CHAPTER 1

Biomechanics of the edentulous state

It would be inaccurate to state that disease edentulism, the unmet need for complete
factors such as caries or periodontal disease are denture treatment will remain high.
the sole causes of patients becoming edentu- 2. Predictions of several surveys regarding a
lous. Some authors actually argue that tooth healthy elderly population indicate that a
loss does not bear even a close relationship to high percentage of older people will be
the prevalence of dental disease. Although the edentulous. Therefore the effective de-
latter viewpoint is probably equally inaccurate, mand for prosthetic care for this popula-
research has demonstrated that several nondis- tion is likely to increase.
ease factors, such as attitude, behavior, dental 3. The impact of longevity on edentulism
attendance, and characteristics of the health has not been fully ascertained. Clinical
care system, do play an important role in the experience suggests that the cumulative
decision to become edentulous. In addition, a consequences of biologic and chronologic
significant relationship exists between the aging will likely confront dentists with a
edentulous state and low occupational levels. It significant increase in the number of diffi-
is therefore reasonable to conclude that eden- cult edentulous mouths requiring treat-
tulism is due to various combinations of cul- ment.
tural and attitudinal determinants, and to treat- Irrespective of precise future population
ment received over the past several years. needs, the psychologic and biomechanical im-
The heterogenous etiology of edentulism has plications of tooth loss must never be over-
been tackled on several fronts by the dental looked.
profession, resulting in a reported decrease in Most patients regard tooth loss as mutilating
the numbers of edentulous persons (Fig. 1-1). and as a strong incentive to seek dental care for
More recent reviews of tooth loss and edentu- the preservation of a healthy dentition and so-
lism in various parts of North America and Eu- cially acceptable appearance. Dentists, on the
ropean countries predict that treatment of pa- other hand, regard tooth loss as posing the haz-
tients with complete dentures will continue to ard of an even greater mutilation—the de-
decline in the future while the needs for partial struction of part of the facial skeleton and the
tooth replacement will likely increase in the distortion of soft tissue morphology and func-
short term. While these observations may sug- tion (Fig. 1-2).
gest a reduced dental educational commitment The edentulous state represents a compro-
to treatment of edentulous patients, at the mise in the integrity of the masticatory system
same time some compelling points must be un- that is frequently accompanied by adverse
derscored: functional and cosmetic sequelae, which are
1. Documented evidence supports the idea varyingly perceived by the affected patient.
that, despite projections of declining Perceptions of the edentulous state may range

3
4 The edentulous patient

0
lf 37%

S5ia

[ 32.6%

r 30.1%
ip 30.5% 28.5%
[ New Zealand The Netherlands
L 28.3%
if 25% See
25) & Wales

20/—

[ ue 15% Norway
[ Kee

aT iS% 14.7% United States

[

10 o 9.5% Sweden

[
aH

[ year
eae Pal a yr) ye ee ee es pee]
1955 1960 1965 1970 1975 1980 1985

Fig. 1-1 Reports from different countries indicate a gradual reduction in the number of
edentulous patients. (Redrawn from Bouma J: Thesis, Rijksuniversiteit te Groningen,
1987.)

from feelings of inconvenience to feelings of se- tition when natural teeth are replaced by artifi-
vere handicap. When total loss of teeth is re- cial ones.
garded as equivalent to loss of a body part, its To appreciate the many subtleties associated
treatment implies a range of biomechanical with the edentulous state and the effects of the
problems that involve a wide range of individ- transition from a dentulous to an edentulous
ual tolerances and perceptions. state, one must compare the mechanisms of
This text provides an understanding of the tooth support and denture support. Such a re-
effects of the edentulous condition and de- view will underscore the nature of the altered
scribes its clinical management. environment brought about by the loss of
teeth.
MECHANISMS OF TOOTH SUPPORT
The masticatory apparatus is involved in the
The masticatory system is made up of mor- process of trituration of food. Direct responsi-
phologic, functional, and behavioral compo- bility for this task falls on the teeth and their
nents (Fig. 1-3). The interactions of these supporting tissues. The attachment of teeth in
closely related components are affected by sockets is but one of many important modifica-
changes in the mechanism of support for a den- tions that took place during the period when
 Biomechanics of the edentulous state 5

Fig. 1-2 Partial loss of the mandibular dentition, A, and complete loss of the maxillary
as
dentition, B, have seriously affected this middle-aged patient's appearance, as well
her functional status. Compare the depleted soft tissue support in B and D to the support
obtained by prostheses and the natural teeth, C and =
 6 The edentulous patient

Functions and parafunctions transmitted to the bone that supports it. The
two principal functions of the periodontium are
support and positional adjustment of the tooth,
Dentulous state with a together with the secondary and dependent
periodontal ligament function of sensory perception. The patient
mechanism of support needing complete denture therapy is deprived
of periodontal support, and the entire mecha-
nism of functional load transmission to the sup-
Edentulous state without porting tissues is altered.
a periodontal ligament The mechanisms of tooth support have re-
mechanism of support

f \
ceived a considerable amount of investigation
during the past 25 years, and a number of con-
clusions have been drawn from observations in
Morphologic face height Behavioral/adaptive
Temporomandibular joints responses human and animal studies. As soon as teeth
erupt into the oral cavity and occlusal contact is
Fig. 1-3. Possible interactions between the vari- established, the nonfunctional orientation of
ous components of the masticatory system in the the periodontal fibers changes into a functional
context of a change in the mechanism of occlusal arrangement. This gives maximal stabilization
support.
to the tooth in the alveolar socket and at the
same time allows a physiologic range of tooth
mobility in all directions.
the earliest mammals were evolving from their The occlusal forces exerted on the teeth are
reptilian predecessors. The success of this controlled by the neuromuscular mechanisms
modification is indicated by the fact that it ap- of the masticatory system. Reflex mechanisms
pears to have been rapidly adopted throughout with receptors in the muscles, tendons, joints,
the many different groups of emerging Mam- and periodontal structures regulate mandibular
malia. Teeth function properly only if ade- movements. Through normal function the peri-
quately supported. This support is provided by odontal structures in a healthy dentition un-
an organ composed of soft and hard connective dergo characteristic mechanical stress. The
tissues, the periodontium. most prominent feature of physiologic occlusal
The periodontium attaches the teeth to the forces is their intermittent, rhythmic, and dy-
bone of the jaws, providing a resilient suspen- namic nature.
sory apparatus resistant to functional forces. It Gradual changes in force patterns occur dur-
allows the teeth to adjust their position when ing growth and eruption of the teeth. Abrupt
under stress. The periodontium comprises hard alterations are produced by loss or removal of
connective tissues (cementum and bone) and opposing or adjacent teeth or the placement of
soft connective tissues (the periodontal liga- fixed or removable prostheses. The position
ment and the lamina propria of the gingiva), normally occupied by a tooth in the dental arch
which are covered by epithelium. The peri- depends on the balance of all the forces acting
odontium is regarded as a functional unit and is on that tooth over an extended time. Sustained
attached to the dentin by cementum and to the alterations in the magnitude or duration of the
jawbone by the alveolar process. Continuity forces may cause the position of the tooth to
between these two hard tissue components is change. This change is produced in the struc-
maintained by the periodontal ligament and tural elements of the periodontium as a result
the lamina propria. of the position gradually assumed by the tooth
The periodontal ligament provides the in the alveolus.
means by which force exerted on the tooth is The precise sequence of events that occur
 Biomechanics of the edentulous state 7

