LITMIR.BIZ

      Stability

This can be defined as the resistance to horizontal displacement or rotation – in complete dentures, or around large saddles, this is often determined by the underlying anatomy and ridge form; this is primarily assessed in terms of the cross-sectional profile of the ridge, and how much support the ridge is able to provide before it distorts or displaces.

      From time to time you will notice ridges that present with fibrous aspects, which have a tendency to displace on palpation and loading. You may notice these presentations being referred to as flabby ridges, but this expression is not so well received with patients! Fibrous elements can affect the whole aspect of the ridge, or just the crestal tissues. The impact this has on denture stability will be determined by which anatomical features are affected and is discussed further in Chapter 17.

      When considering shorter or bounded saddles, elements of stability will be derived from the way in which the denture base contacts the hard tissues (either acrylic or cobalt chrome) and engages undercuts. This is largely determined by the ‘path of insertion’ (POI) and is discussed further in Chapter 32. To a degree, the stability of the prosthesis is therefore dependent on how effectively the neighbouring teeth can support lateral loading. This is known as ‘bracing’. If there is inadequate bony support for the abutment teeth then they will also move pathologically, and cause denture instability. This will cause further damage, possibly resulting in secondary occlusal trauma. These aspects will be discussed further, later in the book, in relation to partial denture planning.

      Retention

      This can be defined as the ability of the prosthesis to withstand removal in an axial direction – with complete dentures or areas over large saddles, this is often determined by the degree of coverage (employing cohesive and adhesive contact forces) and whether a border seal can be achieved. It is also important to consider the extensions of the prosthesis when assessing retention – whilst the prosthesis might be stable when fully seated, overextension may cause a lack of retention in function, as the functional sulcus shortens and displaces the denture base. When considering partial dentures and implant-supported overdentures (ISOD), retention becomes a much more active concept, through the use of direct clasps and retentive abutments. ISODs are considered further in Chapter 41.

      Stability vs retention

      I am often asked whether a denture can be stable yet unretentive – and vice versa. The simple answer is yes – to both. The technical challenge comes in ensuring that the prosthesis demonstrates both stability and retention. The key here is that the prosthesis covers the full denture bearing area – and accommodates functional movements within the periphery – the functional sulcus.

      We will revisit the full anatomy of the maxillary and mandibular denture bearing areas (DBA) later – but some important anatomical and functional considerations for stability include:

       The form of the edentulous ridge and palate

       The degree of support offered by the ridges

       The position of the polished surfaces in relation to the neutral zone (Chapter 24)

       The degree to which the maxillary tuberosities are fully captured

       The degree to which the disto-lingual anatomy is captured

      Patients tend to learn how to improve the stability of dentures by improving muscle tone, tongue control and chewing habits. Whilst edentulous patients often have a habit of improving retention by holding dentures up with the posterior dorsum of the tongue, this appears to be a very patient-specific skill.

      Important anatomical aspects for retention include:

       Full coverage of the DBA

       Developing an adequate border sealFully capture the maxillary tuberositiesFully capture the lingual anatomyAccounting for the insertion of buccinators into the retromolar pad

       Ensuring that the denture is adequately extended, but not overextended, in function

      Whilst the DBA and its extensions are very important, the position of the teeth is also critical, particularly in relation to the labio-lingual position of incisors on a lower complete denture. The concept of the neutral zone is very important and this will also be discussed later in Chapter 24. As well as the neutral zone, and impressions to record it, there are other prosthodontic techniques that can be employed to overcome challenges with fibrous ridges – such as:

       The RPI design principle

       The Altered Cast technique

       Various mucostatic or mucocompressive impression techniques

      These will be discussed further later in the book.

      The gag reflex

      This is discussed in more detail in Chapter 46 – however, it is worth mentioning at this early stage that the vast majority of patients presenting with a gag reflex are anticipating movement or loss of retention of their prosthesis. It may be that their current prosthesis is stable and retentive – however, most often I find that this is not the case. It is important to take the time to explain to patients that the best outcome is achieved if a stable and retentive denture is created first, which can then be used as a predictable tool for overcoming a gag reflex. Even in patients where counselling is required in order to overcome psychosocial triggers, a well-fitting prosthesis is necessarily the starting point.

4 Patient assessment for complete dentures

Arguably one of the most important elements of your patient assessment, is about taking the time to understand what the patient wants and why. It is also about making a judgement about how likely you are to succeed with your endeavours – there are a number of risk factors that can alter your chances of success and these should be discussed and recorded before the active elements of treatment begin. The majority of these factors are outlined below, largely as bullet point questions, but please do visit the recommended reading section for details of other academic texts

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