REMOVABLE PROSTHODONTICS
SECTION EDITORS
LOUIS BLATTERFEIN S. HOWARD PAYNE
A contemporary review of the factors involved
complete dentures. Part III: Support
T. E. Jacobson, D.D.S.,* and A. J. Krol, D.D.S.**
University of California, School of Dentistry, San Francisco, Calif., and Veterans Administration Medical Center.
San Francisco, Calif.
C omplete denture support is the resistance to verti-
cal movement of the denture base toward the ridge. It
counteracts those forces 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 to maintain the
established occlusal relations and to promote optimal
function with a minimum of tissueward movement and
base settling.
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
both 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.
Initial denture support is achieved by using impres-
sion procedures that provide optimal extension and
functional loading of the 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-
*Assistant Clinical Professor, Removable Prosthodontics
**Chief of Dental Services, Removable Prosthodontics.
306
in
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 resiliency 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 in the 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 positive contact with the soft, 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 occlusal force, 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-
acteristics minimize base movement, decrease soft tis-
sue trauma, and reduce long-term resorptive changes.
SOFT TISSUES
Supporting soft tissues must be capable of with-
standing the pressures induced through normal func-
tion of the prosthesis. The presence of keratinized,
MARCH 1983 VOLUME 49 NUMBER 3
COMPLETE DENTURE SUPPORT
firmly bound mucosa permits the tissues to better resist
stress. Keratin is a scleroprotein present in the stratum
corneum and is the end product of epithelial degenera-
tion, which protects the vital underlying epithelial
layers.12 Generally, nonkeratinized alveolar mucosa is
not well adapted to tolerate the functionally generated
stresses of a denture base. Excessive trauma to the
mucosa beneath a denture base can lead to abnormal
tissue changes such as the development of parakeratin,
localized hyperkeratosis, and epithelial ulceration or
necrosis.
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 as a “hydraulic cushion” similar to the palm
of the hand as described by Orban.” Some parts of the
masticatory mucosa are without a distinct submucous
layer, yet dense connective tissue of the lamina propria
firmly binds the mucosa to underlying periosteum.
Although not as effective in providing resiliency, this
connective tissue layer serves as a protective base for
the mucosa. The connective tissue bands firmly bind
the masticatory mucosal covering of the edentulous
ridges. Those regions, which possessa thin and/or less
keratinized mucosa over bone 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 is the presence
of tissues that are relatively resistant to remodeling and
resorptive changes. The problems associated with ridge
resorption have been studied extensively by TallgrerP
and others.‘,‘5.‘7 The rate and amount of bone loss and
remodeling that occur in the anterior maxillae and
mandible are of serious concern 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
physiology. The response of bone to external forces is
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. A and B, Both of these patients had worn
complete dentures for over 30 years. Difference in
resorption of mandibles may indicate individual vari-
ations in bone index.
not completely understood. The potential for resorption
of the residual ridges varies between patients (Fig. 1).
There seem to be some characteristics 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
others20and is unique to each individual. At the present
time, bone factor can 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 functionfng prosthesis.
Usually, radiographic observation of previous denture-
induced bone loss provides the only indication of the
patient’s intrinsic bone factor.
Although all bone responds to forces by remodeling
as described by Wolff s law, it is interesting to note that
the supporting alveolar bone may differ m its response
to stress as compared to basal residual ridge bone. The
response of bone to stress varies according to anatomic
location. Thus, bone factor appears to he 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 destruction or
preservation of the bone of the residual ridges. This
concept holds that pressure stimulates resorption
whereas tension maintains the integrity or actually
causes deposition of bone. Tension placed on bone,
such as that observed in the area of musclr attachment,
307

