THE EFFECT OF COMPLETE DENTURES ON ALVEOLAR MUCOSA

KRISHAN KAPUR, D.M.D., MS.,” AND GERALD SHKLAR, D.D.S., MS.“*

Tufts University, School of Dental Medicine, Boston, Mass.

of the histologic features of the structures that support den-

A N UNDERSTANDING
tures is necessary for proper therapeutic measures in complete denture pros-
theses112 Studies on the histology of denture-bearing tissues have been few in num-
ber in the light of existing problems.
Brinch3 and Pendelton4 made some of the original postmortem studies of
denture-bearing tissues. Brinch3 observed pronounced histologic changes in the
epithelium, connective tissue, and glandular tissue of palatine mucosa obtained from
twelve subjects who had worn dentures. He attributed epithelial injury chiefly to
mechanical factors, while the deeper changes were thought to be caused by chemo-
toxic decomposition products, as well as by an insulating effect of the denture base.
Ostlund5 studied the effect of complete dentures on the “gum tissues” through
an observation of clinical changes and the examination of histologic sections from
biopsies of palatine mucosa from a large group of denture and nondenture wearers.
He stated, “Normally the epithelium is covered by a horny layer, which protects
the underlying tissues against mechanical, chemical, and bacterial injury.” Ostlund5
reported that, with the use of complete dentures, pronounced histologic changes
occurred despite the normal clinical appearance of the denture mucosa. He further
reported a decrease in thickness, and, finally, the disappearance of the horny layer
from the epithelium, resulting in parakeratosis. Ostlund5 also stated, “The increase
observed in the epithelium was thus due partly to an increase in the volume of the
individual cells and partly to the oedematisation of the tissues.”
The purpose of this study was to investigate the changes occurring in denture-
bearing mucosa after the use of’ removable dentures. A biopsy study was performed
on specimens collected at different time intervals from the same patient before and
after the use of dentures.

PROCEDURE

Nine subjects who had only six anterior teeth remaining in the maxillary
dental arch and a full or a partial complement of natural teeth in the mandibular

Read before the International Association for Dental Research, St. Louis, MO.
Supported in part by a grant from the General Electric Company, Dental Health Section,
Ashland, Mass.
*Associate Professor of Partial Denture Prosthesis.
**Professor of Oral Pathology and Research Professor of Periodontology.
1030
Volume 13 ALVEOLAR MUCOSA 1031
Nulnber 6

arch were chosen from a previous study (Fig. 1). These subjects were scheduled
for the replacement of the maxillary teeth with an immediate denture, and for the
restoration of the mandibular dentition with or without a removable partial pros-
thesis.6 Subjects ranged in age from 16 to 49 years and had not used removable
prosthetic restorations in their maxillary dental arch.
A complete medical and dental history along with colored slides and roentgeno-
grams were obtained for each subject. The subjects were screened for systemic
abnormalities. The gingivae around the six remaining natural teeth and the mucosa
of the posterior residual ridges on each side were examined for their color and
texture, and the presence of abrasions.
One side of the posterior edentulous ridge and the gingivae around the three
ant:erior teeth were stimulated with a power-driven toothbrush on week days for a
period of four weeks, while the other side was used as a control. This stimulation
was provided in sections and each section was stimulated for 15 seconds each day.
Twenty-four hours after the final stimulation treatment, biopsies were taken from
the gingival and edentulous alveolar mucosa from identical control and experimental
bicuspid areas (Fig. 2, A).

Fig. l.-The maxillary dental arch prior to biopsy and extraction of anterior teeth.

Immediate dentures were inserted at the time of the biopsies and the subjects
were recalled twelve weeks after the insertion of the dentures (Fig. 3). The im-
mediate dentures were constructed for all subjects by the same investigator (K. K.)
using the same technique for all patients. Nonanatomic acrylic resin teeth were used
and arranged on a flat plane for all 9 patients. Seven of the 9 patients had a bi-
lateral removable lower partial denture. Six of these partial dentures were bilateral
free-end denture base restorations, and the seventh removable partial denture was
bilaterally tooth borne. One patient had a complete lower denture, while the other
patient had some natural lower teeth and refused the replacement of the missing
teeth.
Twelve weeks after the insertion of dentures, biopsies were taken from similar
locations in the bicuspid regions on both sides of the dental arch (Figs. 2, B and C,
and 4). All biopsy specimens were taken by the same dentist (G. S.). Histologic
sections were prepared with the use of a hematosylin-eosin stain, the Ayoub mod-
ification of the Mallory connective tissue stain. and the periodic acid-Schiff tech-
nique for mucopolysaccharides.
 J. Pros. Den.
1032 KAPUR AND SHKLAR Nov.-Dec., 1963

