Definition : That quality of maintaining a constant character or position in the presence of forces that threaten to disturb it.

Or The quality of a prosthesis to be firm, steady or constant, to resist displacement by functional horizontal or rotational stresses. Denture Stability : The resistance of a denture to movement on its tissue foundation, especially to lateral (horizontal) forces as opposed to vertical displacement (termed denture retention) INTRODUCTION: Stability ensures the physiological comfort of the patient. Denture instability adversely affects support and retention. A denture that shifts easily in response to laterally applied forces that are generated during most of the functions of the mouth, causes a disruption in the border seal and prevents the denture base from correctly relating to the supporting tissues. This results in deleterious forces on the edentulous ridges during function. Factors contributing to stability : - Fish in 1948 described a denture as having 3 surfaces : 1. The impression surface. 2. The occlusal surface. 3. The polished surface. Though all these three surfaces are developed independently, they are integrated to create a stable, functional and esthetic result. - Thus the factors contributing to stability can be categorised under the following headings : 1. The relationship of the denture base to the underlying tissues. 2. The relationship of the external surface and border to the surrounding oro-facial musculature. 3. The relationship of the opposing occlusal surfaces.
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. . . . . . .JPD 99, GPT 7

4. Education of the patient. IRELATIONSHIP OF THE DENTURE BASE TO THE UNDERLYING TISSUES: This will be discussed under the following headings : 1. Residual ridge anatomy. 2. Denture base adaptation. 3. The mandibular lingual flange. 1. Residual ridge anatomy : Residual ridge height and conformation are limiting factors for stability. a) Large, square, broad ridges offer a greater resistance to lateral forces than do small, narrow and tapered ridges. (Fig. 1) b) Small and rounded irregularities also contribute favourably to stability. Alveoloplasty should therefore be limited to removal of bone that would prevent the fabrication of a successful prosthesis. Ex in case of sharp spicules, severe undercuts and insufficient inter-arch space. But removal of all irregularities to create a smooth, even ridge would diminish the potential stability. c) The arch form: Square or tapered arches tend to resist rotation of the prosthesis better than the ovoid arches. d) Shape of the palatal vault : Stability is limited by the length and angulation of the palatal ridge slopes. A steep or high arched palate enhances stability by providing greater surface area of contact and long inclines approaching at right angles to the direction of force. But vertical forces tend to unseat the denture easily. According to Burns DR et al, (JPD 95, Vol.73 (4)) Treatment alternatives to increase stability including - Ridge augmentation or vestibular augmentation (Fig. 2)

- Dental implants to provide anchorage for an all implant supported prosthesis. - Mucosa and implant supported overdentures were assessed. The study indicated superior statistics with respect to implant overdentures and a slight but significant improvement in the soft tissue response. According to W. Kalk et al. (IJP 1992 No. 3 Vol. 5) Stability was assessed in 3 groups : 1. Who needed preprosthetic surgery but which was contraindicated, had received new dentures. 2. Same as 1 but were treated with vestibuloplasty and lowering off the floor of the mouth before denture fabrication. 3. Control groups without residual ridge related problem who were treated with new complete dentures. The least displacement of the mandibular dentures occurred in groups 2 & 3, greatest in 1. Loosening caused by tipping of the mandibular denture was least in group 2 because of elimination of the muscle attachments and increase in the extensions. 2. Denture base adaptation : - The relationship of the intaglio of the denture base to the underlying tissues is dependent on the impression procedures of the clinician. - Health of the tissues at the time of impression making is important. Stability is compromised in the following cases : Inflamed mucosa. Distorted or displaced tissues

Hyperplastic tissue.