when force is applied to a tooth and then re- Table 1-1 Calculation of total time during 24
leased is not clear, and likewise the relative im- hours when direct functional occlusal force is
portance of the constituent structural elements applied to the periodontal tissues
of the periodontium is not known. It appears, CHEWING
however, that in the healthy state the following Actual chewing time per meal 450 sec
factors are involved: (1) magnitude, rate, and Four meals per day 1800 sec
duration of the force; (2) biologic status of the One chewing stroke per sec 1800 strokes
Duration of each stroke 0.3 sec
periodontal ligament, which is related to the
Total chewing forces per day 540 sec (9 min)
previous loading history during the day; and (3)
long-term factors such as the patient's age and SWALLOWING
general systemic health. Apparently changes in Meals
force patterns acting on the teeth over ex- Duration of one deglutition 1 sec
During chewing, three deglutitions 30 sec (0.5 min)
tended periods elicit adjustments in the sup-
per min, one third with occlusal
porting tissues. Consequently the application force
of greater loads during mastication tends to
cause an increase in the width of the periodon- Between meals
Daytime: 25 per hr (16 hr) 400 sec (6.6 min)
tal ligament and in the number and density of
Sleep: 10 per hr (8 hr) 80 sec (1.3 min)
principal fibers. Very little change in tooth po- tora. 1050 sec = 17.5 min
sition occurs, however. More sustained, but
From Graf H: Dent Clin North Am 13:659-665, 1969.
smaller, forces cause a change in tooth position;
and thus an equilibrium position is reestab-
lished. The specific thresholds of force and
time required for these changes are unknown, ture of the food fragment), reach a peak, and
and they vary in different people. abruptly return to zero. The magnitude, rise
The greatest forces acting on the teeth are time, and interval between thrusts differ
normally produced during mastication and among persons and depend on the consistency
deglutition, and they are essentially vertical in of the food, the point in the chewing sequence,
direction. Each thrust is of short duration, and and the dental status. The direction of the
for most people, at least, chewing is restricted forces is principally perpendicular to the oc-
to short periods during the day. Deglutition, clusal plane in normal function, but the for-
on the other hand, occurs about 500 times a ward angulation of most natural teeth leads to
day, and tooth contacts during swallowing are the introduction of a horizontal component that
usually of longer duration than those occurring tends to tilt the teeth mesially as well as buccal-
during chewing. Loads of a lower order but ly or lingually. Upper incisors may be dis-
longer duration are produced throughout the placed labially with each biting thrust, and
day by the tongue and _perioral-circumoral these tooth movements quite probably cause
musculature. These forces are predominantly proximal wear facets to develop.
in the horizontal direction. Estimates of peak In healthy dentitions, teeth are not in occlu-
forces from the tongue, cheeks, and lips have sion except during the functional movements of
been made, and lingual force appears to exceed chewing and deglutition and during the move-
buccolabial force during activity. During rest ments of parafunction. These various mandibu-
or inactive periods the total forces may be of lar movements and their significance are de-
similar magnitude. scribed later. It has been calculated that the to-
During mastication, biting forces are trans- tal time during which the teeth are subjected
mitted through the bolus to the opposing teeth to functional forces of mastication and degluti-
tion during an entire day amounts to approxi-
whether the teeth make contact or not. These
mately 17.5 minutes (Table 1-1). More than
forces increase steadily (depending on the na-
 8 The edentulous patient

half of this time is attributable to jaw-closing and are in the region of 44 lb (20 kg) for the
forces applied during deglutition. Thus the to- natural teeth. Maximum forces of 13 to 16 lb (6
tal time and the range of forces seem to be well to 8 kg) during chewing have been recorded
within the tolerance level of healthy periodon- with complete dentures, but the average loads
tal tissues. are probably much less than these. In fact,
maximal bite forces appear to be five to six
MECHANISMS OF COMPLETE DENTURE
times less for complete denture wearers than
SUPPORT
for persons with natural teeth. The forces re-
The basic problem in the treatment of eden- quired for chewing vary with the type of food
tulous patients lies in the nature of the differ- being chewed. Prosthetic patients frequently
ence between the ways natural teeth and their limit the loading of supporting tissues by se-
artificial replacements are attached to the sup- lecting food that does not require masticatory
porting bone. effort exceeding their tissue tolerance.
The unsuitability of the tissues supporting
complete dentures for load-bearing function Mucosa support
must be immediately recognized. In normal The area of mucosa available to receive the
function in the dentulous state, light loads are load from complete dentures is limited when
placed on the mucous membrane. With com- compared to the corresponding areas of sup-
plete dentures, the mucous membrane _ is port available for natural dentitions. Research-
forced to serve the same purpose as the peri- ers have computed the mean denture-bearing
odontal ligaments that provide support for nat- area to be 22.96 cm? in the edentulous maxillae
ural teeth. and approximately 12.25 cm? in an edentulous
mandible. These figures, particularly the man-
Masticatory loads
dibular ones, are in dramatic contrast with the
Masticatory loads are much smaller than 45 cm” of area of periodontal ligament available
those that can be produced by conscious effort in each dental arch (Fig. 1-4). It must also be

Fig. 1-4 The area of period

ontal ligamen t supporting an intact natural
been computed to be approximately 45 cm2 in dentition has
each arch. When teeth are lost and a pa-
tient becomes edentu lous, quantitative and qualitative aspects
of support for an occlu-
sion are severely compromised (see Figs.
1-3 and 1-5)
 Biomechanics of the edentulous state 9

