CLINICAL RESEARCH

aAssociate PrProsthodonticbAssociate PrProsthodonticcAssociate Pr

306

Influence of denture adhesives on occlusion anddisocclusion times

Mohamed Hussein Abdelnabi, BDS, MSc, PhD,a Amal Ali Swelem, BDS, MSc, PhD,b andAyman A. Al-Dharrab, BDS, MSc, MPhil, PhDc

ABSTRACTStatement of problem. The effectiveness of adhesives in enhancing several functional aspects ofcomplete denture performance has been well established. The direct influence of adhesives onocclusal contact simultaneity has not yet been investigated.

Purpose. The purpose of this crossover clinical trial was to evaluate quantitatively the influence ofadhesives on occlusal balance by recording timed occlusal contacts; namely occlusion time (OT)and disocclusion time during right (DT-right) and left (DT-left) excursions by using computerizedocclusal analysis.

Material and methods. A crossover clinical trial was adopted. Assessments were carried out whileparticipants (n=49) wore their dentures first without then with adhesives. Computerized occlusalanalysis using the T-Scan III system was conducted to perform baseline computer-guided occlusaladjustment for conventionally fabricated dentures. Retention and stability assessment using themodified Kapur index and recording of OT and DT-right and DT-left values using the T-Scan IIIwere subsequently carried out for all dentures, first without adhesives and then after applicationof adhesive. All T-Scan procedures were carried out by the same clinician. Wilcoxon signed-ranktest was used to analyze the Kapur index scores and occlusal parameters (a=.05).

Results. Stability and retention of conventional dentures ranged initially from good to very good.However, adhesive application resulted in significant improvement (P<.001) in stability andretention and a significant decrease in duration of all occlusal parameters (OT [P=.003], DT-right[P=.003], and DT-left [P=.008]).

Conclusions. Adhesives significantly decreased OT and DT durations in initially well-fittingcomplete dentures with fairly well balanced occlusion, and further enhanced denture stabilityand occlusal contact simultaneity. (J Prosthet Dent 2016;115:306-312)

Growing use of adhesives bycomplete denture wearers isaccounted for by the subjec-tively perceived enhancementin overall denture perfor-mance,1-5 even in well-madeand well-fitting prostheses.6,7

Denture adhesives werefound to improve the individ-uals’ mastication efficiency1

and their ability to managetheir conventional dentures2

and to increase their comfort,confidence, and satisfactionwith their prostheses1,3,7 and,hence, their overall quality oflife.2 A number of objectivemethods have been imple-mented to demonstrate theeffectiveness of denture adhe-sives in improving retentionand stability,8-12 in decreasingdenture dislodgement13-15 andmovement during func-

tion,16,17 and in improving masticatory performance andocclusal force.7,18-22 It is only logical to assume that allthese enhancements are either indicative of or attribut-able to the denture’s overall occlusal contact simultaneity.However, to date, dental publications lacks clinicalstudies that objectively assess the occlusal balance and

ofessor, Oral and Maxillofacial Prosthodontic Department, Faculty of DentDepartment, Faculty of Dentistry, Minia University, Egypt.ofessor, Oral and Maxillofacial Prosthodontic Department, Faculty of DentDepartment, Faculty of Oral and Dental Medicine, Cairo University, Egyp

ofessor, Oral and Maxillofacial Prosthodontic Department, Faculty of Dent

occlusal contact simultaneity of complete dentures withand without adhesives.

Intraoral clinical assessment of occlusal contactsimultaneity, however, is challenging when using con-ventional methods. It includes the use of articulatingpaper, occlusal indicator wax, patient feedback, and

istry, King Abdulaziz University, Jeddah, Saudi Arabia; and Removable

istry, King Abdulaziz University, Jeddah, Saudi Arabia; and Removablet.istry, King Abdulaziz University, Jeddah, Saudi Arabia.

