Journal of Clinical Gerontology & Geriatrics 5 (2014) 101e104

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Journal of Clinical Gerontology & Geriatrics

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Review article

Biomechanics and clinical implications of complete edentulous state

Lalit Kumar, MDS *
Department of Prosthodontics, Dr Harvansh Singh Judge Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India

a r t i c l e i n f o a b s t r a c t

Article history: The edentulous state represents a compromise in the integrity of the masticatory system. It is frequently
Received 10 December 2013 accompanied by adverse functional and esthetic sequelae, which are varyingly perceived by the affected
Received in revised form patient. Perceptions of the edentulous state may range from feelings of inconvenience to feelings of
12 February 2014
severe handicap because many regard total loss of teeth as equivalent to the loss of a body part.
Accepted 16 March 2014
Available online 28 May 2014
Consequently, the required treatment addresses a range of biomechanical problems that involve a wide
range of individual tolerances and perceptions.
Copyright Ó 2014, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan
Keywords:
Aesthetics
LLC. Open access under CC BY-NC-ND license.
Complete dentures
Stomatognathic system
Temporomandibular joint (TMJ)

1. Introduction are affected by changes in the mechanism of support for a dentition

when natural teeth are replaced by artificial or prosthetic ones.2
The heterogeneous etiology of edentulism has been tackled on Teeth function properly only if adequately supported, and this
several worldwide fronts by the dental profession, resulting in a support is provided by the periodontium, an organ composed of
reported decrease in the numbers of edentulous persons. Research soft and hard connective tissues. The periodontium attaches the
has demonstrated that several nondisease factors such as attitude, teeth to the bone of the jaws, providing a resilient suspensory
behavior, financial, dental attendance, and characteristics of the apparatus resistant to functional forces. It allows the teeth to adjust
health care system play an important role in the decision to become their position when under stress.
edentulous.1 The periodontal ligament provides the means by which force
The clinical implications of an edentulous stomatognathic sys- exerted on the tooth is transmitted to the bone that supports it. The
tem are considered under the following factors: (1) modifications two principal functions of the periodontium are support and po-
in areas of support (natural dentition vs. complete denture); (2) sitional adjustment of the tooth, together with the secondary and
functional and parafunctional considerations; (3) changes in dependent function of sensory perception. The patient who needs
morphologic face height, and temporomandibular joint (TMJ); and complete denture therapy is deprived of periodontal support, and
(4) cosmetic changes and adaptive responses. the entire mechanism of functional load transmission to the sup-
porting tissues is altered.
The occlusal forces exerted on the teeth are controlled by the
neuromuscular mechanisms of the masticatory system.3 Reflex
2. Modifications in areas of support (natural dentition vs. mechanisms with receptors in the muscles, tendons, joints, and
complete denture) periodontal structures regulate mandibular movements. The most
prominent feature of physiological occlusal forces is their inter-
2.1. Support mechanism for the natural dentition mittent, rhythmic, and dynamic nature. The greatest forces acting
on the teeth are normally produced during mastication and
The masticatory system is made up of closely related morpho- deglutition, and they are essentially vertical in direction. Each
logical, functional, and behavioral components. Their interactions thrust is of short duration, and for most people, chewing is
restricted to short periods during the day. Deglutition, by contrast,
occurs about 500 times a day (Zemlin, 1998), and tooth contacts
* Department of Prosthodontics, Dr Harvansh Singh Judge Institute of Dental
during swallowing are usually of longer duration than those
Sciences and Hospital, Panjab University, Chandigarh, India.
E-mail address: drlalitbida@gmail.com. occurring during chewing.

http://dx.doi.org/10.1016/j.jcgg.2014.03.001
2210-8335/Copyright Ó 2014, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. Open access under CC BY-NC-ND license.
102 L. Kumar / Journal of Clinical Gerontology & Geriatrics 5 (2014) 101e104