remembered that the denture-bearing area which factors are most important for the ob-
(basal seat) becomes progressively smaller as served variations (Fig. 1-5). Two concepts have
residual ridges resorb. Furthermore, the mu- been advanced concerning the inevitable loss
cosa demonstrates little tolerance or adaptabil- of residual bone: One contends that as a direct
ity to denture wearing. This minimal tolerance consequence of loss of the periodontal struc-
can be reduced still further by the presence of tures, variable progressive bone reduction oc-
systemic disease such as anemia, nutritional curs. The other maintains that residual bone
deficiencies, hypertension, or diabetes. In fact, loss is not a necessary consequence of tooth re-
any disturbance of the normal metabolic pro- moval but is dependent on a series of poorly
cesses may lower the upper limit of mucosal understood factors.
tolerance and initiate inflammation. Clinical experience strongly suggests a defi-
nite relationship between healthy periodontal
Residual ridge ligaments and maintained integrity of alveolar
The residual ridge consists of denture- bone; hence the dentist's commitment to pres-
bearing mucosa, the submucosa and _perios- ervation and protection of any remaining teeth
teum, and the underlying residual alveolar (Chapters 3 and 25) to minimize or avoid ad-
bone. Residual bone is that bone of the alveo- vanced residual ridge reduction. On the other
lar process that remains after teeth are lost. hand, no relationship has been found between
When the alveolar process is made edentulous periodontal status before tooth extractions and
by loss of teeth, the alveoli that contained the subsequent patterns of residual ridge resorp-
roots of the teeth fill in with new bone. This al- tion.
veolar process becomes the residual ridge, It is apparent that the support for the com-
which is the foundation for dentures. plete denture is conspicuously limited in its
A variety of changes occur in the residual adaptive ability and its inherent capability of
bone after tooth extraction and wearing of com- simulating the role of the periodontium. The
plete dentures. They result from three facts: (1) mechanism of support is further complicated
function modifies the internal structure of by the fact that complete dentures move in re-
bone; (2) pressure tends to cause bone resorp- lation to the underlying bone during function.
tion; and (3) tension can in some situations This movement is related to the resiliency of
bring about bone deposition. Alveolar bone the supporting mucosa and the inherent insta-
supporting natural teeth receives tensile loads bility of the dentures during function. Almost
through a large area of periodontal ligament. all “principles” of complete denture construc-
The edentulous residual ridge receives vertical, tion have been formulated to minimize the
diagonal, and horizontal loads applied by a forces transmitted to the supporting structures
denture with a surface area much smaller than or to decrease the movement of the prostheses
the total area of the periodontal ligaments of all in relation to them (Section HI). Conclusions
the natural teeth that had been present. Clini- regarding denture stability are usually based on
cal experience underscores the frequently re- clinical experience, but denture instability has
markable adaptive range of the masticatory sys- the potential of being traumatic to the support-
tem. On the other hand, edentulous patients ing tissue. Movement of denture bases in any
demonstrate very little adaptation of the sup- direction on their basal seats can cause tissue
porting tissues to functional requirements. damage. In fact it is tempting to construe the
One of the few firm facts relating to edentu- recurrent movements of removable prostheses
lous patients is that the wearing of dentures is as parafunctional movement and a major factor
for residual ridge reduction.
almost invariably accompanied by an undesir-
able bone loss. The magnitude of this loss is ex- Factors affecting the retention of complete
tremely variable, and little is known about dentures are considered as either physical or
10 The edentulous patient

Fig. 1-5 A, Panoramic radiographs showing the jaws of four edentulous patients.
Re-
sidual ridge reduction has occurred to variable extents. In B,
the rate of ridge reduction
is quantified between two stages of observation (a and b). The
difference, a — b, repre-
sents the reduction in height of the alveolar ridges between
stages of observation.
Shaded area denotes resorption. (B modified from Tallgren A:
J Prosthet Dent 27:120-
132, 1972.)
 Biomechanics of the edentulous state 11

muscular. Three physical factors are involved equilibrium. This equilibrium is dependent on
in denture retention and under the control of the interactions of the many components rep-
the dentist: resented in Fig. 1-3. The substitution of a
1. Maximal extension of the denture base complete denture for the teeth/periodontium
2. Maximal area of contact between the mu- mechanism alters this equilibrium. An analysis
cous membrane and the denture base of this alteration is the basis for understanding
3. Intimate contact of the denture base and the significance of the edentulous state.
its basal seat
The muscular factors can be used to increase Occlusion
retention (and stability) of dentures. The bucci- The primary components of human dental
nator, the orbicularis oris, and the intrinsic and occlusion are (1) the dentition, (2) the neuro-
extrinsic muscles of the tongue are the key muscular system, and (3) the craniofacial struc-
muscles of this activity. Impression techniques, tures. The development and maturation of
the design of the labial, buccal, and lingual pol- these components are interrelated, so that
ished surfaces of the denture, and the form of growth, adaptation, and change actively partic-
the dental arch should all be considered in bal- ipate in the development of an adult occlusion.
ancing the forces generated by the tongue and The dentition develops in a milieu character-
perioral musculature and the occlusal forces as ized by a period of dental alveolar and craniofa-
well. cial adaptability (Fig. 1-6), which is also a time
As the form and size of the denture- when motor skills and neuromuscular learning
supporting tissues (the basal seat) change, the are developing. Clinical treatment at this time
physiologic muscular forces become more im- may take advantage of such responsive adaptive
portant in denture retention. The newly in- mechanisms; for example, teeth can be guided
serted dentures will promote changes in the into their correct alignment by orthodontic
underlying mucosa and bone. treatment.
In a healthy adult dentition, dental adaptive
Psychologic effect on retention mechanisms are restricted to wear, extrusion,
The dentures may have an adverse psycho- and drifting of teeth. Bony adaptations are es-
logic effect on the patient, and the nervous in- sentially of a reparative nature and are slow in
fluences that result may affect the salivary se- their operation. Protective reflexes are learned
cretions and thus affect retention. Eventually so one can avoid pain and inefficiency of the
patients acquire an ability to retain their den- masticatory system. If and when an adult den-
tures by means of their oral musculature. This tition begins to deteriorate, the dentist resorts
muscular stabilization of dentures is probably to fixed or removable prosthodontic therapy in
accompanied by a reduction in the physical attempts to maintain a functional occlusal equi-
forces used in retaining their dentures. Quite librium. This period is characterized by greatly
clearly, the physical forces of retention can be diminished dental and reflex adaptation and by
improved and reestablished, up to a point, by pathologic bone resorption. Obviously the
careful and frequent attention to the denture presence of tooth loss and disease and the de-
status. This is done by periodic inspection and pletion of reparative processes pose a major
by relining and rebasing procedures (Section prosthodontic problem. Finally, in the edentu-
V). lous state there are few natural adaptive mech-
anisms left. The prosthesis rests on tissues that
FUNCTIONAL AND PARAFUNCTIONAL will change progressively and irreversibly. The
CONSIDERATIONS artificial occlusion serves in an environment
The masticatory system appears to operate characterized by constant change that is mainly
best in an environment of continuing functional egressive.
 12 The edentulous patient

. Extensive sensory input

2. Development of motor skills and
Developing dentition
neuromuscular learning
3. Dental, alveolar, craniofacial adaptability

. Dental adaptation (wearing, drifting, extrusion)

Healthy adult dentition . Bone adaptation is reparative
3. Learned protective reflexes

. Partial edentulism
Deteriorating adult dentition 2. Periodontal disease ;
. Diminished dental reflex adaptation

i . Residual ridge reduction

The edentulous state 2. Compromised reflex adaptability
3. Increase in parafunctional movements

Fig. 1-6 Development and adaptation of the occlusion. (After Moyers RE: Dent Clin
North Am 13:523-536, 1969.)