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Clinical ImplicationsClinically acceptable stability and occlusal contactsimultaneity can be achieved in well-fittingconventional complete dentures with fairly wellbalanced occlusion; however, using dentureadhesives could significantly enhance them.

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subjective interpretation.23-25 These methods arestraightforward and quick23 yet questionable, as none hasdemonstrated the ability to provide contact timesequence24 or quantify occlusal forces.25 Although artic-ulating paper has been the most commonly usedmethod,25 its marks are affected by occlusal morphology,patient occlusion quality, and the salivary impregnationof dental surfaces, which can diffuse the articulatingpaper ink and lead to false positives.26 Additionally, itsmarking repeatability is poor as it is subject to frag-mentation and perforation during intercuspation.27

Articulating paper is an insufficient indicator of occlusalcontact simultaneity because it cannot register contactforce or time sequencing26 and because the size of thepaper mark is only indicative of contact location andsurface area and is an unreliable indicator of appliedocclusal load.25

The objective assessment of occlusal equilibration hasbeen possible in recent years through computerizedocclusal analysis. The T-Scan system was developed byManess et al28 in 1987. The latest version (T-Scan III)provides a dynamic visual evaluation of a patient’s oc-clusion from initial tooth contact to maximum inter-cuspation.24,29,30 The system records relative forcevalues,31 but it allows for objective quantitative evalua-tion of occlusal balance by recording timed occlusalcontacts and by displaying numerical values for occlusionand disocclusion times.

Occlusion time (OT) is the time from the first contactof occluding teeth to maximum intercuspation, and dis-occlusion time (DT) is the time from maximum inter-cuspation to complete disocclusion during lateralmovement.32-34 The clinical goal is to reach maximumintercuspation in less than 0.2 second35 and disoccludeall posterior teeth in less than 0.4 second.36 The shorterthe OT, the less time required to contact all teeth and thefewer the prematurities as the patient closes intomaximum intercuspation, indicating occlusal contactsimultaneity and equilibration. Shorter DT (less than 0.5second) has shown to decrease contractile muscle activitysignificantly to near resting state values during mandib-ular excursions and decrease the stress on the temporo-mandibular joints (TMJs).36-38

The T-Scan system was found to be considerably accurateand reliable24,29,38-43 and has been implemented in different

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clinical dental applications,33,34,36-38,44-49 including completedenture prosthodontics.23,30,32,50,51 However, studies usingcomputerized occlusal analysis with complete denture wearersmostly used earlier versions of the system.23,32,50,51 Of thosestudies, only 1 investigated both OT and DT in completedenture wearers.32 Published dental studies that implementedthe recently introduced T-scan III system with completedentures are scarce. To the best of these authors’ knowledge,only 1 published clinical study used the T-Scan III to performcomputer-guided occlusal-corrective adjustments to improvethe occlusal balance of complete dentures by using the centerof force concept.30

To date, no published data are available for the defi-nite impact of denture adhesives on occlusal contactsimultaneity. The purpose of the current study was toquantitatively and objectively assess the influence ofdenture adhesives on occlusal parameters, namely OTand DT, in complete denture wearers using the T-ScanIII computerized occlusal analysis system. The null hy-pothesis of this study was that denture adhesives had nosignificant effect on occlusion and disocclusion times.

MATERIAL AND METHODS

A crossover clinical trial was adopted. The assessment wascarried out with conventional complete dentures (withoutadhesives) and thenwith the same dentures after adhesiveapplication. The study sample included 49 completelyedentulous participants, 37 men and 13 women (47 to62 years of age, with an average of 55.1 years of age)selected from the Department of Oral and MaxillofacialProsthodontics at King Abdulaziz University, Faculty ofDentistry. Power analysis was conducted using software(G*Power, v. 3.0.10; University of Kiel). Use of an alphavalue of .05, a sample size of 49 was found to yield a powerof 0.9. All participants were given detailed informationabout the investigation and gavewritten informed consentfor their participation. The study protocol was reviewedand approved by the Faculty Research Ethical Committee.

