REMOVABLE PROSTHODONTICS SECTION EDITORS. LOUIS BLATTERFEIN $. HOWARD PAYNE A contemporary review of the factors involved in complete dentures. Part III: Support T. E, Jacobson, D.DS,* and A. J. Krol, D.DS."* University of California, School of Dentistry, San Francisco, Calif, and Veterans Administration Medical Genter, San Francisco, C Cone dure pointe veri cal movement of the denture base toward the ridge. Tt counteracts those forees directed toward the ridge at right angles to the occlusal surfaces. Support involves a consideration of the relationship between the intaglio of the denture base and the underlying tissue surface under varying degrees and types of function. This relationship must be developed so as 10 maintain the established occlusal relations and to promote optimal function with a minirmum of tssueward movement and base setting. ‘TYPES OF SUPPORT Support may be considered from two points of view. First, the maxillary and mandibular dentures should conform to the underlying tissues so that the occlusal surfaces can correctly oppose one another at the time of insertion. Bilateral simultaneous contact should exist ‘bath at initial closure and under functional loading. Second, the denture bases should maintain this rela- tionship for a period of time. This property indicates the need for consideration of denture support in terms of longevity. Without long-term support complete denture retention and stability also become compro- mised. Tnitial denture support is achieved by using impres- sion procedures that provide optimal extension and functional loading ofthe supporting tissues, which vary in their resiliency. Long-term support is obtained by directing the forces of occlusal loading toward those tissues most resistant to remodeling and resorptive changes Effective support is realized when (1) the denture is ‘extended to cover a maximal surface area without impinging on movable or friable tissues, (2) those tissues most capable of resisting resorption are selec~ **Chiel of Deral Service, Removable Prnhodontics, 306 tively loaded during function, (3) those tissues most capable of resisting vertical displacement are allowed to ‘make firm contact with the denture base during function, and (4) compensation is made for the varying tissue resilieney to provide for uniform denture base movement under Function and maintain a harmonious ‘occlusal relationship. Most prosthodontic texts agree that maximal border extension is essential in providing denture support. Many techniques documented inthe literature describe border molding procedures designed to determine the location of the denture border and its relationship to the peripheral tissues, thereby gaining optimal exten- sion." Most require that the denture be extended to make postive eontact with the sof, yielding peripheral tissues as limited by muscle function and bony or tendinous anatomic structures. The basic “snowshoe principle” of maximal extension is that given a con- stant ocelusal foree, a broader denture-bearing area decreases the stress per unit area under the denture base, decreases tissue displacement, and reduces den- ture-base movement. NATURE OF SUPPORTING TISSUES Having determined the outline form of the total denture-bearing area, one must study the nature of the supporting tissues contained within the borders. Sever- al factors govern the selection of those tissues best suited to provide support. Ideally, the soft tissues should be firmly bound to underlying cortical bone, contain a resilient layer of submucosa, and be covered. by keratinized mucosa. The underlying bone should be resistant to pressure-induced remodeling. These char- ize hase movement, decrease soft sue trauma, and reduce long-term resorptive changes. SOFT TISSUES Supporting soft tissues must be capable of with standing the pressures induced through normal fune- tion of the promesis. The presence of keratinized, MARCH 1953 VOLUMES NUMBERfirmly bound mucosa permits the tissues to better resist stress. Keratin isa seleroprotein present in the stratum, ‘corneum and is the end product of epithelial degenera- tion, which protects the vital underlying epithelial layers." Generally, nonkeratinized alveolar mucosa is rot well adapted to tolerate the functionally generated suresses of a denture base. Excessive trauma to the ‘mucosa beneath a denture base can lead to abnormal tiseue changes such as the development of parakeratin, localized hyperkeratosis, and epithelial ulceration or ‘The presence of a layer of resilient submucosa permits moderate compressibility without mechanical impingement of the mucosa between the denture base ‘and underlying bone. The fatty and glandular submu- ‘cosa acts a8 a "hydraulic cushion” similar tothe palm ‘of the hand as described by Orban." Some parts of the ‘masticatory mucosa are without @ distinct submucous layer, yet dense connective tiseue ofthe lamina propria firmly binds the mucosa to underlying periosteum, Although not as effective in providing resiliency, this ‘connective tissue layer serves as & protective base for the mucosa, The connective tissue bands firmly bind the masticatory mucosal covering of the edentulous ridges. Those regions, which postess a thin and/or less Leratinized mucosa over hone without an intervening layer of submucosa, should be relieved or recorded without displacement, This eliminates impingement of soft tissues between the denture base and bony founda- tion during occlusal loading, thereby minimizing soft