The design and fabrication of a prosthetic oc- tion with instrumentation, techniques, and use
clusion have led to fascinating controversies. of materials. Narrow beliefs and dogmas are
Dental occlusion was studied first in the field of gradually being replaced by enlightened rea-
complete dentures and then in other disci- soning. Dentists are aware of the need for a
plines. The early workers encountered enor- better understanding of the physiology of the
mous mechanical difficulties in constructing masticatory system and its application in com-
reasonably fitting dentures that would be both plete denture service.
durable and esthetic. Inevitably these dentists Complete dentures are so designed that
had to be mechanically, rather than biologi- their occlusal surfaces permit both functional
cally, minded. Anatomy was the first of the bi- and parafunctional movements of the mandi-
ologic basic sciences to be related to prosth- ble. Orofacial and tongue muscles play an im-
odontic services. Later, histology and physiol- portant role in retaining and stabilizing com-
ogy were recognized as having an essential role plete dentures. This is accomplished by ar-
in the treatment of edentulous patients. The rangement of the artificial teeth to occupy a
emphasis on and application of these basic sci- “neutral zone” in the edentulous mouth so the
ences lifted prosthodontics from the early me- teeth will occupy a space determined by the
chanical art to the applied clinical science it is functional balance of the orofacial and tongue
today. musculature. Thus the teeth in the dental arch
Currently, complete denture service is char- need not necessarily be placed directly over
acterized by an integration of biologic informa- the residual ridges.
 Biomechanics of the edentulous state 13

Function: mastication and swallowing compensate for the smaller number of teeth by
Mastication consists of a rhythmic separation more prolonged or a larger number of chewing
and apposition of the jaws and involves bio- strokes—they merely swallow larger food par-
physical and biochemical processes including ticles. Although it appears that the importance
the use of the lips, teeth, cheeks, tongue, pal- of a good dentition or denture in promoting di-
ate, and all the oral structures to prepare food gestion and utilization of food has not been ad-
for swallowing. During masticatory movements equately demonstrated, clinical experience
the tongue and cheek muscles play an essential suggests that the quality of the prosthetic ser-
role in keeping the food bolus between the oc- vice may have a direct bearing on the denture
clusal surfaces of the teeth. The control of mas- wearers masticatory performance.
tication within the narrow limits of tolerance of As mentioned previously, the maximal bite
the mouth requires considerable sensory infor- force in denture wearers is five to six times less
mation, since deviations from the normal path than in dentulous subjects. Edentulous pa-
of mandibular movement can injure the tients are clearly handicapped in masticatory
tongue, buccal mucosa, and even the teeth and function, and even clinically satisfactory com-
their supporting tissues. Here, again, the read- plete dentures are a poor substitute for natural
ers attention must be drawn to the importance teeth.
of the placement of the arch of artificial teeth Mandibular movements. The results of stud-
in the making of complete dentures. The teeth ies of mandibular movement patterns of com-
must be placed within the confines of a func- plete denture patients indicate that these
tional balance of the musculature involved in movements are similar in denture-wearing pa-
controlling the food bolus between the occlusal tients and persons with natural teeth. Treat-
surfaces of the teeth. ment of partially edentulous and edentulous
The comminution of much twentieth-century patients therefore might improve their chewing
food does not demand a vigorous masticatory efficiency and masticatory muscle activity,
performance. Mastication has other functions, which would be accompanied by a decreased
however. It is necessary for a full appreciation duration of the occlusion phase and contribute
of the flavor of foods and is therefore indirectly to a lessening of elevator muscle activity.
involved in the excitation of salivary and gastric Chewing occurs chiefly in the premolar and
secretions. Since mastication results in the mix- molar regions, and both right and left sides are
ing of food with saliva, it facilitates not only used to about the same extent. The position of
swallowing but the digestion of carbohydrates the food bolus during mastication is dependent
by amylase as well. Amylase activity, of but mi- on the consistency of the food, and the tougher
nor importance while food is in the mouth, is the consistency the greater is the person's pref-
responsible for the continuation of carbohy- erence for using the premolar region. The lat-
drate digestion in the stomach, and this phase ter observation is apparent even in patients
can account for as much as 60% of the total car- who have worn bilateral, soft —tissue—
bohydrate digestion. Although no reports of supported, mandibular partial dentures oppos-
quantitative tests on the importance of chewing ing complete upper dentures. It is interesting
on the various stages of digestion have ap- to note the obvious advantage accruing to a pa-
peared, it has been concluded that masticatory tient by the replacement of missing premolar
efficiency as low as 25% is adequate for com- and molar segments and by the fact that these
plete digestion of foods. Other investigations patients do not chew predominantly in the seg-
have noted that loss of teeth can lead to dimin- ments where natural teeth are present.
ished masticatory efficiency. Patients do not Reference has been made to the importance
14 The edentulous patient

of a complete denture occlusion compatible corded have been in selected experimental ar-
with the forces developed during deglutition.: eas. Furthermore, the dentures used in the
Tooth contacts while swallowing are fleeting in studies have been designed so maximum inter-
nature, and they occur many times during a cuspation of the artificial teeth would be in
24-hour day. It has been suggested that the ef- centric relation, or the terminal hinge position
fects of the frequency and duration of tooth of the mandible at the selected vertical dimen-
contacts while swallowing may be significant in sion. Other occlusal concepts that claim other
denture base deformation. Swallowing may in condylar or muscular positions as preferable for
the course of a day contribute more to a complete denture construction have not been
greater accumulated transfer of energy from investigated for occlusal tooth contact patterns.
the denture base to the underlying mucosa In all instances the frequency of tooth contact
than mastication does. on the nonchewing side has been greater than
Both the occurrence of tooth contacts and on the chewing side, irrespective of the side on
the observation that the mandible braces itself which the patient chewed or the tooth form or
against the maxillae in denture patients during arrangement used.
swallowing suggest that a complete denture oc- It has recently been shown that denture
clusion should be compatible with the forces wearers with good masticatory performance use
generated by mandibular movements of deglu- a more bilateral muscle effort during chewing
tition. Electromyographic swallowing patterns whereas those with poor performance employ
have been shown to be influenced by changes more of a unilateral effort; the patterns of mus-
of natural and complete denture occlusion. cle activity were studied by means of electro-
The pronounced differences between per- myography.
sons with natural teeth and patients wearing Apparently tissue displacement beneath the
complete dentures are conspicuous in_ this denture base results in tilting of the dentures
functional context: (1) the mucosal mechanism and tooth contacts on the nonchewing side.
of support as opposed to support by the peri- Also occlusal pressure on the dentures dis-
odontium, (2) the movements of the dentures places soft tissues of the basal seat and allows
during mastication, (3) the progressive changes the dentures to move closer to the supporting
in maxillomandibular relations and the even- bone. This change of position under pressure
tual migration of dentures (described in the induces a change in the relationship of the
discussion of morphologic face height, p. 20), teeth to each other.
and (4) the different physical stimuli to the sen- The presence of inanimate foreign objects
sorimotor systems. (dentures) in an edentulous mouth is bound to
The denture-bearing tissues are constantly elicit different stimuli to the sensorimotor sys-
exposed to the frictional contact of the overly- tem, which in turn influences the cyclic masti-
ing denture bases. Dentures move during mas- catory stroke pattern. Both exteroceptors and
tication as a result of the dislodging forces of proprioceptors are probably affected by the
the surrounding musculature. These move- size, shape, position, pressure from, and mo-
ments manifest themselves as displacing, lift- bility of the prostheses. The exact role and rel-
ing, sliding, tilting, or rotation of the dentures. ative importance of mucosal stimuli in the con-
Furthermore, opposing tooth contacts occur trol of jaw movements need clarification, but it
with both natural and artificial teeth during has been clearly demonstrated that control of
function and parafunction throughout the day dentures by muscle activity is reduced if sur-
and during sleep. face anesthetic is applied to the oral mucous
Masticatory investigations have been limited membrane. Although it is tempting to assume
to few subjects, and the occlusal contacts re- that there is a correlation between oral stereog-
 Biomechanics of the edentulous state 15