All participants had an Angle class I jaw relationshipwith no history of temporomandibular disorders. Theiredentulous conditions fell within classes I and II based onthe prosthodontic diagnostic index (PDI) classificationsystem for complete edentulism.52 Exclusion criteria werethe presence of major medical problems or severe chronicdiseases or any intraoral soft or hard tissue pathology.

New conventional maxillary and mandibular com-plete dentures were fabricated for all participants in aconventional manner. Elastomeric definitive impres-sions (Imprint II Garant; 3M ESPE) with border tracingwere made in custom trays. Maxillomandibular recordswere made using intraocclusal records and mounted onsemiadjustable articulators (Hanau Wide-Vue articu-lator; Whip Mix Corp) using facebow (Hanau Spring-Bow; Whip Mix Corp), centric relation, and protrusive

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Table 1.Modified Kapur index evaluation criteria (Olshan modification)

Retention Stability

5 = Excellent: excellent resistanceto vertical pull and lateral force

4 = Excellent: no rocking on supportingstructures under pressure

4 = Very good: very good resistanceto vertical pull and lateral force

3 = Good: very slight rocking onsupporting structures under pressure

3 = Good: moderate resistance tovertical pull and lateral force

2 = Fair: sufficient stability; demonstratesslight rocking under pressure

2 = Fair: moderate resistance tovertical pull and little or noresistance to lateral force

1 = Poor: some stability; demonstratesmoderate rocking under pressure

1 = Poor: slight resistance tovertical pull and little or noresistance to lateral force

0 = No stability: extreme rocking underpressure

0: No retention: denturedisplaces itself

Figure 1. T-Scan III high-definition Generation IV sensor.

Figure 2. Sensor held parallel to occlusal plane and centered at midlinebetween central incisors.

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records. The occlusal scheme was bilaterally balancedocclusion with 20-degree artificial teeth (Trubyte IPN;Dentsply Intl). Laboratory remounting was carried outto correct occlusal changes due to processing errors.The necessary intraoral clinical adjustments were thencarried out in a conventional manner on the day ofdenture insertion and continued throughout the firstweek until participants were free from any discomfortfrom their dentures. Clinical remounting procedureswere then carried out 2 weeks later to refine occlusalcontacts after denture settling. Before any occlusalparameter recording, computer-guided occlusal ad-justment procedures were carried out on all conven-tional dentures as a baseline measure. Participants wereallowed to use their conventional dentures for 2 weeksthen were recalled for the OT and DT recording pro-cedures. In the same appointment, the retention andstability of the conventional dentures were assessedintraorally by a single experienced examiner (M.H.A.)using the modified Kapur criteria (Olshan modifica-tion)10 (Table 1).

Participants were then left without their dentures for 2weeks (washout period)22,53 before adhesive application.

Paste denture adhesive (Corega; Stafford-Miller Ltd)was used in this study. The amount and application ofadhesive followed manufacturer’s recommendations andwere demonstrated to the participants after giving themall necessary instructions. Participants were asked to usethe denture adhesive for 2 weeks and then recalled for thesecond OT and DT recording procedures that were carriedout while the participants wore their adhesive-retaineddentures. The same examiner (M.H.A.) reassessed theretention and stability of the adhesive-retained dentures.

Computerized occlusal analysis was conducted usingthe T-Scan system (T-Scan III v8; Tekscan Inc). Thesystem uses a 100-mmethick recording sensor (high-definition generation IV sensor; Tekscan Inc) (Fig. 1) thatscanned in 0.003-second increments. The system wasinitially used to perform computer-guided occlusaladjustment for all dentures. It was then used to recordocclusal parameters, namely, OT and DT, for dentures

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without and with denture adhesives. All scanning pro-cedures were carried out by the same clinician (A.A.S.).

The size of the sensor (large or small) was chosen tosuit the participant’s dental arch. Prior to any occlusaldata acquisition and according to the manufacturer’srecommendation, a proper sensitivity range was estab-lished,35,54 and sensor conditioning procedures of 2 to4 test closures29,38 were performed for each participant.