- Denture base adaptation may be improved by the use of tissue liners, adhesives,and fixatives. - Mucostatic impression techniques increase stability because of less displacement of tissues during impression making and hence less rebounding of the displaced tissues. 1. The mandibular lingual flange : A properly formed denture base outline develops a seal than can be maintained during most of the normal oral functions. The labial and buccal flanges have well defined landmarks that can be visually evaluated. The distolingual extension of the lingual flange is developed arbitrarily. The lingual slope of the mandible is at 90 degrees to the occlusal plane which is a desirable feature. The posterior lingual flange can be extended more inferiorly than anterior lingual flange, although posterior fibres of mylohyoid muscle attach more superiorly on the mandible; they descend vertically to attach to the hyoid bone. When contracted the muscle fibres extend medio-inferiorly allowing the posterior flange to extend to/or beyond the mylohyoid ridge. Anteriorly the muscle fibres are directed more horizontally to communicate with fibres of the opposite side. When contracted the fibres tense the floor of the mouth and limit the extension of the anterior lingual flange.(Fig.3&4) - Any flange extensions beyond the mylohyoid ridge must incline medially away from the mandible to allow for the mandibular mylohyoid muscle contraction. The degree of positive contact of firm ridge to flange may be compromised by the presence of a thin mucosa overlying the bony ridge slopes that dont tolerate the stresses effectively and may require relief.
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According to C. H. Jooste and C.J.Thomas, (IJP 1992 Vol. 5 No.1) Analysis of cineradiographic tracings of movements of marker placed in the mandibular dentures with and without denture extensions during chewing exercises revealed that an extension had a stabilizing effect on the mandibular complete denture. Sublingual Crescent Area : Definition : The crescent shaped area on the anterior floor of the mouth formed by the lingual wall of the mandible and the adjacent sublingual fold. It is the area of the anterior alveolingual sulcus. . GPT 7 Extension of the denture over the resting tissues of the sublingual crescent area completes the border seal and increase the covering surface of the dentures resulting in : 1. Increased retention by allowing the tongue to aid in holding the dentures in place. swallowing, speaking and eating. IIRELATIONSHIP TO OF THE EXTERNAL THE SURROUNDING SURFACE AND OROFACIAL PERIPHERY (Fig.5) 2. Denture is more stable during normal tongue movements such as

MUSCULATURE : Actions of the musculature on the denture base generally result in lateral and vertical dislodging forces. Factors involving musculature and the polished surface of the denture can facilitate stability if : 1. Action of certain groups are permitted to occur without interference by the denture base so that they wont dislodge the prosthesis during function. 2. Dentist recognizes that normal functioning of some muscle groups external can be used to enhance stability ie. alterations in
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contours can lead to dynamic seating and stabilizing action directed towards the prosthesis. (Fig.6&7) The action of Levator Anguli Oris, Incisivus, Depressor Anguli Oris, Mentalis, Mylohyoid and Genioglosus can dislodge the denture base if they are not allowed to function freely. Proper border or muscle molding ensures optimal border extensions. The following factors will be considered : 1. The external surface of the denture 2. Influence of oro-facial musculature 3. Modiolus and associated musculature 4. The neutral zone 1. The external surface of the denture : The location and form of the polished surfaces given by wax to obtain convexity or concavity facially and lingually contribute to functional stability of dentures. Fish believed that the contours of the polished surface provided the principal factor governing complete denture stability. He wrote The shape of the buccal, labial and lingual surfaces can wreck stability as completely as a bad impression or a wrong bite. Thus the horizontal forces exerted by the tongue and cheek can act either as a placing or displacing agent. The lingual and buccal borders of mandibular denture and the buccal borders of maxillary denture can be made concave so that the tongue and cheek will grip and seat the denture.(Fig.8 to 13) 2. Influence of Oro-Facial Musculature : The basic geometric design of denture bases should be triangular ie. in a frontal cross-section the maxillary and mandibular dentures should appear as 2 triangles whose apexes correspond to the occlusal surface.(Fig.14)
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- Maxillary buccal flange should incline laterally and superiorly. - Mandibular laterally and inferiorly and its lingual flange medially and inferiorly. Such inclination provides favourable vertical component to any horizontally directed forces. The tongue should rest against the lingual flange which is inclined medially away from the mandible and concave. A normal tongue position has the following features : a. It should completely fill the floor of the mouth. b. The lateral borders should rest over the ridge on the occlusal surface of the teeth. c. The tip or apex rests on or is just to the lingual side of the lower anterior ridge. According to PAJ. Culver and I. Watt (BDJ 1973 Vol. 135) Although it is recognized that the tongue and the oral musculature in general play a large part in stabilizing the upper denture, great emphasis is still placed in the standard text books and in several papers on the physical mechanisms by which denture retention and stability is achieved. The peripheral seal achieved by these mechanisms is in fact broken in function and the tongue apparently pushes the denture up and hence stabilizes it. 3. Modiolus and the associated musculature : The modiolus or the tendinous node near the corner of the mouth is formed by the intersection of several muscles of the cheeks and lips including : Zygomaticus Quadratus Labii Superioris Levator Anguli Oris (Caninus) Mentalis
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Depressor Anguli Oris (Triangularis ) Depressor Labii Inferioris Buccinator Risorious Orbicularis oris

