prosthodontists agree that the polished surface
of a complete denture should possess certain contours to
maximize the retentive potential of the functioning
orofacial musculature.3-14 Craddock described the
gripping action of the buccinator muscle on the
buccal flange of a mandibular complete denture. To
maximize the role of the polished surface of complete
dentures, some authors have recommended that the
external base contours and tooth position be function-
ally determined. lo-l4 Proper contour and design of the
polished surface should harmonize with the function of
the tongue, lips, and cheeks to effect a seating of the
denture.
The occlusal surfaces are also important in provid-
ing a retentive prosthesis. Schlosser9 and Fishls believed
that a balanced functional occlusion is critical in
promoting denture retention. Regardless of the occlusal
scheme chosen, the occlusion must be free of interfer-
ences within the functional range of movement of the
patient to avoid dislodging forces. The position of the
teeth within each arch and the level and inclination of
the occlusal plane are important in maintaining a
stable retentive prosthesis.
TISSUE SURFACE
Several biologic and physical factors have been
described as determining the relationship of the tissue
surface of the denture base to the underlying soft
tissues that will provide optimal retention. It is the
understanding of these determinants that may ulti-
mately govern success or failure. Although magnetic
devices, implants, mechanical attachments, and recon-
structive surgical procedures have been suggested and
used in !certain situations, they do not substitute for an
awareness of the scientific principles involved in den-
ture retention. The most commonly listed factors of
retention include adhesion, cohesion, interfacial surface
tension, gravity, intimate tissue contact, peripheral
(border) seal, atmospheric pressure, and neuromuscu-
lar control.
DEFINITION OF FACTORS
Adhesion. Adhesion is the physical force involved in
the attraction between unlike molecules. A drop of
water introduced on the surface of a solid glass plate
will resist movement away from the glass in proportion
to the adhesion between the unlike materials.
Cohesion. Cohesion is the physical factor of electro-
magnetic force acting between molecules of the same
material. A molecule within a fluid has an attraction
exerted on it on all sides by neighboring molecules. The
same molecule exerts an attractive force on the neigh-
boring molecules equal in magnitude but opposite in
direction. Forces of cohesion are responsible for main-
taining the continuity of a water droplet when placed
in contact with another material.
Interfacial surface tension. This term pervades
much of the literature written concerning denture
retention obtained through the mucostatic techniques
popularized by Page. I63 Page describes interfacial
surface tension as a phenomenon similar to Wilsons
adhesion by contact. Both of these terms refer to the
forces involved in maintaining the attraction of two
opposed ground solid plates with an intervening fluid
film that resists displacing forces applied at right angles
to the fluid film surface., l9 PageZo states that interfa-
cial surface tension operates by virtue of a thin fluid
film between two intimately contacted objects. This
term is redundant in that such phenomena can be
described by the actions and interactions of the remain-
6 JANUARY 1983 VOLUME 49 NUMBER 1
COMPLETE DENTURE RETENTION
ing factors of denture retention.2 To simplify the
following discussion interfacial surface tension as a
phrase will not be used, although the phenomenon to
which it refers will be explained.
Gravity. The definition here is self-explanatory.
The physical force primarily concerns the mandibular
prosthesis.
Intimate tissue contact. Intimate tissue contact is
the biologic factor that refers to the close adaptation of
the denture base to the underlying soft tissues. The
impression technique will determine the degree of
intimate tissue contact obtained with the tissues at rest
and during function.
Border seal. Border seal is the biologic factor that
involves intimate contact of the denture borders with
the surrounding soft tissue. The seal encompasses the
circumference of the denture and includes features such
as beading and posterior palatal seal to enhance its
effectiveness.
Atmospheric pressure. Atmospheric pressure is the
physical factor of hydrostatic pressure due to the
weight of the atmosphere on the earths surface. At sea
level this force amounts to 14.7 psi.