For all scanning procedures, participants were askedto sit in a relaxed upright position in the dental chair. Thesensor was held consistently in the same position withrespect to the teeth. It was aligned to be parallel to theocclusal plane and centered on the midline between thecentral incisors (Fig. 2).38 For each participant, the samesensor was used throughout the adjustment andrecording procedures.

Before occlusal parameter recording, corrective occlusaladjustments were carried out using the center of force(COF) concept for each participant.30,50 Each participantwas asked to firmly occlude into the sensor with theirdentures until maximum intercuspation occurred, holdingtheir teeth together for 1 to 3 seconds, and then dis-occluding and reintercuspating into the sensor once again.Premature contacts were then specifically adjusted basedon the overloaded contact locations displayed anddemarcated within the system’s 2D (Fig. 3) and 3D (Fig. 4)force/view panes (through color coding and force values).

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Figure 3. COF analysis preadjustment scan: 2D force/view shows COFmarker located in left anterior of gray eclipse with unequal distributionbetween right (41.2%) and left (58.8%) sides. COF, center of force.

Figure 4. Pre-adjustment scan: 3D force/view shows premature contactsat particular areas, indicated by pink and red columns (representinghigher intensity forces).

Figure 5. COF analysis postadjustment scan (after a series of clinicalcorrective guided occlusal adjustments): 2D force/view shows COFmarker assuming midline position (located within white eclipse nearly atcenter) with right (49.4%) to left (50.6%) force balance approaching 50%bilaterally. COF, center of force.

Figure 6. Postadjustment scan: 3D force/view shows absence of high-intensity force columns and more favorable force distribution pattern.

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The corrective occlusal adjustment procedure was re-peated until a reasonably centered, measurably balancedforce distribution (50% ±2% on each side) was achieved ineach denture (Figs. 5, 6).

Occlusal parameters (OT and DT) were recorded forthe occlusally balanced dentures in each participant on 2occasions: first without adhesives (conventional den-tures) and second after adhesive application (adhesive-retained dentures). Participants were asked to occlude onthe sensor in centric occlusion with normal pressure untilmaximum intercuspation, then hold their teeth togetherfor a period of 1 to 3 seconds, start a right or left excur-sion from that completely intercuspated position, andthen disocclude.38 This was repeated 4 times for the rightexcursion (DT-right) and 4 times for the left excursion(DT-left). Mean OT, DT-right, and DT-left were thencalculated by taking the averages of the recordings.

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Statistical analysis was performed with software(SPSS v.16.0 [IBM Corp] for Windows [Microsoft Corp]).Data were collected, tabulated, and presented as means,standard deviations, and medians. The Wilcoxon signed-rank test (a=.05) was used to compare the modifiedKapur index scores (qualitative variables) of the samedentures with and without denture adhesives. TheKolmogorov-Smirnov test of normality was conductedfor the OT, DT-right, and DT-left data. Most of thevariables were not found to be normally distributed. Datawere, therefore, statistically analyzed with the Wilcoxonsigned-rank test (a=.05). Intraexaminer agreement wasalso determined for the Kapur index assessments andocclusal analysis recordings using Kappa statistics.

RESULTS

Kappa statistics revealed very good intraexamineragreement for both denture retention stability assess-ments (0.83) and occlusal analysis recordings (0.79).Modified Kapur index scores revealed that the stabilityand retention of both the maxillary and mandibularconventional dentures ranged from good to very good,indicating that the conventional dentures fit well initially.

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Table 2. Kapur index (Olshan modification) scores in conventional andadhesive-retained compete dentures (n=49)

Denture response

I Conventionaldentures

II Adhesive-retaineddentures

P*Mean (±SD) Median Mean (±SD) Median

Maxillary denture

Retention 3.53 (0.50) 4.00 4.73 (0.45) 5.00 <.001

Stability 3.39 (0.53) 3.00 3.98 (0.38) 4.00 <.001

Mandibular denture

Retention 3.42 (0.67) 4.00 4.67 (0.47) 5.00 <.001

Stability 3.16 (0.72) 3.00 3.92 (0.45) 4.00 <.001

SD, Standard Deviation.*Wilcoxon signed rank test; highly significant at P<.001.