Loads of a lower order but longer duration are produced receives vertical, diagonal, and horizontal loads applied by a den-
throughout the day by the tongue and circumoral musculature. ture with a surface area much smaller than the total area of the
These forces are predominantly in the horizontal direction. During periodontal ligaments of all the natural teeth that had been present.
rest or inactive periods, the total forces may be of similar magni- One of the firm facts relating to edentulous patients is that
tude. During mastication, biting forces are transmitted through the wearing dentures is almost invariably accompanied by an unde-
bolus to the opposing teeth whether or not the teeth make contact.4 sirable and irreversible bone loss. The magnitude of this bone loss is
These forces increase steadily (depending on the nature of the food extremely variable. So the dentist must take care for the preser-
fragment), reach a peak, and abruptly return to zero. The direction vation and protection of any remaining teeth to minimize or avoid
of the forces is principally perpendicular to the occlusal plane. advanced residual ridge reduction. The compromised support is
Upper incisors may be displaced labially with each biting thrust, further complicated because complete dentures move in relation to
and these tooth movements probably cause proximal wear facets to the underlying bone during function. So the construction of com-
develop. plete denture should be formulated to minimize the force trans-
It has been calculated that the total time during which the teeth mitted to the supporting structure or to decrease the movement of
are subjected to functional forces of mastication and deglutition the prosthesis in relation to them.
during an entire day amounts to approximately 17.5 minutes5 There are two physical factors involved in denture retention that
(Table 1). More than half of this time is attributable to jaw closing are under the control of the dentist and are technique driven. One is
forces applied during deglutition. Therefore, the total time and the the maximal extension of the denture base and the other maximal
range of forces seem to be well within the tolerance level of healthy intimate contact of the denture base and its basal seat.
periodontal tissues. It must be emphasized that the collective forces Muscular factors can be used to increase retention and stability
acting on a prosthetic occlusion are not likely to be controlled or of the dentures. In fact, the buccinator, the orbicularis oris, and the
attenuated as effectively as they appear to be by the natural intrinsic and extrinsic muscles of the tongue are the key muscles
dentition. Consequently, the time-dependent response of complete that the dentist harnesses to achieve this objective by means of
denture tissue support will manifest itself differently from those impression techniques. The design of the labial buccal and lingual
changes observed in the natural dentition. polished surface of the denture and the form of the dental arch are
considered in balancing the forces generated by the tongue and
2.2. Support mechanism for complete dentures perioral musculature.