Neuromuscular control. Neuromuscular control
refers to the functional forces exerted by the muscula-
ture of the patient that can affect retention. This is
primarily a learned biologic phenomenon. Certain
characteristics can be incorporated into the external
contours of the denture base to promote neuromuscular
control.
Although most authors agree that all these factors
contribute to denture retention, there is disagreement
regarding the relative importance of each. As early as
1886 Wilson was describing adhesion as the overrid-
ing determinant. Proponents of the mucostatic theory
place little or no emphasis on the role of atmospheric
pressure or border seal in retention. They attribute
denture retention to forces of adhesion and cohesion
resulting from the intimate tissue contact of the denture
base at rest.13b 6x *. 22x 23 Other prosthodontists believe
that atmospheric pressure together with intimate tissue
contact and peripheral seal comprise the most critical
retentive factors.24-34 Contrasting research reports have
been written in support of many of the factors. It is
necessary to critically analyze these widely divergent
opinions based on a study of the relevant research in
the prosthodontic literature.
LABORATORY MODEL SYSTEMS
Any attempt to explain the physical factors of
retention must begin with laboratory bench studies of
model systems that represent clinical situations. The
THE JOURNAL OF PROSTHETIC DENTISTRY
Atm. Pmssure
Atm.
Pressure
I
c
Meniscus
I
PCl
Fig. 3. Atmospheric pressure (Pa) is in equilibrium
with fluid pressure exerted on molecules within capil-
lary tube at level of liquid in container. Therefore,
pressure on molecules along doffed line (A) is equal to
Pa. Fluid pressure exerted on molecules at higher level
(B) is less than at level A in proportion to distance
between A and B. Because B is less than A, B is less than
Pa, which indicates presence of a pressure gradi-
ent across meniscus, which is maintained by surface
tension.
simplest system involves the attraction of two glass
slabs placed in direct apposition with an interposed
fluid film. In 1948 Stanitz2 used this model to explain
the part played by the fluid film in denture retention.
In review the phenomenon of surface tension is defined
as the force that maintains the surface continuity of a
fluid. This results from the imbalance in cohesive
forces between molecules present at the surface. The
cohesive attraction between molecules is balanced in
equilibrium within the fluid. At the surface the absence
of neighboring molecules creates the one-sided attrac-
tion and imbalance that causes a free potential energy
called surface tension. It is a relatively small force
when considered alone, but by interacting with other
physical factors it becomes an important determinant.
When water rises vertically in a column within a
capillary tube standing in an open container of water,
the fluid pressure within the water at the height of the
column is less than that at the base. The pressure at the
base of the column is equal to atmospheric pressure,
and therefore the pressure at the height of the column is
JACOBSON AND KROL
Meniscus
1
F
Fig. 4. Two glass slabs are separated by a thin fluid
film, indicated by shaded area. Top: Pressure exerted on
molecules within fluid film is equal to surrounding Pa
(atmospheric pressure at equilibrium). Bottom: Effect
of a separating force (F) exerted on the two glass slabs.
Now fluid pressure within film is less than atmospher-
ic pressure (Pal. Pressure gradient that develops is
maintained by surface tension of meniscus.
less than atmospheric pressure. This phenomenon
creates a pressure gradient across the meniscus (Fig. 3).
Although it is the forces of adhesion and cohesion that
cause the water to rise in the tube, it is the forces of
surface tension that maintain the difference in pressure
across the meniscus.
This same phenomenon explains the force that holds
two glass slabs together. Under a dislodging force
perpendicular to the fluid film, the pressure within the
fluid decreases. Together with surrounding atmospher-
ic pressure, this creates a pressure gradient across the
peripheral meniscus that has formed (Fig. 4). The
force needed to separate the glass plates is proportional
to the degree of pressure gradient that develops multi-
plied by the surface area involved. The smaller the film
thickness, the greater the pressure difference and
therefore the greater the force required to achieve
separation. A 0.0005-inch film thickness requires a
separating force of 1.68 psi. The fluid film can act in a
similar manner in complete denture retention.
tension, which drastically reduced the required sepa-
rating force. If the active forces involved in these
phenomena were primarily adhesion and cohesion, the
separating forces required would not drastically change
on immersion or reduction of atmospheric pressure.