Table 3.Occlusion and disocclusion times (seconds) in conventional andadhesive-retained compete dentures (n=49)

Occlusion parameter

I Conventionaldentures

Mean (±SD)

II Adhesive-retaineddentures

Mean (±SD) P*

OT 0.48 (0.23) 0.35 (0.17) .003

DT-right 0.56 (0.34) 0.37 (0.32) .003

DT-left 0.54 (0.33) 0.35 (0.27) .008

DT, disocclusion time; OT, occlusion time; SD, standard deviation.*Calculated with Wilcoxon signed rank test; significant at P<.05.

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Statistical analysis revealed significant improvement(P<.001) in the retention and stability of both denturesafter adhesive application (Table 2). Mean values andstandard deviations for OT, DT-right, and DT-left arepresented in Table 3. Statistical analysis revealed a sig-nificant decrease in duration of all occlusal parameterswith the adhesive-retained dentures compared with theconventional ones.

DISCUSSION

Results of the current study led to rejection of the nullhypotheses. Application of denture adhesives signifi-cantly shortened OT and DT duration in complete den-ture wearers. OT and DT have been used by severalresearchers23,32-34,38,47-49 as occlusal evaluation parame-ters. These variables are considered definitive parametersin expressing and quantitatively evaluating the state ofocclusal equilibration, regardless of the prosthesis type orocclusal scheme used.23,32 As mentioned earlier, theseparameters represent the time lag obtained from occlusalcontact recordings from the first premature contact tomaximum intercuspation and from maximum inter-cuspation to complete disocclusion during lateral move-ment. As a result, shorter durations indicate stableocclusal balance of dentures on their residual ridges andthe absence of premature contacts.23

To ensure valid and reliable results, several measureswere considered. The study was designed as a cross-overclinical trial to exclude individual variations. Dentureretention and stability were assessed by 1 examiner(M.H.A.). Similarly, all occlusal adjustments and occlusalparameter recordings were carried out by 1 clinician(A.A.S.). This was done to exclude interexaminer varia-tions, as no studies have investigated operator influenceon the values obtained from the scanning system.33 Forall occlusal adjustment and recording procedures, par-ticipants were asked to sit in a relaxed upright position inthe dental chair as an increasingly significant relationshipbetween the sagittal plane head-neck posture and initialocclusal contacts has been reported for those over the ageof 30.55 Sensors were individually held consistently in the

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same position38 to minimize sensor-positioning vari-ability and assure stability during repeated closure. Thisensured that the same sensing elements were repeatedlyloaded by the same cusps in all records.31,38 According tothe manufacturer, T-scan III sensors can be used up to 15to 25 times while still retaining high standards of reli-ability. Accordingly, for each participant, the same sensorwas used throughout the adjustment and recordingprocedures to eliminate any intersensor variability.

To make sure that the obtained results were due tothe influence of denture adhesives exclusively, otherfactors that may negatively affect denture stability andhence occlusal balance were eliminated. Only partici-pants with class I or II complete edentulous states (basedon the PDI system), in which the residual ridgemorphology and location of muscle attachments werefavorable, were included in the current study. Two pre-recording measures, including the assessment of dentureretention and stability using the modified Kapur scaleand computer-guided occlusal adjustment using the T-Scan III center of force analysis30,50 were carried out. Thiswas necessary to ensure a sound baseline for originallywell-fitted dentures with fairly well-balanced occlusionand to avoid the influence of offset deflective occlusalcontacts and instability on the obtained results.Furthermore, to ensure that the “with” adhesive valueswere solely due to adhesive application and not due toparticipant adaptation to their dentures, a 2-weekwashout period was adopted.22,53 The participants werealso asked to wear their conventional dentures for 2weeks only given that denture adaptation requires 90days.15