As none of these muscles contain fibres that have more than one bony attachment, they depend on fixation of the modiolus to allow isometric contraction. Contraction of triangularis, caninus, and zygomaticus fixes the modiolus allowing the middle fibres of the buccinator to contract isometrically, thus allowing it to control the food bolus on the occlusal table. The superior fibres of the buccinator seat the maxillary denture and the inferior fibres contribute to mandibular denture stability. 3. The neutral zone: Definition : The potential space between the lips or cheeks on one side and the tongue on the other; that area or position where the forces between the tongue and cheeks or lips are equal or neutralized. The idea is to establish harmony between the polished surface of the denture and the associated musculature. The musculature should functionally mold not only the borders but the entire polished surface. The teeth placed within the neutral zone are balanced. Thus this functional rather

than anatomic placement of the teeth further enhances the stability of the denture by minimizing active forces. III RELATIONSHIP OF OPPOSING OCCLUSAL SURFACES : The dentures must be free of interferences within the functional range of movement of the patient, (this refers to the positions through which the lower jaw moves horizontally during normal speech, swallowing and mastication.) During both functional and parafunctional movements the occlusal surfaces shouldnt strike prematurely in localized area. Such contacts cause uneven stresses to be transmitted to the dentures during function resulting in lateral and torquing forces that destabilize the denture. Theories of Occlusion: 1. Occlusion in Centric Relation : According to Woelfel et. al. (JPD 1962 Vol. 12) : They showed that most functional closures of the complete denture patients occurred in closed proximity to centric relation. For this reason the relationship of the mandible to the maxilla should be recorded in the most retruded position for maximum stability and efficiency. For many patients the normal range of horizontal movements of mandible is limited to centric relation. This is true in case of skeletal class III patients. Excursive balance may not be necessary in such patients. Patients with a wider functional range of movements as in skeletal class II require consideration of premature occlusal contacts which occur when the mandible dosent close in centric relation. In such cases, the horizontal forces can be minimized by training the patient to place food bilaterally to ensure simultaneous posterior teeth contact.
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2. Balanced Articulation : Definition :The bilateral, simultaneous anterior and posterior occlusal contact of teeth in centric and eccentric positionsGPT 7 Or The occlusal contacts of maxillary and mandibular teeth initially in maximum intercuspation and their continuous contacts during movements from this position along specific working, balancing and protrusive guidance pathways developed on the occlusal surfaces of the teeth. ..Boucher Stability of the dentures is partially dependent upon the contact of a tooth in one part of the arch to balance tooth contact in another part of the arch in case of artificial teeth. Natural teeth are surrounded by bone and except for movements within the limits of their periodontal attachments they can be considered fixed whereas artificial teeth are attached to a movable base resting on soft tissues that can be displaced. When natural teeth are present bone receives stimulation, tensile in nature which contributes to normal bone physiology. But dentures cant replace this stimulation. Arranging artificial teeth to provide excursive balance minimizes localized stress concentration and lateral dislodging forces by ensuring multiple points of contact. On closure through a bolus of food, bilateral posterior teeth contacts within the range of balance ensures good seating of the prosthesis. Though proof lacks to support the validity of a balanced articulation during chewing, it appears to be more important when there is no food in the mouth. Brewer reported that in 24 hrs. test period, tooth contact during chewing was only 10 minutes whereas non-chewing activities amounted to 2-4 hours of contact. The horizontal movements of the mandible generated by an articulator simulate para-functional rather than functional jaw movements

and teeth are balanced to provide stability during these anticipated movements.