nosis and purposeful oral motor activity, the re- Table 1-2 Direction, duration, and magnitude of
sults of most investigations up to now indicate the forces generated during function and
that successful denture wearing possibly in- parafunction
volves factors other than oral perception and Force generated
oral performance.
Duration and
Direction magnitude
Parafunction
Mastication Mainly vertical Intermittent and
Nonfunctional or parafunctional habits in- light
volving repeated or sustained occlusion of the Diurnal only
teeth can be harmful to the teeth or other com- Parafunction Frequently hori- | Prolonged, possi-
ponents of the masticatory system. There are zontal as well bly excessive
as vertical Both diurnal and
no epidemiologic studies about the incidence of
nocturnal
parafunctional occlusal stress in normal or den-
ture-wearing populations. However, clinical
experience indicates that bruxism is common imental closure of the teeth is part of the pro-
and is a frequent cause of the complaint of cess of adaptation. A strong response of the
soreness of the denture-bearing mucous mem- lower lip and mentalis muscle has been ob-
brane. In the denture wearer, parafunctional served electromyographically in long-term
habits can cause additional loading on the den- complete denture wearers with impaired reten-
ture-bearing tissues (Table 1-2). The unsuitabil- tion and stability of the lower denture. It is fea-
ity of the mechanism of denture support has al- sible and probable that the tentative occlusal
ready been recognized and described. contacts resulting may trigger the development
The neurophysiologic basis underlying brux- of habitual nonfunctional occlusion.
ism has been studied experimentally both in The mechanism whereby pressure causes
animals and in humans. The neuromuscular soreness of the mucous membrane is probably
mechanism can be explained by an increase in related to an interruption or a diminution of
the tonic activity in the jaw muscles. Emotional the blood flow in the small blood vessels in the
or nervous tension, pain or discomfort, the tissues. These vascular changes could very well
stresses of everyday life, and occlusal interfer- upset the metabolism of the involved tissues.
ences are some of the factors that can increase The relationship between parafunction and re-
muscle tonus and lead to nonfunctional gnash- sidual ridge reduction has not been investi-
ing and clenching. gated. It is tempting, however, to include
The initial discomfort associated with wear- parafunction as a possible significant prosthetic
ing new dentures is known to evoke unusual variable that contributes to the magnitude of
patterns of behavior in the surrounding muscu- ridge reduction.
lature. Frequently the complaint of a sore Distribution of stress to the
tongue is related to a habit of thrusting the denture-supporting tissues
tongue against the denture. The patient is usu-
ally unaware of the causal relationship between The need for fulfilling the fundamental ob-
the painful tongue and its contact with the jectives of good prosthodontic treatment is un-
teeth. Similarly patients tend to occlude the derscored by the preceding information. All
teeth of new dentures frequently at first — per- possible methods should be undertaken to en-
haps to strengthen confidence in retention un- sure continued tissue health by minimizing the
til the surrounding muscles become accus- potential traumatic effects of complete denture
tomed or because some accommodation in the wear. The capability of the supporting tissues
chewing pattern is usually required and exper- to resist pressure should be improved when-
16 The edentulous patient

ever possible by adequate preparation of both posed on these ridges. Up to now there has
hard and soft tissues. Mucosal health can be been no specific evidence to indict any one fac-
promoted by hygienic and therapeutic mea- tor as causing advanced ridge reduction. How-
sures, and tissue-conditioning techniques may ever, strong theoretical evidence exists to jus-
be applied when appropriate. Complete den- tify the development of permanently resilient
ture base extension within morphologic and lining materials in complete dentures. These
functional limits will reduce considerably the materials could permit a wider dispersion of
occlusal load per unit area of mucosa. Resilient forces and result in the transmission of less
denture base lining materials may be used, and force per unit area of supporting tissues. Such a
the masticatory loading may be decreased by soft denture lining material would effectively
reduction of the area of the occlusal table. increase the thickness of the oral tissue by
Currently, for practical purposes, denture serving as an analogue of the mucoperiosteum,
bases are made of rigid materials. These may with its relatively low elastic modulus.
be one of various types of resins, metals, or The distance increment between the hard
combinations. The dentist must recognize that denture base and the nonresilient bony support
the prolonged contact of these bases with their would be increased, with hypothetical salutary
underlying tissues is bound to elicit changes in long-term results. The Academy of Denture
the tissues. Furthermore, the tissues are sus- Prosthetics has listed ideas for future research
ceptible to changes caused by the increased in denture base materials. The list enumerates
longevity of patients and the effects of aging on needed qualities for the improvement of den-
tissues, as well as by the functional and ture base materials and cites the following de-
parafunctional demands that patients make on sirable properties:
their denture-supporting tissues. Many den-
1. Possessing variable consistency under varying
tists have been tempted to equate the preva-
mouth conditions
lent residual ridge reduction in the edentulous
2. Selectively resilient—compatible with resil-
population with excessive stresses that are im- iency of the tissues

Initial thickness
100
Instantaneous elastic
compression
Delayed elastic
Delayed elastic recovery
compression ~— Instantaneous elastic
recovery

20 4~— Constant pressure applied —- Pressure removed —/ ~—-

Percent
original
of
tissue
thickness
0) a= a aaa Je are
0 2 4 6 8 10 12 14 16 #18 240
Minutes (4 hr)

Fig. 1-7 Typical behavior of tissue under a constant pressure load for
10 min. Notice
the 90% recovery within 8 min following removal of the pressure.
Total recovery requires
4 hr. (From Kydd WL, et al: Int Dent J 21 >430-441, 1971.)
 Biomechanics of the edentulous state 17

3. Resilient with quick recovery— able to recover tic decompression occurs when the pressure is
shape quickly after deforming forces are re- removed. This is followed by a continuing de-
moved layed elastic recovery. Histologically the
4. Compressible on the tissue side but rigid on stressed oral mucosa has an altered morpho-
the occlusal side logic pattern. The loaded epithelium demon-
5. Shock absorbing strates a decrease in the depth of the epithelial
6. Controlling or reducing forces transmitted
ridges, and the connective tissue papillae are
through the base to the underlying tissue
7. Possessing flexibility that can be controlled
obliterated. The extent of these alterations var-
and varied in processing as desired ies with the force and duration of the applied
pressure. Human soft tissues may take as long
It can be argued that during function and as 4 hours to recover after moderate loading for
parafunction, pressures are applied by the den- 10 minutes.
tures that displace the soft tissues. These pres- A change in tissue displaceability can also be
sures deform the mucoperiosteum and inter- demonstrated as being a function of age. A
fere with the circulation of blood, nutrients, longer period is needed for the recovery of dis-
and metabolites. Several studies have demon- placed mucosa in elderly people (68 to 70
strated such changes in soft tissue contour as a years) than in young adults (21 to 27 years)
result of mechanical stress. The viscoelastic (Fig. 1-8). It appears that any intraoral prosthe-
character of denture-supporting tissue has been sis can be intruded into the denture-supporting
described (Fig. 1-7). There is an initial elastic oral mucosa by up to 20% of the mucosal thick-
compression of soft tissues that takes place in- ness with relatively small occluding forces (0.2
stantly on application of load. After the elastic g/mm?). It has also been shown that pressures
phase there is a delayed elastic deformation of as small as 0.13 g/mm? will displace human soft
the tissue that takes place more slowly and tissues to 95% of their resting thickness. This
continues to diminish in rate of change as dura- indicates that impression materials, for exam-
tion of load is extended. An instantaneous elas- ple, must flow readily and with minimal pres-