tissue trauma and reducing pressure-induced bony remodeling, HARD TISSUES Another requirement of ideal support isthe presence of tissues that are relatively resistant to remodeling and ‘esorptive changes. The problems assaciated with ridge resorption have been studied extensively by Tallgren'* and others"! The rate and amount of bone loss and remodeling that occur in the anterior maxillae and mandible are of serious concer in prosthodontics. Although overdentures can greatly reduce such bone loss, consideration must be given to the maintenance of alveolar ridge height in the conventional complete denture patient. Minimizing the pressures in those regions most susceptible and directing the forces toward those regions relatively resistant to resorption ‘can help to maintain healthy residual ridges. BONE FACTOR ‘Much remains to be researched in the field of bone hystology. ‘The response of bone to external forces is Fig, 1. A and B, Both of these patients had worn complete dentures for over 30. years. Difference tt resorption of mandibles may indicate individual vari- ations in bone index not completely understood. The potential for resorption, fof the residual ridges varies between patients (Fig. 1). ‘There seem to be some characteristes within the biologic makeup of the individual that determine the relative resistance of bone to resorption. ‘This intrinsic bone factor is described by Glickman," Krol." and ‘others and is unique to each individual. At the present time, bone factor ean be determined only by studying the previous response of the patient's bone to stress. Such stress may be in the form of extractions, surgical trauma, or forces generated by a functioning prosthesis. Usually, radiographic observation of previous denture= Induced bone loss provides the only indication of the tiatient’sintsinsie bone factor. ‘Although all bone responds to forces by remodeling as described by Wolf's law, itis interesting to note that the supporting alveolar bone may differ its response to stress as compared to basal residual ridge bone. The responce of bone to stress varies according to anatomic location. Thus, bone factor appears to be related to local anatomic and physiologic variations within and between individuals (Fig. 2) ‘The generally accepted. pressure-tension concept appears to play an important role in the destcuction or preservation of the bone of the residual ridges. Thi ‘concept holds that pressure stimulates resorption Whereas tension maintains the integrity or actually ‘causes deposition of bone. Tension placed oa bone, such as that abserved in the area of musele attachment,Fig. 2. This patient wore a mandibular overdenture several years, Note that marked resorption is limited. to regions of basal bone and that alveolar bone remains at 4 favorable height adjacent to remai teeth 3 Fig. 3. Edentulous mandible demonstrates that even following severe zesorption, the getial tubercles remain relatively unchanged. tends to preserve the quality ofthe bone and sometimes results in bone deposition. There is no physiologic ‘mechanism whereby a complete denture can transmit tension to bone; therefore, most forces applied beneath dentures result in pressure and subsequent resorptive ‘changes. One ofthe objectives of the prosthadontist isto ‘minimize and control the rate of these changes. Cortical bone is more resistant to resorption than cancellous or medullary bone. Use of cortical bone ia support of complete dentures permits the prosthesis 10 ‘maintain its recorded relationship to the edentulous ridge over a longer period of time. Regions of muscle fiber and tendinous attachments to cortical plate through Sharpey’s fibers ensure tension on bone. This tension minimizes the resorptive changes that would ‘otherwise be the normal response of bone to pressure. ‘A classic example of muscle attachment enhancing the resistance to remodeling is often scen in severely atrophied mandibular edentulous ridges. These mandi- bles exhibit prominent mylohyoid ridges, genial tuber- cles, and mental protuberances (Fig. 3). Such regions remain remarkably unchanged as a result of associated muscle attachments. Tt is, therefore, a keratinized ‘masticatory mucosa firmly bound to underlying cortical JACORSON AND KROL, Fig. 4. Notice anatomic demarcation between struc- tures that ultimately form pear-shaped pad and retro- ‘molar pad of edentulous mandibular ridges. Glandular retromolar pad i posterior to pear-shaped pad, which is formed by scar Hiseue of extraction site of mandibu- la third molar fusing with retromolar papilla. (From Sicher, Hand DuBruly E. L: Oral Anatomy, ed 6. St Louis, 1975, The C. V. Mosby Co.) bone through a variable zone of connective tissue and submucosa with associated muscle attachments that provides the ideal denture-bearing tissue. ANATOMIC CONSIDERATIONS OF DENTURE-BEARING AREA ‘As Edwards and Boucher" noted: “Since the success ‘of complete dentures depends largely on the relation of the dentures to anatomic structures which support and limit them, familiarity with the location and character of these structures is essential.” Based on clinical and histologic impressions, the dentist can categorize the ddenture-bearing tissues into primary and secondary support and recognize tissues that require relief to ‘minimize pressure, MANDIBULAR ANATOMIC CONSIDERATIONS “The primary stres-bearing regions on the mandible ‘must include the pear-shaped pad and the buccal shelf. ‘The pear-shaped pad is the mort distal extent of