3. Lingualised Occlusion : First described by S. Howard Payne in 1941. This form of denture occlusion articulates the maxillary palatal cusps with the mandibular occlusal surfaces in centric working and non-working mandibular positions. Lingualised occlusion provides : a. b. Limited range of excursive balance and Directing the forces to the lingual side of the lower ridge

during working side contacts. This minimizes horizontal stress and enhances denture stability by controlling leverages induced by eccentric tooth contacts. According to Curtis .M Becker et al.( JPD 1977, 38 (6)): Using lingualised occlusion satisfactory occlusion is easily obtained, and balanced occlusion can be accomplished. Selection of artificial teeth : The selection of anatomic, semianatomic or non-anatomic artificial teeth depends : - Partially on the chosen occlusal scheme - Quality of the residual ridge ie. Height and conformation. If balanced articulation is desired throughout a limited functional range of movement for patients with deficient residual ridges, the use of nonanatomic zero-degree teeth set on a curve may provide desired occlusal contacts while eliminating the interlocking of opposing anatomic teeth. The tooth position and occlusal plane : A.Tooth position :
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When forces act on a body in such a way that no motion results, there is a balance or equilibrium. This should be the primary consideration with the forces that act on the teeth and the denture bases with their resultant effect on the movement of the base. A stable base is the ultimate goal. Total stability isnt possible because of the yielding nature of the supporting structures. Lever Balance is the basis of balanced occlusion. Some rules in teeth arrangement are : 1. The wider and larger the ridge and closer the teeth are to the ridge, greater is the lever balance. 2. Wider the ridge,narrower the teeth bucco-lingually greater the balance and vice-versa. 3. More lingual the teeth placed in relation to the ridge crest, greater the balance; more buccal the placement of teeth, poorer the balance. 4. More centered the forces of occlusion antero-posteriorly greater the stability of the base. Tooth position as well as tooth contact complement each other for total balance. Maxillary anterior tooth position : The arch curvature should correspond to curvature of alveolar ridge, facial contour and maxillary lip position. Arranging teeth into a square arch form on a tapering or ovoid residual alveolar ridge causes canines to be labial to crest of maxillary ridge than central incisors, resulting in bicuspids being more buccal to the ridge than they should be. Working side occlusal pressure produces a displacing tendency, the ridge crest acting as a fulcrum. Normal Anterior Alveolar resorption: The labial axial inclination of the natural anterior teeth places the incisal edges labial to the fulcrum line about which the tooth would tend to rotate when under incisal force or when the occlusal contact area is anterior
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(Fig.15&16)

to alveolar support. Therefore if prosthetic teeth were placed in exactly the same position as natural they would be labial to the alveolar support. More labial bone may be lost due to alveolectomy because of undercuts and also residual ridge atrophy. (Fig.17) The net result is a mechanically unfavourable tooth position in relation to the denture base foundation. However, this position is required for esthetics and function. But if this acknowledged unfavourable relationship is combined with the error of a square arch on a tapering ridge, unnecessary torque and instability are created. Mandibular anterior tooth position: This must confirm to the maxillary arch.Errors in maxillary tooth position will be transferred to the mandibular arch. Posterior teeth position: a. Maxillary : Normal posterior maxillary teeth have a buccal axial inclination while mandibular teeth have a lingual axial inclination. The normal alveolar bone resorption that takes place after extraction can result in a slight crossbite relationship of the ridge crests. This isnt difficult to visualize since the bony support of the mandibular teeth is slightly buccal to the maxillary bony support before extraction. Due to buccal plate reduction in surgical procedures this cross-bite tendency is augmented. Finally any advances in resorption process results in a complete crossbite ridge relation.(Fig.18&19) The maxillary posterior teeth may be arranged too far buccally for the following reasons : 1. Anterior square arch form set on an ovoid ridge which causes canines and bicuspids to be placed buccally. 2. A slight crossbite relationship of the ridges due to the axial inclination of the natural teeth before extraction.