Note that the use of glass slabs that are ground to
allow optical contact introduces molecular forces that
could never occur in clinical prosthetics. Optical con-
tact implies a separation between two objects that is
small compared to a wavelength of light. The molec-
ular forces here act independently of the factors dis-
cussed above, and the system involves an attraction that
resembles a single solid piece rather than separated
solids. Use of such experimental models may explain
some of the research reports that do not recognize the
importance of atmospheric pressure in resisting plate
separation.
Further studies use more complex experimental
models. Skinner30 and Skinner and Chung31 reported
results of controlled laboratory studies of baseplates
constructed on master casts with a resilient surface
layer simulating soft tissue. Testing the effects of post
dam (posterior palatal seal), relief chambers, and
border seal, they concluded that the posterior palatal
seal and border seal enhanced retention of the base-
plates, while the use of relief areas reduced this
property.
These studies also confirmed the experiments of
Ostlund3 regarding the effect of 1 mm perforations in
the base on retention. Except for those at the ridge
crest, introduction of small perforations significantly
reduced the baseplate retention. These observations
support the importance of using intimate tissue contact
and border seal to promote atmospheric pressure. If
adhesion and cohesion were predominant, the lack of
posterior palatal and border seal and the presence of
small perforations would not significantly alter the
retentive properties.
CLINICAL STUDIES AND OBSERVATIONS
Tysonz9 demonstrated the role of surface tension and
atmospheric pressure in denture retention in a series of
experiments in 1967. He confirmed the importance of a
thin fluid film between two plates in producing a
pressure gradient maintained by surface tension. The
system further demonstrated the importance of atmo-
spheric pressure through the use of a bell jar, which
enabled the experiments to be carried out under
varying atmospheric pressures. The separating force
proved to be directly proportional to the atmospheric
pressure. Immersing the entire system in water elimi-
nated the pressure gradient and effect of surface
A conclusive clinical study by Snyder et al.2* in 1945
demonstrated the effect of reduced atmospheric pres-
sure on the retention of maxillary complete dentures
constructed for seven patients. Measurements made in
a pressure chamber at 4.7 psi simulating a 30,000-foot
ascent above the earth demonstrated a decrease in
denture retention. With a 70% decrease in atmospheric
pressure, a 50% decrease in retention was noted.
At sea level the force of atmospheric pressure acts
with approximately 14.7 psi against the external
surface of the denture, provided no air or gaseous
pressure exists between the denture base and the tissue
8
JANUARY 1983 VOLUME 49 NUMBER 1
COMPLETE DENTURE RETENTION
surface. In reality some gas always exists due to the
partial pressure of gases dissolved in the saliva. The
presence of dissolved gases or air inclusions serves to
decrease the effectiveness of atmospheric pressure pro-
portionately.
Clinical observations of the authors are also in
agreement with the research results cited. The intro-
duction of a small palatal perforation or the presence of
an inadequate posterior palatal seal markedly reduces
the physical retention of most maxillary complete
dentures. Such effects would not be observed if the
forces of adhesion and cohesion, which depend primar-
ily on the surface area of intimate contact, were the
critical retentive factors. Certainly removal of a poste-
rior palatal seal or placement of a 1 mm perforation
does not significantly alter the surface area.
THE ROLE OF PHYSICAL FACTORS
The results of these studies and observations clearly
explain the physical retention of complete dentures.