———_>l
4
20 —— Constant pressure ——_><—_—_—_—- Pressure removed
applied

0- a 7 =a aT sla 1 la 1 }
6 8 10 12 14 16 18 20
thickness
original
of
in
Tissue
percent 0 2 4
Minutes

in an el-
Fig. 1-8 Comparison of responses to tissue loading and removal of the load
essential ly the same. The removal of
derly and a young adult. The compression curve is
of recovery. The load was 11 g/mm*. (From Kydd
load shows definite differences in rate
WL, et al: Int Dent J 21:430-444, 1971 a)
18 The edentulous patient

sure when an impression is being made. be of greater significance than the effect of
Pressures under complete maxillary dentures mastication.
have been recorded using a closed fluid system It appears that pressure may cause tissue
connected to a pressure transducer and _ re- damage by occluding the local circulation, sub-
corder to register positive and negative pres- ject to a force/time threshold. The harmful ef-
sures in four subjects at four locations. Each fect of pressure can be avoided by diminution
subject performed a number of controlled mas- or elimination of either factor. The amount of
ticatory and nonmasticatory activities. The force generated by a patient's masticatory sys-
findings indicated that a number of nonmastica- tem is not controlled by the dentist. The den-
tory activities (smoking, swallowing, speaking) tist may seek to minimize force distribution by
can create as much positive and negative pres- maximizing denture base coverage and devel-
sures on the supporting tissues as masticatory oping an optimal denture occlusion. Occlusal
activities do, and sometimes more. surfaces of the artificial teeth can be made
It has been observed that people swallow ap- smaller, and the patient can be instructed to
proximately one and a half times per minute handle parafunctional habits through education
while reading, which would total approximately and understanding. Forces can also be reduced
1500 swallows per day unrelated to eating or or diluted by use of a permanently resilient
drinking. When converted to meter/kilogram liner if such materials are readily available (Fig.
units, this amounts to about 1750 N per day 1-9). The time factor can be controlled to a
from swallowing alone. large extent by frequent rest periods for the
The rapid fluctuation from positive to nega- denture-supporting tissues. Leaving the den-
tive pressures indicates a pressure wave be- tures out of the mouth during sleeping hours is
neath the denture. This is attributable to rock- recommended. Oral tissues were designed to
ing or movement or to a flow of fluid within the be exposed to oral fluids and to be stimulated
vascular channels that possibly creates trauma by the action of tongue, lips, and cheeks. Noc-
with each tooth contact. It is tempting to sug- turnal rest can achieve this objective, along
gest that these pressures could affect the soft with a quantitative diminution in the duration
tissue and the blood and lymph vessels, per- of exposure of these tissues to stress.
haps causing sclerosis, diminished blood sup- The efficiency of temporary soft or treatment
ply, and the many morphologic variants we en- liners in routine prosthodontic practice has
counter in our edentulous patients. The effect proved the value of such an approach in treat-
of these continually occurring non—masticatory ing soft tissue problems. The contribution of
induced pressure changes and waves may well permanent liners to the maintenance of sup-

Function and parafunction

generate
y Force x Time
Pressure eae vy v
Y Controlled by Controlled partially by
Tissue damaged by occluding 1. Correct clinical techniques nocturnal tissue rest
local circulation 2. Use of a permanent soft liner

Fig. 1-9 Increased denture base coverage and use of a soft liner diminish the
force per
unit area directed to the basal seat. The pressure-time threshold may
thus be raised.
 Biomechanics of the edentulous state 19

porting tissue integrity and morphology is still of a material that would be permanently resil-
hypothetical, however. ient, not absorb fluids, adhere to denture base
A number of resilient liners with furtive materials, and be chemically stable. The sili-
claims to permanency have appeared on the cone rubber resilient liners, when properly
market in recent years. Their major use, how- used, have been found to be the most appro-
ever, has been as a therapeutic measure for pa- priate of the various types available, but they
tients who cannot tolerate the stresses induced too are only temporary expedients. They sup-
by dentures. Clinical experience indicates al- port yeast growth (such as Candida albicans)
most universal tissue tolerance of these materi- (Fig 1-10) and they must be inspected regularly
als and acceptable patient reactions. At by the dentist and replaced when unsatisfac-
present, the materials have to be considered as tory. The use of proper cleansers and home
temporary expedients, since none of the soft care habits has contributed to the employment
liners has a life expectancy comparable to that of these materials, with significantly beneficial
of the resin denture base. results. It must be emphasized, however, that
The most frequently used liners are usually using these materials does not preclude adher-
produced from silicone rubbers or acrylic res- ence to the fundamental principles of complete
ins. Recent reports also suggest the possible denture construction. Nevertheless, when used
employment of hydrophilic polymers and fluo- intelligently, resilient liners can be an excellent
ropolymers. Research has been in the direction adjunct in prosthodontics.

Fig. 1-10 A, Recently completed resilient liner on a mandibular denture. B, A 6 mo old

mo old re-
resilient liner with foci of yeast colonies already apparent. C, A neglected 12
silient liner with almost total coverage by yeast colonies.
20 The edentulous patient