Results of the current study revealed a significantdecrease in OT and DT times after the use of dentureadhesives. The mean OT decreased significantly to 0.35second, which approaches the recommended time of 0.2second. Similarly, mean DT-right and DT-left valuesdecreased significantly to 0.37 and 0.35 second, respec-tively, effectively achieving the recommended time of 0.4second. To the best of these authors’ knowledge, nopublished studies have compared conventional andadhesive-retained dentures with regard to OT and DT.Thus direct comparison was not possible. However, theseresults indicate that adhesive application even to well-fitting, occlusally balanced dentures further improved

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the stability and occlusal simultaneity between the den-tures. This could be attributed to their mechanism ofaction. Adhesives usually increase the contact andadaptation between the tissues and the denture and forma retentive force between the denture and oral mucosa bymeans of an intermediary film composed of a combina-tion of the adhesive, saliva, and other oral fluids.4 Thisincreases the amount of the denture seating surface incontact with the dentureebearing tissues, which in-creases the resistance of the prosthesis to dislodge-ment.6,11 Adhesives significantly increase the retentionand stability of complete dentures,4-6,8-14,16,18,19 even forthose that were initially well-fitting,6 as confirmed also bythe findings of the current study. Consequently, adhe-sives reduce denture displacement and dislodgementduring function.6,7,13,16 Adhesives were also found toreduce rotational denture movement and masticationtime.14 Accordingly, adhesives help in the even distri-bution of occlusal forces across the denture-bearing areaduring function, thereby limiting local pressure points.17

Therefore, the improved occlusal contact simultaneityachieved and possibly maintained by the use of adhesivesmay be attributed to the considerable reduction of pre-mature contacts resulting from denture movement dur-ing function. The authors, however, emphasize theproper use of denture adhesives and the avoidance oftheir overuse or misuse.

In their clinical study, Sierpinska et al,32 used theT-scan II occlusal analysis system and reported an averageof 0.42 second for OT, 0.48 second for DT-right, and 0.45second for DT-left for participants with new conventionalcomplete dentures. In the current study, the mean OT,DT-right, and DT-left times recorded for conventionaldentures were 0.48 second 0.56 second, and 0.54 second,respectively. Although the values are close, differencesmay be attributed to the different system versions andstudy designs. In another clinical study, Haralur34 usedthe T-Scan III system and reported an average of 0.69second, 0.79 second, and 0.91 second for OT, DT-right.and DT-left times, respectively, in normal dentate in-dividuals (n=50) with healthy TMJs. That study’s valueswere higher than those obtained in the current study.Those findings cannot be directly compared with thecurrent findings because of the differences in dentition.However, those values could support the assumption thatthe results obtained with the conventional dentures in thisstudy, although they do not represent the recommendedvalues, still did not exceed the values obtained for naturaldentitions with healthy TMJs. This implies that the valuesin the current research could still be considered withinclinically acceptable limits, because all dentures wereinitially well-fitting with fairly well-balanced occlusion.

These authors acknowledge that the current study didnot cover all completely edentulous situations and waslimited only to those with favorable denture-bearing

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conditions. The use of adhesives and their influence onocclusal parameters (OT and DT) in participants withfairly poor or unfavorable denture bearing conditionscould be the scope of future research.

CONCLUSIONS

Within the limitations of the study design and given thespecific patient population, the application of dentureadhesives was found to significantly decrease OT and DTdurations in initially well-fitting complete dentures withfairly balanced occlusion and further enhance denturestability and occlusal contact simultaneity.

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Corresponding author:Dr Amal Ali SwelemKing Abdulaziz UniversityPO Box 80209Jeddah 21589SAUDI ARABIAEmail: amalswelem@hotmail.com

AcknowledgmentsThe authors thank the facilities of Advanced Technology Dental Research Labo-ratory, Faculty of Dentistry, King Abdulaziz University for technical support.

Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

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