3. Advanced alveolar atrophy leads to increased crossbite relation of the ridge. 4. Placement of mandibular teeth slightly buccal to the crest of the ridge. 5. Tendency to avoid crossbite arrangement results in placing maxillary posterior teeth in a buccal position. Working side occlusal pressure causes a displacing tendency because the line of force is buccal to the fulcrum. More lateral pressure is exerted on the residual alveolar ridge and this results in a more rapid resorption. Perhaps, because we can usually give the patient more stability and retention on the maxillary denture we tend to abuse it. Another reason for avoidance of crossbite is the lack of understanding of its equilibration. A crossbite is less efficient than the normal bucco-lingual teeth position. However, a crossbite on a very stable base is better than a normal buccolingual relation of teeth on an unstable damaging base. b. Mandibular: Many operators avoid ridge lap grinding made necessary by the limits of space and thickness of the baseplates, by placing lower posterior teeth buccal to the ridge. The tooth is positioned so as to have the lingual cusp and fossa over the crest of the ridge. If poor lingual cusp contact exists on the working side excursions, displacing torques develop. The buccal cusp of the lower teeth are buccal to the center of the alveolar crest which acts as a fulcrum, thus creating a displacing force. The lingual cusp creates no torque. If the guiding inclines of the cusps are not reduced and equilibrated on a suitable articulator, more lateral forces will be added. Hence the buccal cusp and fossa of the mandibular posterior teeth should be directly over the crest of the ridge. The difference between this position and that mentioned before is 2mm in the lingual direction, and thus results in more stability and less lateral force. This is because occlusal pressure on the tooth falls close to the fulcrum and creates little or no
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torque. But this requires the buccal aspect of the ridge lap and the base to be ground in that area which in turn depends on the availability of space between the ridges. (Fig.20 to 23)

According to C. H. Jooste & C.J. Thomas( Jol. of oral Rehabilitation, 1992, Vol. 19): A study was conducted on 6 patients with previous denture experience. Metal indicators were placed on either side of the mandibular dentures and a Co-Cr alloy marker was inserted in the left bucco-posterior area of the mandible in each case. In new dentures posterior teeth were positioned upto the retromolar pad, over the slope of the posterior mandibular alveolar ridge. After habituation had taken place a cineradiographic recording was made of chewing. A 2nd recording was made with the teeth removed form the inclines. Denture movement was observed by measuring the distances between the markers on an analyzer projector. The results showed a significant difference between the two values. The movement was less after the removal of the teeth over the incline. These results support the clinical observation that teeth placed over a basal tissue incline have a destabilizing effect during complete denture function. B) Occlusal Plane : A study of functions of mouth during chewing shows an intimate relationship between the tongue, mandibular posterior teeth and the buccinator muscle. The occlusal plane if incorrectly located results in the malfunction of the soft structures. A mandibular occlusal plane that is too high can result in reduced stability. A high occlusal plane forces the tongue into a new position higher than its normal position. This causes the tongue to loose much of its accuracy. The higher position causes the floor of the mouth to rise and

create undue pressure on the border of the lingual flange. This leads to disruption of the normal position of the floor of the mouth and hence : a. Partial loss of border seal b. Lateral forces directed against the teeth are magnified c. The tongue is unable to reach over the food table into the buccal vestibule making control of food bolus difficult. (Fig.24&25) A raised occlusal plane is usually present when the vertical