CHANGES IN MORPHOLOGIC in edentulous and complete denture—wearing

FACE HEIGHT AND THE patients.
TEMPOROMANDIBULAR JOINTS Maxillomandibular morphologic changes take
Face height place slowly over a period of years and depend
Numerous descriptions of TMJ function have on the balance of osteoblastic and osteoclastic
evolved as a result of several research methods. activity. The articular surfaces of the temporo-
The basic physiologic relation between the mandibular joints are also involved, and at
condyles, the disks, and their glenoid fossae these sites growth and remodeling are medi-
appears to be maintained during maximal oc- ated through the proliferative activity of the ar-
clusal contacts and during all movements ticular cartilages. In the facial skeleton any di-
guided by occlusal elements. It seems logical mensional changes in morphologic face height
that in the treatment with complete dentures, or the jawbones as a result of the loss of teeth
the dentist should seek to maintain or restore are inevitably transmitted to the TMJs joints. It
this basic physiologic relation. The border is not surprising, then, that these articular sur-
movements of the mandible are reproducible faces undergo a slow but continuous remodel-
and all other movements take place within the ing throughout life. Such remodeling is proba-
confines of the classic “envelopes of motion.” bly the means whereby the congruity of the
Researchers have concluded that the passive opposing articular surfaces is maintained, even
hinge movement has a constant and definite ro- in the presence of dimensional or functional
tational and reproducible character. The repro- changes in other parts of the facial skeleton.
ducibility of the posterior border path is of tre- The reduction of the residual ridges (Fig. 1-
mendous practical significance in the treatment 11) tends to cause a resultant reduction in total
of prosthodontic patients and is described in face height and an increase in mandibular prog-
Section HI. However, this reproducibility has nathism. In complete denture wearers the
been established in healthy young persons mean reduction in height of the mandibular
only. It must be recalled that most edentulous process measured in the anterior region may
patients have experienced a period with varia- be 6.6 mm, approximately four times greater
tions on the theme of a mutilated dentition. In than the mean reduction occurring in the max-
the course of this period, pathologic or adap- illary process. Cephalometric observations and
tive changes of the TMJs may have occurred. longitudinal studies support the hypothesis that
Several authors suggest that structural alter- the vertical dimension of rest position of the
ations can take place in the TMJs. These inves- jaws does not remain stable and can be altered
tigations are mainly based on autopsy studies; over time, usurping the previously popular
hence the results are only speculative. concept of a stable vertical dimension of rest
Although the terminal stage of skeletal position.
growth is usually accepted as being at 20 to 25 It is obvious that complete dentures con-
years of age, it is recognized that growth and structed to conform to clinical decisions regard-
remodeling of the bony skeleton continue well ing jaw relation records are placed in an envi-
into adult life. Such growth accounts for di- ronment that retains considerable potential for
mensional changes in the adult facial skeleton. change. Thus concepts of reproducible and rel-
It is well known today that morphologic face atively unchangeable mandibular border move-
height increases with age in persons possessing ments may not apply as closely to edentulous
an intact or relatively intact dentition. How- patients as they do to persons with a healthy
ever, a premature reduction in morphologic dentition. Practical methods that recognize
face height occurs with attrition or abrasion of these facts are described in subsequent chap-
teeth. This reduction is even more conspicuous ters. It must be reemphasized, however, that
 Biomechanics of the edentulous state 21

Fig. 1-11 A, A 67-year-old man who has worn unserviced dentures for almost 20 years.
Notice the reduction in total face height and the increased mandibular prognathism.
B, Contrast his appearance with that of a 24-year-old woman who recently acquired com-
plete dentures but posed for this picture with her dentures out of her mouth.

the recognition that jaw relations are not im- with the mandible at or near the centric rela-
mutable does not invalidate the clinical re- tion position. The unconscious or reflex swal-
quirement of using a centric relation record as low is important in the developing dentition.
a starting point for developing a prosthetic oc- The act and frequency of swallowing are impor-
clusion. tant influences in the movement of teeth
Centric relation. Concepts of centric relation within the muscle matrix, and this movement
of the upper and lower jaws have been a dom- determines the tooth position and occlusal rela-
inant factor in prosthodontic thinking on occlu- tions. The erupting teeth are guided into occlu-
sion. Centric relation is defined as the most sion by the surrounding musculature (the mus-
posterior position of the mandible relative to cle matrix) whereas the position of the mandi-
the maxillae at the established vertical dimen- ble is determined by its location in space dur-
sion. Centric relation coincides with a repro- ing the act of unconscious swallowing. The
ducible posterior hinge position of the mandi- contacts of inclined planes of the teeth aid in
ble, and it may be recorded with a high degree the alignment of the erupting dentition. It
of accuracy. It is considered the essential rela- must be remembered that in this developmen-
tionship in any prosthodontic treatment. tal period most of the mandibular activities
The use of centric relation has its physiologic have not yet been learned, at least not in their
justification as well. In the vast majority of pa- adult form.
tients, unconscious swallowing is carried out The occlusion of complete dentures is de-
22 The edentulous patient

Temporomandibular joint changes

signed to harmonize with the primitive and un-
conditioned reflex of the patient's unconscious Several authors claim that impaired dental
swallow. Tooth contacts and mandibular brac- efficiency resulting from partial tooth loss and
ing against the maxillae occur during swallow- absence of, or incorrect, prosthodontic treat-
ing by complete denture patients. This sug- ment can bring about TMJ pain and dysfunc-
gests that complete denture occlusions must be tion or even degenerative changes in the joints.
compatible with the forces developed during Published clinical reports on functional disor-
deglutition to prevent disharmonious occlusal ders of the masticatory system have included
contacts that could cause trauma to the basal patients who are denture wearers. It is possible
seat of dentures. During swallowing the mandi- that these denture wearers’ difficulties started
ble is close to, or in, centric relation or the po- before the offending teeth were removed.
sition of maximum mandibular retrusion rela- However, there are indications also that the
tive to the maxillae at the established vertical impairment of denture quality plays a role in
dimension of occlusion. It is conceded, how- the development of signs and symptoms of TM
ever, that most functional natural tooth con- disorders since such signs and symptoms are
tacts occur in a mandibular position anterior to often significantly reduced after the insertion of
centric relation, a position referred to as cen- new dentures.
tric occlusion. Although the relationship between occlusion
In complete denture prosthodontics the posi- and degenerative joint disease (DJD) is not
tion of maximum planned intercuspation of completely clear, the dentist is tempted to be-
teeth, or centric occlusion, is established to co- lieve that a depleted or inadequately cared for
incide with the patient's centric relation. The dentition obviously loads the temporomandibu-
centric occlusion position occupied by the man- lar joints. Denturer wearers have been shown
dible in the dentate patient cannot be regis- to suffer from DJD more frequently than per-
tered with sufficient accuracy when the patient sons with a complete natural dentition, but this
becomes edentulous. In other words, the mus- may be age related rather than due to the state
cle memory pattern of the mandibular muscu- of the dentition. The hypothesis that degenera-
lature would not be effective in edentulous pa- tive joint disease is a process rather than a dis-
tients. Clinical experience supports the convic- ease entity has been advanced. The process in-
tion that the recording of centric relation is an volves joint changes that cause an imbalance in
essential starting point in the design of an arti- adaptation and a degeneration that results from
ficial occlusion. alterations in functional demands on or the
However, one must realize that an integral functional capacity of the joints.
part of the definition of centric relation—at Research strongly suggests that purely dental
the established vertical dimension— has poten- factors may be important in the etiology of de-
tial for change. This change is brought about generative joint disease of the mandibular
by alterations in denture-supporting tissues condyles. Involvement of the temporomandib-
and facial height morphology and by morpho- ular joints in degenerative diseases is well doc-
- logic changes in the TMJs. An appreciation for umented; however, it must be appreciated that
the dynamic nature of centric relation in den- the onset of degenerative conditions is fre-
ture wearing patients recognizes the changing quently in the adult years and, since the
functional requirements of the masticatory sys- greater number of denture wearers are adult,
tem. It also accounts for different concepts and the treatment of such conditions is very much
techniques of design of occlusions (which are the concern of the dentist. Clinical experience
described in Section III). and long-term studies indicate that the applica-
 Biomechanics of the edentulous state 23