The surface tension created at the meniscus of the
denture border maintains a pressure gradient between
the atmospheric pressure and the reduced pressure
within the fluid film that occurs during dislodging
forces (Fig. 5). To be effective air must be excluded
from the intaglio, and the fluid film must be as thin as
possible. Intimate tissue contact is the biologic factor
that promotes these conditions by eliminating air
entrapment. The border seal maintains this relation-
ship by preventing the ingress of air once the denture is
seated. Border seal also maintains the thin fluid film at
the denture border, allowing a meniscus to develop in
response to displacing forces. Posterior palatal seal
may be defined as the posterior border seal of the
prosthesis. Although adhesion and cohesion are second-
ary forces that act within the fluid film, their primary
contribution involves forming and maintaining the
surface tension of the peripheral meniscus.
The physical factor of gravity contributes to mandib-
ular complete denture retention. Although it is some-
times difficult to bring the other factors of retention
into play when constructing a lower denture, gravity
aids in providing the necessary force to maintain the
prosthesis in place at rest. Grunewald35 recommended
gold-base complete dentures of a weight similar to that
of the lost teeth and alveolar tissues. Such a technique
would enhance the effectiveness of gravity on the
retentive properties of the prosthesis.
NEUROMUSCULAR CONTROL
Every prosthodontist recognizes the ability of certain
patients to wear their dentures and function without
Fig. 5. Thin fluid film exists (shaded area) between
denture base and tissues of residual ridges. Meniscus
that develops at border of denture is similar to that
shown in Fig. 4 between two glass slabs. Note that
position of meniscus will depend on where soft tissue
loses contact with denture border. Draping effect of
cheeks may provide a meniscus along polished surface
of denture border CA). When cheek is retracted, menis-
cus is developed at denture border (5).
complaint despite the fact that they may be extremely
ill fitting, unstable, or even broken. The author cites a
patient who presented on routine examination wearing
a mandibular complete denture that had fractured into
three pieces. The patient was able to manipulate the
fractured denture and use it during mas#tication (Fig.
6). The biologic factor of neuromuscular control grad-
ually becomes a major determinant in complete denture
retention as experienced patients learn to alter their
muscular function to harmonize with thr: prosthesis.
The fields of oral perception, sensation, and proprio-
ception are currently being researched. Individuals
appear to vary in their ability to develop the motor
coordination and conditioned reflexes necessary to
manipulate intraoral prostheses. While some patients
are able to adapt to restorations that seem to be
unacceptable, others appear to have difficulty learning
to control any dentures, regardless of the contours,
design, or occlusion. It is muscular control that enables
patients to function with dentures that rest on basal
tissues that have undergone resorptive changes and no
longer relate to the intaglio of the denture base.
Studies by Brill et al. 36 demonstrate that older
patients have more difficulty adjusting to new complete
dentures. This may result from the progressive cerebral
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 6. A, Three fragments of an interim mandibular denture. B, Patient is able to
manipulate three fragments through exceptional neuromuscular control.
atrophy that affects related neurologic systems. They
also demonstrated the dramatic decrease in mandibular
complete denture retention that accompanied local
anesthesia of the oral mucosa in experienced denture
patients. 37 This was especially marked in those patients
with severely compromised residual ridge height and
conformation.
Incorporation of certain physical and biologic factors
will assist patients during their development of the
neuromuscular skills by providing the initial retention
that is necessary for the psychologic comfort of the
patient and success of the prosthesis. The mechanical
factors of the polished and occlusal surfaces, physical
and biologic factors of the tissue surface, and biologic
factor of neuromuscular control interact to provide
retention of complete dentures from the time of delivery
until the prosthesis becomes unserviceable.
CLINICAL IMPLICATIONS
Clinical procedures and techniques should be
selected so as to incorporate these factors into the
finished denture. For example an impression material
pith adequate flow properties should be used to avoid
uneven pressure during impression procedures that
could result in a localized rebounding effect of the
compressed tissues under the denture base and/or
denture sore spots. Either of these conditions could
result in uneven seating of the finished denture and loss
of ideal intimate tissue contact.