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 a favorable height adjacent to remaining
teeth.
Fig. 3. Edentulous mandible demonstrates that even
following severe resorption, the genial tubercles
remain relatively unchanged.
tends to preserve the quality of the 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 of the objectives of the prosthodontist is to
minimize and control the rate of these changes.
Cortical bone is more resistant to resorption than
cancellous or medullary bone. Use of cortical bone in
support of complete dentures permits the prosthesis to
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 seen 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. It is, therefore, a keratinized
masticatory mucosa firmly bound to underlying cortical
308
JACOBSON AND KROL
Retromolor pod with glands 1
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 is posterior to pear-shaped pad, which
is formed by scar tissue of extraction site of mandibu-
lar third molar fusing with retromolar papilla. (From
Sicher, H., and DuBrul, 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
denture-bearing tissues into primary and secondary
support and recognize tissues that require relief to
minimize pressure.
MANDIBULAR ANATOMIC
CONSIDERATIONS
The primary stress-bearing regions on the mandible
must include the pear-shaped pad and the buccal shelf.
The pear-shaped pad is the most distal extent of the
keratinized masticatory mucosa of the mandibular
MARCH 1983 VOLUME 49 NUMBER 3
COMPLETE DENTURE SUPPORT

ridge and is formed by the scarring pattern of the

extracted third molar and its retromolar papilla (Fig.
4). The term was first coined by Craddock*’ to differ-
entiate it from the more distal retromolar pad, which is
composed of alveolar mucosa overlying glandular and
loose alveolar connective tissue. 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
Fig. 5. A, Underextension of mandibular partial den-
settling of the denture base posteriorly (Fig. 5). ture short of pear-shaped pad contributed to marked
Many authors recognize the importance of the resorption of residual ridge area, which was covered
buccal shelf as a primary support area for the mandib- by denture. B, Lack of adequate support contributed to
ular denture.* R.9.I” 12~22It is usually covered by mucosa settling of extension base secondary to resorption.
with an intervening submucous layer containing glan-
dular connective tissue and buccinator muscle fibers. changes occurring more rapidly than in the areas of
The buccinator muscle is attached inferiorly along the primary support.
buccal shelf between the ridge crest and the external The remaining anatomic regions of the mandible are
oblique ridge.” The muscle fibers run along the shelf not usually essential in providing denture support. The
in a longitudinal anteroposterior direction, permitting less keratinized alveolar mucosa of the lingual and
the denture base to rest directly on a portion of the anterior labial ridge slopes lies directly over basal bone
buccinator muscle without displacement. This buccina- and does not tolierate pressure well. In fact, the lingual
tor muscle attachment extends posteriorly to include tissue over the mylohyoid ridge often requires relief to
the pear-shaped pad area. Again, owing to the nature reduce impingement of the mucosa. The denture bor-
of the overlying soft tissues and the presence of muscle der is extended into the movable soft tissue to effect
attachments, these regions provide primary support for border seal and not to promote support. In markedly
the mandibular denture base. resorbed mandibles, the genial tubercles provide a bony
The role of the mandibular residual ridge crest in foundation resistant to resorption due to the genioglos-
support depends on the nature of the ridge and the bone sus muscle attachments, but the friabie overlying
factor of the individual patient. Patients exhibiting mucosa usually obviates its use as a primary stress-
broad, square, well-developed residual ridges covered bearing area capable of resisting vertical forces. The
by firmly bound masticatory mucosa plus a favorable mandibular anatomic regions and their relative contri-
intrinsic bone factor may rely on the ridges for support. bution to denture support are outlined in Fig. 6 and are
Generally, the ridge crests are reserved as secondary based on the average healthy edentulous mandible.
support areas. The lack of muscle attachments and Individual variations may dictate changes from the
presence of cancellous bone usually result in resorptive normally desired relationship of denture hase to under-