the keratinized masticatory mucosa of the mandibular MARCH 1965 VOLUME 49 NUMBERS.ridge and is formed by the scarring pattern of the extracted third molar and its retromolar papilla ( 4), The term wae first coined by Craddock’ to differ: tentiate it from the more distal retromolar pad, whichis ‘composed of alveolar mucosa overlying glandular and loose alveolar connective tise. Clinicians must recog nize the differences between the pear-shaped pad and ‘the retromolar pad based on anatomic location and histologic composition. Frequently, the entire area of the distal ridge crest is referred to as retromoloar pad. ‘This leads to confusion in determining the mandibular denture extension. ‘The retromolar pad is not a favorable denture~ bearing area. The junction of the pear-shaped and retromolar pad demarcates the distal border of a properly extended mandibular complete denture, ‘The pear-shaped pad area is associated with muscle and or tendinous attachments of the buccinator, supe rior constrictor, and temporal muscles. The deep and superficial tendons of the temporal muscles insert ‘medially and laterally in the mandible at the posterior border of the pear-shaped pad. Such muscle attach- ments and the overlying, firmly bound masticatory mucosa provide a stress-bearing region that is relatively resistant to resorptive changes. If the mandibular denture is short of this region, there will be more rapid resorption of the distal alveolar ridge and a resulting settling of the denture base posteriorly (Fig. 5) "Many authors recognize the importance of the buccal shelf as a primary support area for the mandib- vular denture? **""? Tt ig usually covered by mucosa with an intervening submucous layer containing glan- ular connective tissue and buccinator muscle fibers. ‘The buccinator muscle is attached inferiorly along the buccal shelf between the ridge crest and the external ‘oblique ridge." The muscle fibers run along the shelf {longitudinal anteroposterior direction, permitting the denture base to rest directly on a portion of the bbueeinator musele without displacement. This buccina- tor muscle attachment extends posteriorly to include the pear-shaped pad area. Again, owing to the nature of the overlying soft tissues and the presence of muscle attachments, these regions provide primary support for the mandibular denture base. ‘The role of the mandibular residual ridge crest in support depends on the nature of the ridge and the bone factor of the individual patient, Patients exhibiting. broad, square, well-developed residual ridges covered by firmly bound masticatory mucosa plus a favorable {intrinsic bone factor may rely on the ridges for support Generally, the ridge crests are reserved as secondary support areas, The lack of muscle attachments and presence of cancellous bone usually result in resorptive Fg. 5. A, Underextension of mandibular partial den- ture short of pearahaped pad contributed to marked resorption of fesidual vidge area, which was covered bby denture. B, Lack of adequate support contributed to sottling of extension base seconday to fesorption. changes occurring more rapidly than in the areas of primary support. "The remaining anatomic regions of the mandible are not usually essential in providing denture support. The less keratinized alveolar mucosa of the lingual and anterior labial ridge slopes lies directly over basal bone and does not tolerate pressure well Is fact, the lingual tissue over the mylohyoid ridge often requires relief to reduce impingement of the mucosa. The denture bor~ der is extended into the movable soft tissue to effect, border seal and not to promote support. In markedly resorbed mandibles, the genial tubercles provide a bony foundation resistant to resorption due 1o the genioglos- sus muscle attachments, but the friable overlying mucosa usually obviates its use as a primary stress- bearing area capable of resisting versical forees. The ‘mandibular anatomic regions and their relative contri bution todenture support are outlined in Fig. 6 and are based on the average healthy edentulous mandible. Individual variations may dictate changes from the normally desired relationship of denture base to under~ 309Fig. 6. Relative importance of various anatomic regions of mandible in providing denture support Paimary support areas must include buccal shelf and pearshaped pad (1"). Ridge crest and area of genial fubereler may be treated as secondary support areas (2°). Lingual and labial ridge inclines are either relieved (&) or noncontributing (N/C). lying iasues. For example, the presence of pendulous, redundant, fibrous connective tissues over the mandib- Glar ridge crest would. preclde itr wie even for secondary support, Patients who have undergone vestibuloplasty proce- dures with splicthiceness skin grafts have favorable keratinized tsnue overlying regions of muscle atach- ments such a5 the genial tubercles (Fig. 7). Those genial tubercles covered by a skin graft would be considered as primary support regions. The regions that will contribute to the complete denture support should govern the selection of impression procedures. MAXILLARY ANATOMIC ‘CONSIDERATIONS In the maxillae the horizontal portion of the hard palate lateral to the midline raphe should provide primary support for complete dentures. Van Scotter ‘and Boucher!