2.2.1. Mucosal support and masticatory loads 3. Function: mastication and other mandibular movements
The area of mucosa available to receive the load from complete
dentures is limited when compared with the corresponding areas Mastication consists of a rhythmic separation and apposition of
of support available for natural dentitions. Researchers have the jaws and involves biophysical and biochemical processes,
computed the mean denture bearing area to be 22.96 cm2 in the including the use of the lips, teeth, cheeks, tongue, palate, and all
edentulous maxillae and approximately 12.25 cm2 in an edentulous the oral structures to prepare food for swallowing. During masti-
mandible.6 Furthermore, the mucosa demonstrates little tolerance catory movements, the tongue and cheek muscles play an essential
or adaptability to denture wearing. This minimal tolerance can still role in keeping the food bolus between the occlusal surfaces of the
be reduced further by the presence of systemic diseases such as teeth. The teeth must be placed within the confines of a functional
anemia, hypertension, or diabetes, as well as nutritional de- balance of the musculature involved in controlling the food bolus
ficiencies. In fact, any disturbance of the normal metabolic pro- between the occlusal surfaces of the teeth.
cesses may lower the upper limit of mucosal tolerance and initiate Clinical experience suggests that the quality of the prosthetic
inflammation. service may have a direct bearing on the denture wearer’s masti-
catory performance. The maximal bite force in denture wearers is
2.2.2. Residual ridge five to six times less than that in dentulous individuals.8 Edentulous
The residual ridge consists of denture-bearing mucosa, the patients are clearly handicapped in masticatory function, and even
submucosa and periosteum, and the underlying residual alveolar clinically satisfactory complete dentures are a poor substitute for
bone. A variety of changes occur in the residual bone after tooth natural teeth.
extraction and use of complete dentures.7 The alveolar bone sup- The pronounced differences between persons with natural teeth
porting natural teeth receives tensile loads through a large area of and patients with complete dentures are conspicuous in this
periodontal ligament, whereas the edentulous residual ridge functional context: (1) the mucosal mechanism of support as
opposed to support by the periodontium; (2) the movements of the
dentures during mastication; (3) the progressive changes in max-
Table 1 illomandibular relations and the eventual migration of dentures;
Calculation of total time of oral tissue under chewing force per day. and (4) the different physical stimuli to the sensor motor systems.
Chewing The denture-bearing tissues are constantly exposed to the fric-
Actual chewing time per meal 450 s tional contact of the overlying denture bases. Dentures move dur-
Chewing time for 4 meals/d 1800 s* ing mastication because of the dislodging forces of the surrounding
1 chewing stroke 0.3 s
Total time of chewing forces/d 540 s (9 min)
musculature. These movements manifest themselves as displacing,
(1 chewing stroke
4 meals) lifting, sliding, tilting, or rotating of the dentures. Furthermore,
Swallowing opposing tooth contacts occur with both natural and artificial teeth
During meals during function and parafunction when the patient is both awake
Duration of 1 deglutition 1s
and asleep.
During chewing 3 deglutitions/min 1800 s* (30 min)
3/3 ¼ 30 s
One-third of force than the occlusal force (0.5 min) Apparently, tissue displacement beneath the denture base re-
In between meals sults in tilting of the dentures and tooth contacts on the non-
Daytime 25 s/h (16 h) 400 s (6.6 min) chewing side. In addition, occlusal pressure on the dentures
Night-time 10 s/h (8 h) 80 s (1.3 min) displaces soft tissues of the basal seat and allows the dentures to
Total 1050 s (17.5 min)
move closer to the supporting bone. This change of position under
 L. Kumar / Journal of Clinical Gerontology & Geriatrics 5 (2014) 101e104 103