THE JOURNAL OF PROSTHETIC DENTISTRY 309


Fig. 6. Relative importance of various anatomic
regions of mandible in providing denture support.
Primary support areas must include buccal shelf and
pear-shaped pad (2 “). Ridge crest and area of genial
tubercles may be treated as secondary support areas
(2”). Lingual and labial ridge inclines are either
relieved 07) or noncontributing (N/C).
lying tissues. For example, the presence of pendulous,
redundant, fibrous connective tissues over the mandib-
ular ridge crest would preclude its use even for
secondary support.
Patients who have undergone vestibuloplasty proce-
dures with split-thickness skin grafts have favorable
keratinized tissue overlying regions of muscle attach-
ments such as 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 Scatter
and Boucher” describe the histology of the palate in
detail. Keratinized masticator-y mucosa overlies a dis-
tinct submucous layer everywhere but at the midline
suture. The submucosa contains fatty tissue anterolat-
erally and glandular tissue posterolaterally. This resil-
ient 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
unyielding, has little or no submucosa, and must be
relieved to avoid tissue impingement between the
denture base and bone.12However, the relief should be
minimal to permit light contact of this tissue with the
denture base under masticatory loading.
310
JACOBSON 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 of the hard palate, composed of the
palatine processes of the maxillae and the horizontal
processesof the palatine bones, has been shown to resist
resorptive 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-
act the pressure resorption normally expected beneath
a denture base. In any event, the horizontal hard palate
resists resorption and is covered by keratinized mucosa
and resilient submucosa. These properties dictate its
essential function as a primary denture-support 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 stresses transmitted by a
MARCH 1983 VOLUME 49 NUMBER 3
COMPLETE DENTURE SUPPORT
Fig. 8. A and B, Resorption of anterior maxillary
ridge caused by functioning of natural mandibular
anterior teeth against a maxillary complete denture
with inadequate posterior occlusion.
tissue-borne prosthesis.‘“.‘“,2’ Rapid resorption involv-
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 loose, redun-
dant tissue anteriorly together with fibrous, pendulous
tuberosities posteriorly is referred to as the “combina-
tion syndrome” by KellyI (Fig. 8). These and other
associated changes result from excessive forces trans-
mitted to the anterior maxillae. Such forces must be
controlled and minimized by proper design and tech-
nique. Given proper attention, the maxillary ridge
crest can remain relatively resistant to resorption and
should be considered as 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-
tional stresses, and the inclined surface would provide
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 9. Various anatomic regions of maxillae in pro-
viding support. Primary support areas (1 “J should
include horizontal antero- and posterolateral hard
palate. Ridge crest should function at best as a second-
ary support a:rea (2”). Midline suture normally
requires slight relief fR) while denture border is
noncontributing (N/O.
little resistance to vertical base movement. As in the
mandible, the peripheral tissues should be contacted
to obtain a seal but are not essential to support
(Fig. 9).
RELIEF REGIONS
Relief regions fall into three categories. First, tissues
that are susceptible to resorption should not be sub-
jected to functional pressures. These would include
some maxillary and most mandibular ridge crests.
Second are those regions that have a thin mucosa
directly over hard cortical bone. These include the
palatal midline raphe, tori and exostoses, and the
lingual surface of the mandible, especially the mylo-
hyoid ridge. A third category involves these regions of
mucosa overlyirng 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 effect that relationship of
denture base to the underlying tissues that will promote
effective and physiologic support for Ihe 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
311

recognize the need to record the different anatomic
regions under varying degrees of pressure, depending
on the nature of the tissues.‘*6~8~22~ 24-26The rationale
behind these techniques is that certain tissues require
slight placement while others must be recorded at rest
or relieved. On the other hand, proponents of the
mucostatic theory recommend the recording of all
tissues at rest without distortion.27
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 of the tissues at rest,
the mucostatic theory is based on the belief that oral
tissues of the denture-bearing area behave as a confined
fluid following Pascal’s laws of hydrostatics. These
laws state that pressure exerted on a confined fluid will
transmit evenly throughout the fluid. Unfortunately,
the fluid in oral tissues is not confined. The tissue
fluids can move through the interstitial spaces in
response to stresses placed on them. They also vary in
their ability to 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.
Ideally, 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.
Such an impression would provide an equalized distri-
bution of pressure to the supporting tissues during
function and avoid an unstable denture base rocking on
a fulcrum 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
base instability. As Swensor? stated: “Tissue place-
ment for equalization of pressure in order to resist
occlusal 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
more resilient tissues. At rest 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-
312
JACOBSON 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
can 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
to mild tissue displacement. Craddockz9 has noted that
an “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 hydrocol-
loid exhibited the highest pressures followed by thiokol
rubber and metallix oxide-eugenol pastes); (2) more
pressures were measured at the crest of the ridge than
on the palate when no relief was 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.3o Therefore, the selection 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 be able to tolerate functional
stresses 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
base 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.
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MARCH 1983 VOLUME 49 NUMBER 3
COMPLETE DENTURE SUPPORT

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