® describe the histology of the palate in detail. Keratinized masticatory mucosa overliea a dia- ‘inet submucous layer everywhere but at the midline suture. The submucosa contains fatty tissue anterolat= erally and glandular tissue posterolaterally. This resil- ent layer acts as a cushion for the functional stresses transmitted to the mucosa. Dense bands of connective tissue traverse the submucosa, firmly binding the lamina propria of the epithelium to the underlying periosteum. Over the midline raphe the mucosa is de or no submucosa, and must be tissue impingement between the denture base and bone.” However, the relief should be ‘minimal to permit light contact of this tissue with the denture base under masticatory leading. 310 JACORSON AND KROL Fig. 7. Skin has been grafted over area of genial tubercles. Such treatment allows use of genial tuber- cles for primary support. “The cortical bone ofthe hard palate, composed of the palatine processes of the maxillae and the horizontal processes of the palatine bones, has been shown to resist jive changes in longitudinal studies of conven- tional complete denture patients. Clinical observations of patients wearing “roofless” maxillary dentures sub- stantiate the significance of incorporating the hard palate into denture support. Such dentures are often associated with severe alveolar ridge resorption because the hard palate was not included in the support- ing area ‘An explanation for the resistance of the bony hard palate to resorption based on the pressure-tension phenomenon has not been described. The functioning tensor veli and levator palatini muscles of the soft palate may provide the sources of tension that counter- fact the pressure resorption normally expected beneath ‘adenture base. In any event, the horizontal hard palate resists resorption and is covered by keratinized mucosa and resilient submucosa. These properties dictate its cszential function as a primary denture-rupport area. ‘The crest of the maxillary edentulous ridge is also important in complete denture support. The soft tissue is often thick, keratinized, and firmly bound to the periosteum and underlying bone. A layer of dense fibrous connective tissue intervenes between the muco- sa and bone and acts as a resilient liner for the mucosa. Despite this favorable soft tissue covering, the underly- ing cancellous bone is subject to resorptive changes, depending on the intrinsic bone factor of the patient. Clinical research has shown that the maxillary alveolar ridges undergo remodeling changes when subject to the functional strestes transmitted by a MARCH 983 VOLUME4® NUMBER 3Fig. 8 A and B, Resorption of anterior maxillary ridge caused by functioning of natural mandibular Anterior teeth against a manillary complete denture ‘With inadequate posterior occlusion. Lissue-borne prosthesis.'*'°" Rapid resorption invol¥= ing the anterior maxillary ridge beneath a complete denture opposed by mandibular anterior natural denti- tion is frequently seen. Resorption is usually more rapid when the lower anterior teeth are permitted to contact the maxillary denture without simultaneous posterior contact either in centric relation or during, ‘excursive movements. The appearance of loot, redun- dant tissue anteriorly together with fibrous, pendulous tuberosities posteriorly is referred to as the “combina- tion syndzome” by Kelly” (Fig. 8). These and other astociated changes cesult from excessive forces trans ‘mitted to the anterior maxillae. Such forces must be controlled and minimized by proper design and tech- rnique. Given proper attention, the maxillary ridge crest can remain relatively resistant to resorption and should be considered ac a primary or, at the very least, as a secondary supporting area. ‘The remaining facial slopes of the maxillary residual ridges are not essential in the denture support. The nonkeratinized alveolar mucosa cannot tolerate func LNonal stresses, and the inclined surface would provide "THE JOURNAL OF PROSTHETIC DENTISTRY Fig. 9. Various anatomic regions of maxillae in pro- Yiding support Primary support areas (1) should include horizontal antero- and posterolateral. hard Palate, Ridge crest should Function at best aa a second: Bry support area (2"). Midline suture normally Fequires slight Fellef (R) while denture border is oncontributing (NN/C), litle resistance to vertical base movement. As in the ‘mandible, the peripheral tissues should be contacted to obtain a seal but are mot estential to support (Fig. 9). RELIEF REGIONS Retief regions fall into three categories. First tissues shat are susceptible to resorption should not be sub- jected 10 functional pressures. These would include some maxillary and most mandibular ridge crest Second are those regions that have a thin mucosa, directly over hard cortical bone. These include the palatal midline raphe, tori and cxostoses, and the lingual surface of the mandible, especially the mylo- hhyold ridge. A third category involves these regions of mucosa overlying neurovascular bundles such as the incisive papilla and, in some cases, the mental foramen, ‘These should be recorded at rest or relieved according to the techniques used. Sore spots and long adjustment periods will result if these considerations are not followed during the fabrication of complete dentures. Impression techniques, materials, and associated pro cedures should be selected to effec that relationship of denture base tothe underlying tissues that will promote effective and physiologic support for the complete denture. No single cookbook formula can provide this relationship for every patient. Variations in the indi- vidual anatomic and physiologic requirements of each patient will dictate certain alterations in technique. PRACTICAL CONSIDERATIONS ‘One generally accepted principle of impression pro- ‘cedures is that the maximal allowable denture-bearing, surface area should be incorporated. Many authors onrecognize the need to record the different anatomic regions under varying degrees of pressure, depending. fon the nature of the tissues."