This does not mean that one should strive for a
mucostatic or totally pressure-free impression. A slight
generalized pressure on the soft tissues is desirable. Use
of a moderately viscous light-bodied impression materi-
al with sufficient flow, elimination of full-arch relief
spacers in the tray, and use of a nonperforated tray are
among those modifications in technique that can lead to
an impression recording the tissues in a mildly dis-
placed form. This ensures close adaptation of the
denture base and may compensate to a degree for the
10
dimensional changes in the finished dentures that
prevent the intimate tissue contact present in the
impression. Lammie34 and others recognize this com-
pensation and further recommend that slight pressure
be extended peripherally to ensure that the thin fluid
film at the denture border provides the necessary
formation of a meniscus. Therefore during the border-
molding procedure, providing a slight pressure will aid
in positive contact of the denture border at delivery.
The impression material should also provide ade-
quate reproduction of surface detail to prevent small
irregularities capable of entrapping air. Accurate
impressions can only be made of tissues recorded in
their healthy, fully recovered state. The reports of
Lytle38 emphasize the importance of the recovery of
abused oral tissues obtained by not allowing patients to
wear their prostheses for a minimum of 48 hours prior
to impression procedures.
ANATOMIC INFLUENCES ON MAXILLARY
DENTURE RETENTION
Considerations unique to the maxillary complete
denture include the incorporation of a posterior palatal
seal to complete the border seal. The posterior palatal
seal maintains tissue contact during base movement or
soft palate function and compensates for processing
changes. This critical area extends between the hamu-
lar notches along the flexure line of the soft palate. The
posterior palatal seal of the denture must extend
horizontally beyond the supportive hard palate to
include the muscular aponeurosis of the soft palate.
This area is not susceptible to pressure atrophy and
therefore allows moderate tissue displacement to main-
tain the thin fluid film. To obtain the proper amount of
tissue displacement, the posterior palatal seal must be
deeper as the palatal vault becomes steeper to compen-
sate for greater processing error.
Patients exhibiting highly tapered steep palatal
vaults present a special problem. The processing error
JANUARY 1983 VOLUME 49 NUMBER 1
COMPLETE DENTURE RETENTION
Fig. 7. A, Relatively large buccal space. B, Denture must be fabricated to fill space to
ensure adequate border seal along distobuccal flange as limited by functional movement
of coronoid process. C, Denture is shown filling buccal space.
may be so severe that no amount of posterior palatal
seal can compensate for the resulting deficiency in
intimate tissue contact. In these situations a metal base
or subsequent bench-cure reline procedure would be
incorporated into the initial treatment plan.
A region that often causes problems in maintaining
border seal is the buccal space or retrozygomatic space
(Fig. 7). This varies in size and shape but must be filled
to avoid ingress of air beneath the denture base. Care
should be taken to fill the entire buccal space during
border molding and subsequent impression making as
limited by the normal functional range of movement of
the coronoid process.
The remaining border of the maxillary denture
benefits from the draping effect of the lips and cheek
and is not usually a problem in maintaining border seal
if overextension is avoided.
ANATOMIC INFLUENCES ON
MANDIBULAR DENTURE RETENTION
The mandibular denture generally presents the
major problem with regard to retention. Reasons for
this include a movable floor of the mouth, which causes
difficulty in establishing a lingual border seal, and lack
of ideal ridge height and conformation, which mini-
mizes denture stability.
THE JOURNAL OF PROSTHETIC DENTISTRY
Retromolar pad with glands
/
A
Retrarnolor papilla
Fig. 8. Anatomic demarcation between structures that
ultimately forms pear-shaped pad and retromolar pad
of edentulous mandibular ridges. (From Sicher, H.,
and DuBrul, E. L.: Oral Anatomy, ed 6. St. Louis, 1975,
The C. V. Mosby Co.)
11
JACOBSON AND KROL
Fig. 9. A, Clinical appearance of retromylohyoid curtain. B, Glandular, nervous, and
muscular structures that lie deep to mucosa of retromylohyoid curtain.
Fig. 10. 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.