tion of sound prosthodontic principles, accom- Table 1-3 Morphologic changes associated
panied by appropriate supportive therapy, is with the edentulous state
usually adequate to provide these patients with . Deepening of nasolabial groove
comfort. . Loss of labiodental angle
One of the difficulties in managing degener- . Decrease in horizontal labial angle
ative joint involvement is achieving joint rest. . Narrowing of lips
. Increase in columella-philtral angle
Because of the necessity for mastication and for
= . Prognathic
OarhwWND appearance
the avoidance of tensional habits, voluntary or
even enforced rest may be difficult to achieve.
and discussed with the patient. If this is not
INDIVIDUAL BEHAVIORAL possible, photographs of siblings, or of children
AND ADAPTIVE RESPONSES who resemble the patient, may be helpful.
Cosmetic changes Careful explanation of prosthodontic objec-
There is little doubt that tooth loss can ad- tives and methods is the basis for good commu-
versely affect a person's appearance. Patients nication with all patients. This is particularly so
seek dental treatment for both functional and when it becomes apparent to the dentist that
cosmetic reasons, and dentists have been suc- the patient's cosmetic desires exceed morpho-
cessful in restoring or improving many a pa- logic or functional realities.
tient’s appearance (Fig. 1-12).
Table 1-3 lists some of the conspicuous and Dietary changes
clinically challenging cosmetic features that fre- The effect of prosthetic restorations on mas-
quently accompany the edentulous state. It ticatory ability has been studied. Optimal com-
must be emphasized that one or more of these plete dentures appear to improve masticatory
items can be encountered in persons with in- function, which would suggest an improvement
tact dentitions, since the compromised facial in dietary selection. However, researchers
support of the edentulous state is not the ex- have shown that improved oral function will
clusive cause of the morphologic changes. In not in itself lead to changes in dietary selec-
clinical practice we frequently encounter situa- tion. It is concluded that dietary changes prob-
tions in which a patient’s weight loss, age, ably require professional and individually given
heavy tooth attrition, and so on manifest orofa- dietary advice by a trained dietitian.
cial changes suggestive of compromised, or ab-
Adaptive and psychologic responses
sent, dental support for the overlying tissues.
Some patients fail to appreciate the fact that as- The process whereby an edentulous patient
pects of their facial appearance for which they can accept and use complete dentures is com-
are seeking a solution are merely magnified or plex. It requires adaptation of learning, muscu-
else are unrelated to their edentulous predica- lar skill, and motivation and is related to pa-
ment. tient expectations. It is the patient's ability and
These patients can cause the dentist consid- willingness to accept and learn to use the den-
erable frustration. Experience suggests that tures that ultimately determine the degree of
early communication about a patient's cosmetic success of clinical treatment. Helping a patient
expectations should be established to avoid adapt to complete dentures can be one of the
later misunderstanding. Patients should be most difficult, but also one of the most reward-
asked to provide photographs of their preeden- ing, aspects of clinical dentistry.
tulous appearance, and relevant details from Learning means the acquisition of a new ac-
these photographs should be carefully analyzed tivity or change of an existing one. Muscular
24 The edentulous patient

e
e

Fig. 1-12 Before, A, and after, B, clinical views of an edentulous patient who has been
treated by construction of complete upper and lower dentures. Before, C, and after, D,
views of another patient whose old cosmetically unsatisfactory dentures were replaced;
her youth and appealing smile are brought out by the new tooth arrangement. Notice
that
several of the features listed in Table 1-3 are readily discernible in A and C.
 Biomechanics of the edentulous state 25

skill refers to the capacity to coordinate muscu- denture produced by the remaining mandibu-
lar activity so as to execute movement. The ac- lar dentition.
ceptance of complete dentures is accompanied It must be realized that edentulous patients
by a process of habituation, which is defined as expect, and are expected, to adapt to the den-
a “gradual diminution of responses to contin- tures more or less instantaneously and that the
ued or repeated stimuli.” The tactile stimuli adaptation must take place in the context of the
that arise from the contact of the prosthesis patient's oral, systemic, emotional, and psycho-
with the richly innervated oral cavity are prob- logic states.
ably ignored after a short time. Since each Facility for learning and coordination ap-
stage of the decrease in response is related to pears to diminish with age. Advancing age
the memory trace of the previous application of tends to be accompanied by progressive atro-
the stimulus, storage of information from the phy of elements in the cerebral cortex, and a
immediate past is an integral part of habitua- consequent loss in the facility of coordination
tion. Difficulty in the storage of information of occurs. Certainly patient motivation dictates
this type accompanies old age, and this ac- the speed with which adaptation to dentures
counts for the difficulties of older patients in takes place. It is imperative that the dentist de-
getting used to dentures. Furthermore, stimuli termine the patient's motivation in seeking
must be specific and identical to achieve habit- treatment, cultivate this motivation, and seek
uation. This is what probably prevents the to foster it if it is lacking or absent.
transfer of habituation evoked by an old famil- A distinct need exists for dentists to be able
iar denture to a new denture, which inevitably to understand a patient’s motivation in seeking
gives rise to a new range of stimuli. Fish de- prosthodontic care and to identify problems be-
scribes several clinical applications of adapta- fore starting treatment. Emotional factors are
tion problems that may be encountered. The known to play a significant role in the etiology
patient who has worn a complete upper den- of dental problems. The interview and clinical
ture opposing a few natural anterior mandibu- examination are obvious ways to observe the
lar teeth will usually find a complete lower patient and form the best treatment relation-
denture difficult to adapt to. Such a patient has ship. Successful management begins with iden-
to contend with altered size and orientation of tification of anticipated difficulties before treat-
the tongue. The tongue frequently responds to ment starts and with careful planning to meet
the loss of posterior teeth and alveolar bone by specific needs and problems. Dentists must
changing size to bring its lateral borders into train themselves to reassure the patient, to
contact with the buccal mucosa. The insertion perceive the patient’s wishes, and to know how
of a new denture introduces a new environ- and when to limit the patient's expectations.
ment for the tongue, and the intrinsic tongue An essential accompaniment of a denture de-
musculature reorganizes the shape of the sign that is physically compatible with the oral
tongue to conform to the altered space avail- complex is a good interpersonal relationship
able. A degree of retraining of tongue activity between dentist and patient. It is up to the
also takes place. Furthermore, the posterior re- dentist to explore the patient's symptoms and
sidual ridges are now exposed to new sensa- tensions. The way the patient handles other ill-
tions from the overlying prosthesis. Tactile nesses and dental situations will aid in the pre-
stimuli from the tongue and frictional contact diction of future problems. It has been pointed
with food are replaced by pressures transferred out that the secure patient will adjust readily,
via the denture base. Also control of the upper cope with discomfort, and be cooperative.
denture frequently must be unlearned, since It also has been reported that when a com-
the posterior part of the tongue is no longer re- plete denture population was examined for de-
quired to counter the dislodging effect on the pression most of the depressive symptoms
26 The edentulous patient

BIBLIOGRAPHY
were found to coincide with age groups that in-
Atwood DA: A cephalometric study of the clinical rest po-
cluded the greatest proportion of denture sition. II, The variability in the rate of bone loss follow-
wearers. An awareness by the dentist of high- ing the removal of occlusal contacts, J Prosthet Dent
risk groups for depression within the patient 7:544-552, 1957.
Atwood DA: The future of prosthodontics, J Prosthet Dent
pool may help explain difficulties in achieving 51:262-267, 1984.
patient satisfaction with dentures, facilitate rec- Berry DC, Mahood M: Oral stereognosis and oral ability in
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