«**™* The rationale bochind these techniques is that certain tissues require slight placement while others must be recorded at rest fr relieved. On the other hand, proponents of the smucostatic theory recommend the recording of all tissues at rest without distortion.” ‘A truly mucostatic or pressure-free impression is virtually impossible to achieve. The fluid impression ‘material contained in a rigid tray inevitably causes some tissue compression. Even if it were possible to ‘obtain a pressure-free impression ofthe tissues at rest, the mucostatic theory is based on the belief that oral tissues ofthe denturesbearing area behave as a confined uid following Pascal's laws of hydrostatics. These laws state that pressure exerted on a confined fluid will ‘ransmit evenly throughout the fluid. Unfortunately, the fluid in oral tissues is not confined. The tissue ide can move through the interstitial spaces in response to stresses placed on them. ‘They also vary in their ability o tolerate or transmit pressures according, to their anatomic location and histologic makeup. For these reasons, it would seem that the most desirable impression techniques would attempt to provide mild displacement of the more resilient tissues, which are capable of providing denture support and resisting resorption. ‘deally, the tissues beneath the denture base should be recorded in the shape and contour that they assume under a loading force. In this way the more resilient tissues would be more displaced than those tissues that are unyielding, such as the maxillary midline raphe. Sch an impression would prove an equalized dir. ion of pressure to the supporting tissues during function and said anunsable denture base rocking os fa fulerum point of unyielding tissue, such as the midline suture. The concept of equalized pressure distributed over the supporting areas will minimize localized stress concentration, which otherwise leads to pressure-induced resorption, mucosal irritation, and hase instability. As Swenson stated: “Tissue place- ‘ment for equalization of pressure in order to resist ‘celusal stress over the entire bearing area is desir- able..." ‘Selective pressure impressions have some disadvan- tages and limitations. A denture base that records the Functional contours of the bearing area displaces the ore resilient tissues. At reat the denture base may rebound and pull away from the underlying tissues. Because no single technique can provide an equitable distribution of pressures both at rest and under Func- 32 JACORSON AND KROL tion, the dentist must weigh the advantages and disad- vantages in each situation, ‘A technique that incorporates ideas from both the pressure-free and selective-pressure procedures usually fan provide a desirable impression and contribute to the longevity of the final prosthesis. According to their delegated role in support, certain tissues should be recorded at or near rest while others should be subject te mild tissue displacement. Craddock” has noted that 1 “automatic relief” over hard-to-displace tissues can be obtained through the use of more viscous impression material. A study by Frank was conducted to determine the effect of tray modifications and selection of impres- sion materials on pressures exerted on the denture supporting tissues during maxillary edentulous impression procedures. The study concluded that (1) differences in pressure were correlated to the use of different impression materials (irreversible hydrocal- loid exhibited the highest pressures followed by thiokl rubber and metallie oxide-eugenol pastes); (2) more pressures were measured at the crest of the ridge than fon the palate when no relief wae used; and (3) generally, use of either escape vents or relief was equally effective in decreasing pressures and in equal- izing the amount of pressure exerted on the ridge crest ‘and the palatal areas” Therefore, the sclection of impression material and use of relief holes, wax spacers, and localized tray relief are several methods that can control and direct pressure recorded in the impression. SUMMARY Dentists must base their technique on an under- standing of the biologic aspects of the relationship between the denture base and supporting tissues. ‘Those tissues must he able to tolerate functional tresses without promoting patient discomfort and should be recorded in such a manner that these areas provide complete denture support. Anatomic regions that satisfy the requirements for providing primary support should make positive contact with the denture bate under functional loading. Those that are less resistant to long-term changes or are unable to tolerate stress should be relieved of excessive contact with the denture base. Selection of those regions that should provide primary and secondary support depends on the “anatomic variations unique to each patient. REFERENCES 1. Friedman, Edentlous impression proces for manu reeenton and sabi} Prost Base 1957, 2. Preise, HW The posterior gual extension of complete lower denture. 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