REMOVABLE

SECTION EDITORS

PROSTHODONTICS
S. HOWARD PAYNE

LOUIS BLATTERFEIN

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.**

in

University of California, School of Dentistry, San Francisco, Calif., and Veterans Administration Medical Center. San Francisco, Calif.

omplete denture support is the resistance to vertical 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.

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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 relationship 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 compromised. Initial denture support is achieved by using impression 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-

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 extension.“” 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 constant occlusal force, a broader denture-bearing area decreases the stress per unit area under the denture base, decreases tissue displacement, and reduces denture-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. Several 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 characteristics minimize base movement, decrease soft tissue trauma, and reduce long-term resorptive changes.

SOFT TISSUES
Supporting soft tissues must be capable of withstanding the pressures induced through normal function of the prosthesis. The presence of keratinized,

*Assistant Clinical Professor, Removable Prosthodontics **Chief of Dental Services, Removable Prosthodontics.

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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 degeneration, 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 submucosa 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 foundation during occlusal loading, thereby minimizing soft tissue trauma and reducing pressure-induced bony remodeling. HARD TISSUES

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 variations in bone index.

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

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 dentureinduced 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,

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Retromolor

pod with glands

1

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 mandibles exhibit prominent mylohyoid ridges, genial tubercles, 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

Fig. 4. Notice anatomic demarcation between structures that ultimately form pear-shaped pad and retromolar pad of edentulous mandibular ridges. Glandular retromolar pad is posterior to pear-shaped pad, which is formed by scar tissue of extraction site of mandibular 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 DENTURE-BEARING AREA

OF

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
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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 differentiate it from the more distal retromolar pad, which is composed of alveolar mucosa overlying glandular and loose alveolar connective tissue. Clinicians must recognize 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 denturebearing 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, superior 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 attachments 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 settling of the denture base posteriorly (Fig. 5). Many authors recognize the importance of the buccal shelf as a primary support area for the mandibular denture.* R.9. 12~22 is usually covered by mucosa I” It with an intervening submucous layer containing glandular connective tissue and buccinator muscle fibers. The buccinator muscle is attached inferiorly along the buccal shelf between the ridge crest and the external oblique ridge.” The muscle fibers run along the shelf in a longitudinal anteroposterior direction, permitting the denture base to rest directly on a portion of the buccinator muscle without displacement. This buccinator muscle attachment extends posteriorly to include the pear-shaped pad area. Again, owing to the nature of the overlying soft tissues and the presence of muscle attachments, these regions provide primary support for the mandibular denture base. The role of the mandibular residual ridge crest in support depends on the nature of the ridge and the bone factor of the individual patient. Patients exhibiting broad, square, well-developed residual ridges covered by firmly bound masticatory mucosa plus a favorable intrinsic bone factor may rely on the ridges for support. Generally, the ridge crests are reserved as secondary support areas. The lack of muscle attachments and presence of cancellous bone usually result in resorptive
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Fig. 5. A, Underextension of mandibular partial denture short of pear-shaped pad contributed to marked resorption of residual ridge area, which was covered by denture. B, Lack of adequate support contributed to settling of extension base secondary to resorption. changes occurring more rapidly than in the areas of primary support. The remaining anatomic regions of the mandible are not usually essential in providing denture support. The less keratinized alveolar mucosa of the lingual and anterior labial ridge slopes lies directly over basal bone and does not tolierate pressure well. In fact, the lingual tissue over the mylohyoid ridge often requires relief to reduce impingement of the mucosa. The denture border is extended into the movable soft tissue to effect border seal and not to promote support. In markedly resorbed mandibles, the genial tubercles provide a bony foundation resistant to resorption due to the genioglossus muscle attachments, but the friabie overlying mucosa usually obviates its use as a primary stressbearing area capable of resisting vertical forces. The mandibular anatomic regions and their relative contribution to denture support are outlined in Fig. 6 and are based on the average healthy edentulous mandible. Individual variations may dictate changes from the normally desired relationship of denture hase to under309

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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 mandibular ridge crest would preclude its use even for secondary support. Patients who have undergone vestibuloplasty procedures with split-thickness skin grafts have favorable keratinized tissue overlying regions of muscle attachments 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.

Fig. 7. Skin has been grafted over area of genial tubercles. Such treatment allows use of genial tubercles 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 conventional complete denture patients. Clinical observations of patients wearing “roofless” maxillary dentures substantiate 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 supporting 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 counteract 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 mucosa and bone and acts as a resilient liner for the mucosa. Despite this favorable soft tissue covering, the underlying 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

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 distinct submucous layer everywhere but at the midline suture. The submucosa contains fatty tissue anterolaterally and glandular tissue posterolaterally. This resilient 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.