Intimate tissue contact of the mandibular denture
can be achieved through sound impression procedures
as outlined above. The elimination of dislodging forces
by accurate border molding that prevents overextension
can also be accomplished. Special attention to the
triangularis muscle, which attaches in the region of the
mandibular buccal frenum, and the mentalis muscle,
which may be active in the region of the labial flange,
should accompany any border-molding procedure. The
border seal of the entire facial flange of the denture
depends on accurate border molding and is enhanced
by the draping effect of the lips and cheek.
A slight posterior seal may be necessary on the distal
border of the mandibular denture at the point where
the cheek no longer provides contact along the denture
12
border. The denture base should cover the posterior
extension of the firmly bound, keratinized tissue of the
pear-shaped pad. Craddock39 coined the term pear-
shaped pad, which refers to the area formed by the
residual scar of the extracted third molar and the
associated retromolar papilla (Fig. 8). Clinically the
pear-shaped pad is distinguishable by the lighter color
and firmly bound nature of the overlying mucosa.
Immediately distal to the area is the less keratinized,
more resilient, and more vascular retromolar pad. It
contains glandular tissue and a submucous layer that
can tolerate a gentle posterior seal. Lammie34 and Krol
suggest beading this region at the junction of the
pear-shaped and retromolar pad to ensure peripheral
seal along the posterior denture border.
LINGUAL MANDIBULAR ANATOMIC
INFLUENCES
The border seal along the distal extension of the
lingual flange requires an understanding of the anato-
my and dynamic muscle physiology of the region. The
anatomy of the retromylohyoid space is discussed in
detail in several articles in the prosthetic litera-
ture.2r 39-42 The posterolateral portion of the retromylo-
hyoid curtain overlies the superior constrictor muscle,
and the posteromedial aspect covers the palatoglossus
muscle and lateral surface of the tongue. The inferior
wall of the retromylohyoid fossa overlies the subman-
dibular gland, which fills the gap between the superior
constrictor and the most distal attachment of the
mylohyoid muscle. Border molding must allow for the
muscular function in this region. It is possible that
medial pterygoid contraction could influence the con-
tours of the distolingual flange by causing a bulge in
the posterior wall of the retromylohyoid space (Fig. 9).
Adequate seal can be obtained by gently compressing
the tissues of the lateral wall of the retromylohyoid
fossa lingual to the retromolar pad and tucking the
distolingual flange laterally against the mucosa overly-
JANUARY 1983 VOLUME 49 NUMBER 1
COMPLETE DENTURE RETENTION
Fig. 11. A, Waxed anatomic model 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
in anterior. Dotted lines represent an activated mylohyoid muscle.
ing the superior constrictor muscle superiorly and the
loose connective tissue of the mandible inferiorly.
Maximum posterior extension into the fossa is not
necessary. Once the border seal is established, further
posterior extension adds little to the support, stability,
or retention.
The contour and inferior extension of the lingual
flange are dependent on the action and anatomy of the
mylohyoid muscle. The lingual flange slopes medially
away from the mandible to allow for the action of the
mylohyoid muscle (Fig. 10). This inclination also
enhances the ability of the tongue to control the
mandibular denture, providing a seating force to the
denture.
The mandibular attachment of the mylohyoid mus-
cle extends anteroinferiorly along the mylohyoid ridge
from the lingual tuberosity in the molar region to the
genial tubercles at the midline. Posterior fibers extend
vertically to attach to the hyoid bone, while the anterior
fibers extend horizontally to meet the fibers of the
contralateral side to form a midline tendinous raphe
(Fig. 11). This explains why the lingual flange can be
made longer posteriorly despite a more superior mylo-
hyoid muscle attachment.