dimension of occlusion is increased excessively. Various anatomical landmarks such as Stensons duct, retromolar pad should be used to determine an acceptable level of occlusal plane. When excessive mandibular ridge resorption has occurred in comparison to maxillary, the occlusal plane is too low. An occlusal plane that is slightly low causes no problem. Ridge Relationships : A problem of stability is the offset ridge relations seen in prognathic and retrognathic patients. In case of class III patients, sufficient mandibular posterior occlusion must be developed so that the contact against maxillary denture extends posteriorly more than half the distance from the incisive papilla to the hamular notch. Without this contact the maxillary denture would tip antero-superiorly, traumatize the maxillary anterior ridge and loosen the maxillary denture. In case of severe posterior crossbite the normal tooth to tooth While some compromises in the ideal tooth to ridge and tooth position may be altered to provide a stable relationship. to tooth position relationships may be made, the range of such skeletal cosmetic deficiency correction without surgical intervention is limited. Patient Education :

Every patient should be informed regarding the care and proper Patients disregard reasonable limitations in the use of their Failure to follow the dentists advise will eventually lead to In case of retracted tongue position the dentist should guide the

use of the dentures. dentures and this is often inconvenient and needs to be adjusted. damage of the supporting tissues. patient by showing the normal position and demonstrating its significance. For occlusion in centric relation, simultaneous bilateral Incising with anterior teeth should be strictly avoided. No (Fig.26) chewing habits should be encouraged. treatment however sophisticated can be successful without the patients co-operation. Checking stability of the denture : Pressure is applied with the ball of the finger in the premolar molar regions of each side alternately. This pressure must be at right angles to the occlusal surface. If pressure on one side causes the denture to tilt and rise on the other side, it indicates that the teeth on the side on which pressure was applied are outside the ridge. Patient is asked to make excursive movements in case balanced occlusion has been provided. CONCLUSION: Stability prevents antero-posterior shunting of the denture base. It has been cited as the most significant property in providing physiologic comfort to the patient. Denture instability adversely affects retention and support and results in deleterious forces on the edentulous ridges during function and parafunction. It is important to know the factors affecting stability. Though
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to fabricate a perfectly stable denture may not be truely possible, we should still try to achieve the maximum possible.

BIBILIOGRAPHY : 1. 2. 3. 4. 5. 6. 7. 8. Boucher Prosthodontic treatment for edentulous patients Fenn Clinical dental prosthetics Heartwell Syllabus of complete denture Sharry Complete denture prosthodontics Winkler Essentials of complete denture prosthodontics. Glossary of prosthodontic terms VII edition Prospective clinical evaluation of mandibular implant A comparison of different treatment strategies in patients with

overdentrues part I : Burns D.R. ; JPD 1995, 73 (4). atrophic mandibles A clinical evaluation after 65 years : : W. Kalk ; JJP 1992, 5 (3). 9. 10. 11. 12. The influence of retromyhohyoid extension on the mandibular Denture movements and control A preliminary study : Lingualised occlusion in removable prosthodontics Curtis. M. Complete mandibular denture stability when the posterior complete dentures : C.H. Jooste and C.J. Thomas; JJP 1992, 5 (1). P.A.J. Culver and J. Watt : BDJ 1973, 135. Becker, Charles. C. Swoope, Albert. D. Guckes ; JPD 1977; 38 (6). teeth are placed over basal tissue : C.H. Jooste and C.J. Thomas ; Jol of Oral Rehabil ; 1992, 19. 13. 165-172. A contemporary review of the factors involved in complete dentures. Part II : Stabiltiy J.E. Jacobson and A.J. Krol; JPD 1983, 49,

1) 2) 3)

Definition Introduction Factors contributing to stability: Residual ridge anatomy Denture base adaptation Mandibular lingual flange, sublingual crescent area

I) Relationship of denture base to underlying tissues :

I) Relationship of external surface and periphery to the surrounding oro-facial musculature : The external surface of denture Influences of oro-facial musculature Modiolus and associated musculature The neutral zone

I) Relationship of opposing occlusal surfaces : Theories of occlusion Occlusion in centric relation Balanced articulation Lingualised occlusion Tooth position Occlusal plane Ridge relationships II) Patient education 4) 5) Conclusion List of references