CLINICAL OBSERVATIONS

A clinical evaluation of the oral mucosa was made before the biopsy specimens
were taken (Fig. 5). The color and texture of the oral mucosa were observed
closely. No differences were noted. The dentures were rated as good to excellent
for stability, retention, occlusion, and denture extension.

A.

B.

c.

Fig. 2.-A, The site of the biopsy was located prior to extraction of the remaining teeth
and insertion of the dentures. B, A biopsy specimen is on the scalpel blade. C, The site of the
biopsy following the use of a denture was located in a position similar to what it was prior to
denture construction.
Volume 13 ALVEOLAR hlUCOSA 1033
Number 6

hl ICROSCOPIC FINDINGS

Alveolar Mzlcosa Prior to Dcntwc Insertion.-Microscopic examination of

biopsy specimens prior to the insertion of dentures revealed a distinct layer of
keratin in most instances. This layer was often of the parakeratotic variety, with
cell nuclei visible within the stratum corneum. The connective tissue was often in-
filtrated by varying numbers of lymphocytes, plasma cells, and histiocytes.
The edentulous mucosa that had been stimulated with an automatic toothbrush
for a period of four weeks revealed a generalized increase in the width of the stratum
corneum as compared to the unstimulated mucosa (Figs. 6, A and B, and 7, A and
B). The zone of keratin was increased in width, but in many places it appeared
to be irregular and discontinuous. The stimulated mucosa presented greater down-
ward extension of rete pegs than the unstimulated mucosa in some instances (Fig.
6, B).
Alveolar iMucosa Following the Wearing of Dentures for Three Months.-
Biopsy specimens taken after the patients had worn the dentures were compared

Fig. 3.-An immediate maxillary denture and a removable partial mandibular denture are
in position in the mouth.

Fig. 4. Fig. 5.

Fig. 4.-The maxillary dental arch after the use of a complete upper denture for 3
months.
Fig. B.-The position and shape of the biopsy specimen are indicated by the site of removal
in the mouth. The specimen was wedge shaped, extended across the crest of the ridge and to
the mucoperiosteum in depth.
A.

Fig. 6.-Four biopsy specimens from the same subject before and after the use of an im-
mediate complete denture were prepared with hematoxylin-eosin stain. A, Note the narrow zone
of parakeratin representing the stratum corneum on the specimens from the left maxillary al-
veolar ridge prior to use of the denture. B, Note the slightly widened stratum corneum and the
extension of rete pegs on the specimen from the right maxillary alveolar ridge prior to denture
insertion but following stimulation for a period of 4 weeks. C, Note the widened stratum
corneum and presence of a stratum granulosum on the specimen from the left maxillary alveolar
ridge following use of denture for three months. D, Note the widened stratum corneum and the
presence of the stratum granulosum on the specimen from the right maxillary alveolar ridge
following use of denture for 3 months.
A. B.

c. D.

Fig. 7.-Four biopsy specimens from another subject before and after the use of a denture
‘ere prepared with hematoxylin-eosin stain. A, Note the small zone of keratinization and the ex-
msion of rete pegs on the specimen from the left side prior to use of the denture. B, Note the
Icreased width of the stratum corneum of the specimen from the right side prior to use of the
?niure but following stimulation for 4 weeks. C, Note the slight increase in the stratum
lrneum and the presence of a narrow stratum granulosum on the specimen from the left side
lllc~wing use of the denture for 3 months. D, In this instance a marked hyperkeratosis is in
&lence on the specimen from the right side following use of the denture for 3 months.
1036 KAPUR AND SHKLAR