pressure induces a change in the relationship of the teeth to each tooth contacts occur in a mandibular position anterior to centric
other. relation, a position referred to as centric occlusion.
However, in complete denture prosthodontics, the position of
3.1. Parafunctional considerations planned maximum intercuspation of teeth is established to coin-
cide with the patient’s centric relation.12 The coincidence of centric
Parafunctional habits involving repeated or sustained occlusion relation and centric occlusion is consequently referred to as centric
of the teeth can be harmful to the teeth or other components of the relation occlusion (CRG).
masticatory system.9 Teeth clenching is common and is a frequent The centric occlusion position occupied by the mandible in the
cause of the complaint of soreness of the denture-bearing mucosa. dentate patient cannot be registered with sufficient accuracy when
In the denture wearer, parafunctional habits can cause additional the patient becomes edentulous. Consequently, clinical experience
loading on the denture-bearing tissues (Table 2). suggests that the recording of centric relation is the starting point
The initial discomfort associated with wearing new dentures is in the design of an artificial occlusion.
known to evoke unusual patterns of behavior in the surrounding Centric relation at the established vertical dimension has po-
musculature. Frequently, the complaint of a sore tongue is related tential for change. This change is brought about by alterations in
to a habit of thrusting the tongue against the denture. The patient denture-supporting tissues and facial height, as well as by
usually is unaware of the causal relationship between the painful morphological changes in the TMJs. An appreciation for the dy-
tongue and its contact with the teeth. namic nature of centric relation in denture-wearing patients,
particularly in an aging context, recognizes the changing functional
4. Changes in morphology (face height), occlusion, and the requirements of the masticatory system.
TMJs
4.2. TMJ changes
Maxillomandibular morphological changes take place slowly
over a period of years and depend on the balance of osteoblastic The basic physiological relationship among the condyles, the
and osteoclastic activity. The articular surfaces of the TMJs are also disks, and their glenoid fossae appears to be maintained during
involved, and at these sites, growth and remodeling are mediated maximal occlusal contacts and during all movements guided by
through the proliferative activity of the articular cartilages. In the occlusal elements.13 The dentist should seek to maintain or restore
facial skeleton, any dimensional changes in morphological face this basic physiological relation. The border movements of the
height or the jawbones because of the loss of teeth are inevitably mandible are reproducible, and all other movements take place
transmitted to the TMJs. within the confines of the classic “envelopes of motion”.14 The
Articular surfaces undergo a slow but continuous remodeling reproducibility of the posterior border path is of tremendous
throughout life. Such remodeling is probably the means whereby practical significance in the treatment of patients undergoing
the congruity of the opposing articular surfaces is maintained, even prosthodontics.15 It has also been reported that impaired dental
in the presence of dimensional or functional changes in other parts efficiency resulting from partial tooth loss and absence of or
of the facial skeleton. incorrect prosthodontic treatment can influence the outcome of
The reduction of the residual ridges under complete dentures temporomandibular disorders.
and the accompanying reduction in vertical dimension of occlusion
tend to cause a reduction in the total face height and a resultant 5. Aesthetic, behavioral, and adaptive responses
mandibular prognathism. In fact, in complete denture wearers, the
mean reduction in height of the mandibular residual alveolar ridge 5.1. Aesthetic changes
measured in the anterior region may be approximately four times
greater than the mean reduction occurring in the maxillary residual There is little doubt that tooth loss can adversely affect a per-
alveolar process.10 son’s appearance. Patients seek dental treatment for both func-
tional and aesthetic or cosmetic reasons, and dentists have been
4.1. Occlusion successful in restoring or improving many a patient’s appearance16
(Table 3).
The occlusion of complete dentures is designed to harmonize
with the primitive and unconditioned reflex of the patient’s un- 5.2. Behavioral and adaptive responses
conscious swallow.11 Tooth contacts and mandibular bracing
against the maxillae occur during swallowing by complete denture The process whereby an edentulous patient can accept and use
patients. This suggests that complete denture occlusions must be complete dentures is complex. It requires adaptation of learning,
compatible with the forces developed during deglutition to prevent muscular skill, and motivation and is related to the patient’s ex-
disharmonious occlusal contacts that could cause trauma to the pectations. The patient’s ability and willingness to accept and learn
basal seat of dentures. During swallowing, the mandible is close to, to use the dentures ultimately determine the degree of success of
in centric relation, or the position of maximum mandibular retru- clinical treatment. Learning means the acquisition of a new activity
sion relative to the maxillae at the established vertical dimension of or change of an existing one. The facility for learning and coordi-
occlusion. It is conceded, nevertheless, that most functional natural nation appears to diminish with age. Advancing age tends to be

Table 3
Table 2
Aesthetic changes associated with the edentulous state.
Force generated during mastication and parafunction.
 Deepening of nasolabial groove
Direction Duration and magnitude
 Loss of labiodentals angle
Mastication Mainly vertical Intermittent and light diurnal only  Narrowing of lips
Parafunction Frequently horizontal Prolonged, possibly excessive  Increase in columellaephiltral angle
as well as vertical Both diurnal and nocturnal  Prognathic appearance
104 L. Kumar / Journal of Clinical Gerontology & Geriatrics 5 (2014) 101e104