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Fig. 9. Various anatomic regions of maxillae in providing support. Primary support areas (1 “J should include horizontal antero- and posterolateral hard palate. Ridge crest should function at best as a secondary 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 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 involving the anterior maxillary ridge beneath a complete denture opposed by mandibular anterior natural dentition 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, redundant tissue anteriorly together with fibrous, pendulous tuberosities posteriorly is referred to as the “combination syndrome” by KellyI (Fig. 8). These and other associated changes result from excessive forces transmitted to the anterior maxillae. Such forces must be controlled and minimized by proper design and technique. 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 functional stresses, and the inclined surface would provide Relief regions fall into three categories. First, tissues that are susceptible to resorption should not be subjected 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 mylohyoid 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 procedures 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 individual anatomic and physiologic requirements of each patient will dictate certain alterations in technique. PRACTICAL CONSIDERATIONS

One generally accepted principle of impression procedures is that the maximal allowable denture-bearing surface area should be incorporated. Many authors

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recognize the need to record the different anatomic regions under varying degrees of pressure, depending on the nature of the tissues.‘*6~8~22~ The rationale 24-26 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 distribution 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 placement for equalization of pressure in order to resist occlusal stress over the entire bearing area is desirable. . . .” Selective pressure impressions have some disadvantages 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-

tion, the dentist must weigh the advantages and disadvantages 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 impression materials on pressures exerted on the denturesupporting tissues during maxillary edentulous impression procedures. The study concluded that (1) differences in pressure were correlated to the use of different impression materials (irreversible hydrocolloid 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 equalizing 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 understanding 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.
REFERENCES
1. Friedman, S.: Edentulous impression procedures for maximum retention and stability. J PROSTHET DENT 214, 1957. 2. Preiskel, H. W.: The posterior lingual extension of complete lower dentures. J PROSTHET DENT 19:452, 1968.

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8.

9.

10.

11. 12.

13. 14.

IS.

Tllron. G. E.: The denture periphery. J PROSTHET DENT 2:x0, 1952. Tuckfield, W. ,J.: The problem of the mandibular denture. J Dent 3:R. 1953. M,tison. M’. (:. Denture outline form. J Am Dent Assor 593938, 1059 Fisher. R. D.: Six fundamental rules for making full denture impressions. J PROSTHE? DENT 1:135, 1951. Roberts, A. I,: Principles of full denture impression making and their application in practice. J PROSTHET DENT 1:213, 1051. Bcwcher, ( 0.: A critical analysis of midcentury impression rwhniqurs l’or full dentures. J PROSTHET DENT 1:472, 1951. Bereft. S. G.. nnd Haines. R. W.: Structure of the mouth in the mandibular molar region and its relation to the denture. J PROSTHET DENT 12:835, 1962. Nwards. L. F., and Boucher, C. 0.: Anatomy of the mouth in relation to complete dentures. J Am Dent Assoc 29:331, 1042. Barone. J. V.: Physiologic complete denture impressions. J PROSTHE~ DENT 13:800, 1963. Van Scottrr. D. E., and Boucher, L. J.: The nature of supporting tissues for complete dentures. J PROSTHET DENT 153285, 1965. Orban, B.: Oral Histology and Embryology, ed 3. St. Lows. 1’153, The C. V. Mosby <:o. Tallgren, A.: The continuing reduction of the residual alveolar ridges in cx)mplele denture wearers: A mixed-longitudinal study covrrjng 25 years. J PROWHET DENT 27:120, 1972. .\twood. D A.: Some clinical factors related to rate of rcwrp~ion of residual ridges. J PROSTHET DENT 12:441,
1002. (kukson.

Glickman, I.: Clinical Periodonrology, ed ,: Philadelphia. 1972. W. B. Saunders Co., pp 432-439. 19. Krol. Iz. .J: Removable Partial Denture I)e~qrr. An Outline Syllabus. San Francisco. 1976, c:niversitv o! the Pacilic, pp IS-16 20. Henderson, I:,., and Stcffel, V. L,.: McCracken‘s Remrwahle Partial Prosthmodontics.ed 4. Sr. Louis. 19’73. ‘l‘hr (Z. \ Moshy (:a.. pp 166-169. 21. Craddock, F. W.: Prosthetic Dentistry. wl ? it. l,ou~, 1951~ The (1. V. Moshy Co., pp 212-213. 22. Boucher, C. 0: Complete denture unpressionh hased upon Ihe anatomy of the mouth. J Am Dent Assoc 31: i 174, 1044. 23. Alwood. I). .\ : A cephalometrir study 01’ ihe clinical rest posItion of the mandible. Part II. The variability in the rate of bone loss l’ollowing the removal of oc-clusai I cbnlncts. J PKOS ‘I ttt.7’ DENT 7:544. 1957. 24. Carlilr. E. F. Functional adaptation of IOYYI. denture bases.
18. ,J PROSTHET DENT 1:662. 1951.

25. 26. 27. 28. 29. 30.

(Campbell, R. L.. Relief chambrrs in (omplete dentures. J PROSTHET DCN.I. 11:230. 1961. DeVan. kl. M.: Basic principles in imlwwon making. J PROSWET DENT 2:26, 1952. Page. H. L.: Mucostatics-A Principlr, Not :L Technique. (Chicago. 194ti, published hv Ihe author. Swenson, bl. (;.. Complete Dentures, rd 2 St. Louis, 1947, ‘i‘he (1. V. hfoshy Co., pp 13-87, 331-359. Craddock, F. W.: Prosthetic Dentistry--1\ Clinital Outline. ed 3. London, 1956, Hwry Klimpton, pp 00-91 91. 217 Frank, R. P: Analysis of pressurr produced during maxillary edenrulous impression procedures. ,J PK~XI it r Dcx,~ 22:400, 1969

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(G. E.. and Pcrssin. G.: Morphologic changes of the mandible after extractwn and wearing of dentures. Odont Revy l&27, 196’. 17. Kelly, E.. (:hanges caused by a mandibular removable partial dcnturr opposing a maxillary complete denture. J PROSTHET DEN-~ 27:l-N). 1972.

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