with those taken prior to the insertion of dentures. There appeared to be a distinct
increase in the width of the stratum corneum in the specimens taken after the
denture had been worn. The keratin layer was generally of the hyperkeratotic
variety, but zones of parakeratosis were occasionally in evidence.
The mucosa of both the right and left sides of the residual ridge presented an
equal amount of keratinization (Fig. 6, C and D) , indicating that the stimulation of
mucosa prior to the insertion of dentures had no obvious general relationship to the
subsequent tissue reaction to the denture. However, in two of the patients there was
a greater zone of keratin on the side which had been stimulated prior to insertion
of the dentures (Fig. 7, C and 0).
There was evidence of epithelial atrophy or lack of keratinization of the mucosa
in one patient following the wearing of dentures. No evidence of ulceration or severe
inflammation was seen in the tissue obtained from the patients. Chronic inflam-
matory infiltration was minimal and the connective tissue collagen appeared dense
and well formed.

DISCUSSION

Our histologic observations indicate that the wearing of dentures for a given
period of time results in excellent tissue response with the development of an
obvious and well-formed stratum corneum. This zone appears to be increased in
width when compared to biopsy specimens taken prior to the insertion of dentures.
In a previous study,6 it was demonstrated that stimulation of edentulous al-
veolar mucosa with an automatic toothbrush resulted in increased keratinization. It
appears from this study that the stimulation of alveolar mucosa from a well-adapted
denture has a similar and possibly even greater effect.
Our microscopic findings apparently are at some variance with those of
Ostlund.6 However, Ostlund’s biopsies of the palatine mucosa were taken from a
region just ventral to the vibrating line, while ours were taken from the crest of
the edentulous residual ridge. Since Ostlund’s biopsies were taken in the posterior
palatal seal areas, the changes may have been the result of continuous pressure from
the denture base in this region. Biopsy specimens of the ridge present a more ac-
curate picture of mucosal reactions to well-adapted dentures since this tissue rep-
resents an area of mucostatic adaptation. However, the posterior palatal seal area
represents tissue that is deliberately displaced to gain retention for the denture.
If keratinization is a mechanism whereby the tissues gain a greater degree of
protection against local irritation or trauma ,7 then it appears that a well-adapted
denture stimulates the underlying mucosa to produce keratin. The lack of inflam-
mation in the subjacent connective tissue indicates that the denture is not an irritant.
This initial study suggests that well-adapted dentures stimulate rather than
irritate the underlying mucosa. The result is healthy mucosa with slight hyper-
keratinization rather than atrophic changes easily susceptible to local trauma.
Further studies are indicated, particularly in patients susceptible to inflammatory
changes associated with dentures. Stimulation of the mucosa with various devices
and tissue reactions to dentures will be studied in these patients. The effects of
Volume 13 ALVEOLAR MUCOSA
Number 6

stimulation of the mucosa will also be studied in the average denture patient to in-
vestigate the combined effects of the denture plus tissue stimulation with various
devices.

SUM M,ARY

Histologic examination of biopsy specimens prior to the insertion of dentures

and following the wearing of dentures for three months, revealed healthy tissue
with minimal inflammatory infiltration and increased keratinization. The dentures
appeared to stimulate keratinization.

REFERENCES

I. Stansbery, C. J. : Tissue Changes Under Dentures, J.A.D.A. 15:349-353, 1928.

.2. Pendelton, E. C.: The Anatomy of the Maxilla and Its Relation to the Problem of Full
Denture Retention, J.A.D.A. 19:543-572, 1932.
3. Brinch, 0. : Histologiske Undersogelser of Ganevalevet fra Prothesebaerende Patienter,
Tandlaegebl, K’hvn, 36:281-294, 1932.
4. Pendelt;;34E. C.: The Mmute Anatomy of the Denture Bearing Area, J.A.D.A. 21:488-5&l,
ii. Ostlund,S. G.: Effect of Complete Dentures on the Gum Tissues, Acta odont. scandinav.
16:1-36, 1958.
6. Kapur, K., and Shklar, G.: Effects of a Power Device for Oral Physiotherapy on the
Mucosa of the Edentulous Ridge, J. PROS. DEN. 12:762-769, 1962.
7. Hine, M. K.: Use of the Toothbrush m the Treatment of Periodontitis, J.A.D.A. 41:158-
168, 1950.
136 HARRISON AVE.
BOSTON 11, MASS.