accompanied by progressive atrophy of elements in the cerebral 2. Chou HY, Satpute D, Müftü A, Mukundan S, Müftü S. Influence of mastication
and edentulism on mandibular bone density. Comput Methods Biomech Biomed
cortex, and a consequent loss in the facility of coordination occurs.
Engin 2013;20.
A distinct need exists for dentists to be able to understand a pa- 3. Rues S, Lenz J, Türp JC, Schweizerhof K, Schindler HJ. Forces and motor control
tient’s motivation in seeking prosthodontic care and to identify mechanisms during biting in a realistically balanced experimental occlusion.
problems prior to starting treatment.17 Arch Oral Biol 2008;53:1119e28.
4. Yamamoto H, Furuya J, Tamada Y, Kondo H. Impacts of wearing complete
Emotional factors are known to play a significant role in the dentures on bolus transport during feeding in elderly edentulous. J Oral Rehabil
etiology of dental problems. The interview and clinical examination 2013;40:923e31.
are obvious ways to observe the patient and form the best treat- 5. Zarb GA, Bolender CL. Prosthodontic treatment for edentulous patient. 12th ed. St.
Louis, MO: Mosby; 2004. pp. 427e37.
ment relationship. Successful management begins with identifica- 6. Watt DM, Likeman PR. Morphological changes in the denture bearing area
tion of anticipated difficulties prior to when treatment starts and following the extraction of maxillary teeth. Braz Dent J 1974;136:225e35.
with careful planning to meet specific needs and problems. Den- 7. Divaris K, Ntounis A, Marinis A, Polyzois G, Polychronopoulou A. Loss of natural
dentition: multi-level effects among a geriatric population. Gerodontology
tists must train themselves to reassure the patient, to perceive the 2012;29:e192e9.
patient’s wishes, and to know how and when to limit the patient’s 8. Fontijn-Tekamp FA, Slagter AP, Van Der Bilt A, Van ’t Hof MA, Witter DJ, Kalk W,
expectations.18 et al. Biting and chewing in overdentures, full dentures, and natural dentitions.
J Dent Res 2000;79:1519e24.
9. Cosme DC, Baldisserotto SM, Canabarro Sde A, Shinkai RS. Bruxism and
6. Conclusion voluntary maximal bite force in young dentate adults. Int J Prosthodont
2005;18:328e32.
10. Panchbhai AS. Quantitative estimation of vertical heights of maxillary and
The role of prosthodontists is to gain an understanding of the
mandibular jawbones in elderly dentate and edentulous subjects. Spec Care
changes in the form and function of the mouth and jaws, brought Dentist 2013;33:62e9.
about by the total loss of teeth and the possible social and behav- 11. Zhao K, Mai QQ, Wang XD, Yang W, Zhao L. Occlusal designs on masticatory
ioral consequences of tooth loss. They should be able to critically ability and patient satisfaction with complete denture: a systematic review.
J Dent 2013;41:1036e42.
evaluate the influence of complete dentures on the remaining soft 12. Chhabra A, Chhabra N, Makkar S, Sharma A. The controversial issue of centric
tissues and the underlying bony structures so that it helps in un- relation: a historical and current dental perspective. Minerva Stomatol 2011;60:
derstanding the scope and limitations of complete dentures 543e9.
13. Dawson PE. A classification system for occlusions that relates maximal inter-
together with the biocompatibility and physical properties of the cuspation to the position and condition of the temporomandibular joints.
materials used in their construction. J Prosthet Dent 1996;75:60e6.
14. Waysenson B, Salomon J. Three-dimensional recordings of envelopes of motion
related to mandibular movements. J Prosthet Dent 1977;38:52e60.
Conflicts of interest 15. Postic SD, Krsti
c MS, Teodosijevi
c MV. A comparative study of the chewing cycles
of dentate and denture-wearing subjects. Int J Prosthodont 1992;5:244e56.
The author has no conflicts of interest relevant to this article. 16. Itro A, Difalco P, Urciuolo V, Diomajuta A, Corzo L. The aesthetic and functional
restoration in the case of partial edentulism in young patients. Minerva Sto-
matol 2005;54:281e92.
References 17. Friedman N, Landesman HM, Wexler M. The influences of fear, anxiety, and
depression on the patient’s adaptive responses to complete dentures: part I.
1. Hugo FN, Hilgert JB, de Sousa Mda L, Cury JA. Oral status and its association J Prosthet Dent 1987;58:687e9.
with general quality of life in older independent-living south-Brazilians. 18. Patil MS, Patil SB. Geriatric patient d psychological and emotional consider-
Community Dent Oral Epidemiol 2009;37:231e40. ations during dental treatment. Gerodontology 2009;26:72e7.