Certain authors believe that adequate inferior exten-
sion of the flange can provide continuous contact
regardless of tongue position of mobility of the floor of
the mouth.40 However, the inferior extension of the
posterior lingual flange is determined by .:he displacea-
bility of the soft tissue and underlying mylohyoid
muscle when the floor of the mouth is at its most
superior position. In addition, the flange is inclined
medially so that the tissue surface of the lingual flange
is molded by a contracted mylohyoid muscle. At rest the
level of the floor of the mouth may be inferior to the
lingual flange and the mucosa may drop laterally away
from the intaglio as the mylohyoid muscle relaxes. In
such situations the border seal occurs at the border of
the lingual flange when the mylohyoid muscle is active.
When it is inactive, with the tongue retracted or at rest,
the seal may occur as high as along the contact of the
intaglio with mucosa overlying the mylohyoid ridge.
Fortunately, the tongue often occupies the entire space
superior to the floor of the mouth at rest. ISy contacting
the lingual denture surface, it is able to promote a seal
in this region and enhance retention. Accurate border
molding and impression procedures ensure adequate
border seal.
THE JOURNAL OF PROSTHETIC DENTISTRY 13
JACOBSON AND KROL
Genioglossus
Fig. li. Genioglossus muscle in cross section, illus-
trating two main divisions. Superior fibers, A, are
contracted, depressing central body of tongue .and
causing tip to be retracted and floor of mouth to reach
its most superior position. B, Inferior fibers of genio-
glossus.
MANDIBULAR ANTERIOR LINGUAL
INFLUENCES
The most difficult region in which to obtain a border
seal is the anterior lingual border. The mylohyoid
muscle acts anteriorly as well as posteriorly to raise the
floor of the mouth, and the genioglossus muscle func-
tions in the region underlying the lingual frenum. The
superior fibers of the genioglossus muscle attach to the
superior genial tubercles and function in depressing the
body of the tongue. Activation of the inferior fibers of
the genioglossus muscle serves to protract the tongue.
According to Lawson43 it is the action of the superior
genioglossus muscle that pulls the tip of the tongue
posterosuperiorly, depresses the central part of the
tongue to form a concavity during bolus formation, and
causes the anterior floor of the mouth to reach its most
superior position (Fig. 12).
Several methods may be used to establish and
maintain border seal throughout the functional range
of movement of the anterior floor of the mouth. Some
techniques recommend the horizontal extension of the
anterior lingual flange sublingually.+ Here the lingual
Superior most floor
of mouth
Rest
Fig. 13. A technique for establishing anterior lingual
seal is diagrammed. First, denture must be border-
molded to contact superiormost level of floor of
mouth. Extension posteriorly to contact sublingual
folds should maintain a border seal when floor of
mouth is at rest.
Fig. 14. A second technique. to establish anterior lin-
gual seal. A, Denture is extended to most superior
level of floor of mouth. B, Slight pressure on mucosa
overlying lingual slope of anterior mandible ensures a
border seal when tongue is at rest.
flange is extended inferiorly to contact the highest level
of the floor of the mouth (Fig. 13). The flange can then
be extended posteriorly to contact the sublingual folds
and thereby establish a seal when the tongue is at rest
and the floor of the mouth drops. Care is taken not to
impinge on the submandibular or sublingual gland
ducts.
Another technique involves a similar method of
border molding to determine the inferior extension of
the flange. However, a slight displacement of the
mucosa anteriorly can be tolerated and provides a seal
when the muscular floor of the mouth is at rest. This is
accomplished by adding a slight additional amount of
softened border-molding material to the inner surface
of the previously molded anterior lingual area and
14 JANUARY 1983 VOLUME 49 NUMBER 1
COMPLETE DENTURE RETENTION
reseating the custom tray (Fig. 14). Again, the tongue
at rest aids in maintaining the border seal by contacting
the polished lingual flange as well as the mandibular
anterior teeth.
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 dentures.
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Keprmt requestr to:
DR. THEODORE E. JACOBSON
UNIVERSITY OF CALIFORNIA
SCHOOL OF DENTISTRY
SAN FRANCISCO, CA 94143
THE JOURNAL OF PROSTHETIC DENTISTRY
15