THE ROLE OF LEARNING IN DENTURE RETENTION

N. BRILL, L.D.S.,” G. TRYDE, L.D.S.,**AND S. SCH~BELER, L.D.S.**

Royal Dental College, Copenhagen, Denmark

C his patient. The final outcome, may

OMPLETE DENTURE be a challenge both to the dentist and
RETENTION
be it successor failure, is decided by the re-
sponsesof the dentist and his patient to the challenge. Responsesof patients can be
divided into three groups. To one group belong patients who can be treated with
any denture (even the crudest) and will be satisfied. This group is no challenge
to the dentist. To a second group belong those patients who can be treated with
any denture (even one made by the most exacting technique) and never be satisfied.
This group presents a real challenge. Between these two extremes is another
group, which is by far the largest. The difficulties presented by the third group
are usually overcome and will not be considered in this article.
When the first and second groups are compared, however, an intriguing
problem concerning the correlation between denture retention and learning proc-
esses is revealed. Young people usually belong to the first group and are the
“easy” patients. The second group is made up of older people; they are the
“difficult” patients. Young people generally have a high capacity for learning, but
this capacity gradually diminishes with increasing age and becomes extinct in old
age. Progressive atrophy destroys functional elements of the cerebral cortex1 and
subcortical structure9 which are involved in learning processes.” Signs of cerebral
involution generally appear in people in their early forties.4g1Diseases, nutritional
deficiencies, and stress cause an earlier precipitation of these signs2 Because the
initial period of adaptation to complete dentures involves learning and some learn-
ing capacity, it follows that adaptation to complete dentures has neurological
implications.

LEARNING MECHANISMS

Unconditioned reflexes are innate and of ancient phylogenic origin, e.g., the
sucking reflex as seen in the newborn child. They are absolute prerequisites for
survival.5 In order to live a normal life with appropriate muscle activity, however,
man needs more than unconditioned reflexes. He must supplement these reflexes
by establishing conditioned reflexes, and he must learn to modify muscle activity.

Some statements in this article do not reflect the teachings of the Prosthetic Department at
the Royal Dental College, Copenhagen. Nevertheless, the rationale presented is substantiated by
clinical and general observations.
*Associate Professor, Department of Prosthetic Dentistry.
**Instructor, Department of Prosthetic Dentistry.
468
Volunx 10
Iiumber 3 ROLE OF LEARNIKG IN DENTURE RETENTIOK 469

An account of the formation of a conditioned reflex (Fig. 1) is given by

.Elliott” : “U’ith a dog for subject, the ringing of a bell may originally set up im-
,Sulses in a circuit that produces pricking of the ears. Some of the impulse will
‘pass along collaterals to synapses with other circuits, but will not necessarily
activate them, since the synapses may be too resistant. Now if food is given at the
same time as the bell is rung, impulses will run along a path producing salivation
and this will lower resistances in that path, so that impulses from the ear-pricking
circuit can now jump intervening synapses. If this process is repeated frequently,
the barrier between the two systems will, in some way, be permanently weakened.
An arc of lower resistance will then be formed between the ear and the salivary

Fig. l.-Supposed mechanism of the conditioned reflex. A, The path of least resistance is
from ear to ear muscles; the synapse (S) is too resistant for ordinary impulse volleys to cross.
If, however, the path from the taste buds to salivary glands is excited at about the same time,
synaptic resistance at S is lowered and impulses can easily cross from the first chain. B, If this
is repeated frequently, a path of low resistance will be established from ear to salivary glands.
It must be emphasized that each “arc” is in reality a large web of neurons. Hence, break-
through between two arcs is possibly a complex process. (From Elliott, H. C.: Textbook of
the Nervous System, Philadelphia, 1954, J. B. Lippincott Co.)

glands, so that the ringing of a bell will cause salivation. And similarly a rela-
tionship can be set up between any stimulus and any response.” The formation
of such connections is a fundamental mechanism in the learning processes.
“This apparently simple device is, in fact, the most revolutionary develop-
ment in the evolution of the brain.“‘j This means that behavior, including muscle
behavior, is no longer restricted to stereotyped responses performed by inflexible
reflex arcs of ancestral heritage. On the contrary, it means that an individual can
form new reflex arcs which are more suitable to the requirements of sensory
input. He can learn by experience to respond in a purposeful manner to an al-
most infinite number of stimuli .6,7 It should, however, be pointed out that although
470 BRILL, TRYDE, AND SCHtiBELER J. Pros. Den.
May-June, 1960

the nervous connections are easily established in a young nervous system, one
can hardly expect such connections to form other than with difficulty in an aging
system, if they form at all.8

DEMONSTRATION OF PURPOSEFUL MUSCLE BEHAVIOR

A report of a patient and how she mastered challenges set up by her upper
denture will demonstrate the degree of perfection to which an acquired muscle
behavior can develop.
The patient was a 63-year-old woman in good health. Temperamentally she’
was kind, a little shy, but otherwise well balanced. At the age of 25 (38 years
previously), she had been fitted with a complete upper denture which she had
worn since, day and night. She had been fully satisfied with this denture. A
lower denture had never been made. In the years to follow, the number of lower
teeth was gradually reduced by extractions.
Oral inspection revealed an edentulous upper jaw. The residual ridges were
atrophied, but not severely. The mucosa of the ridges and hard palate was dense
and bound firmly to the underlying bone. Its color was natural pink. No denture
ulcers or hyperemic spots could be detected. The cuspids and first premolars re-
mained in the lower jaw. These teeth were abraded slightly and discolored, and
a few fillings were present in them. A slight inflammation of the marginal gingivae
was observed. Mandibular muscles and joints appeared to be structurally and
functionally normal. Apparently this patient, like the majority of persons in need
of dental and prosthetic treatment, was just another ordinary patient; that this
was not so was discovered when the denture was inspected (Fig. 2).
The denture was made of vulcanite rubber and poorly fabricated. No attempt
to establish maximal extension of the denture base had been made. The flanges
were short and thin. The teeth were arranged partly lateral to the ridges, and
no signs of balanced occlusion were found. Because of the atrophy of the ridges
which had occurred during the 38 years the denture had been in use, the denture
base did not even approach fitting its foundation. As a consequence, the physical

Fig. 2. Fig. 3.
Fig. 2.-The denture had been worn for a total of 38 years.
Fig. 3.-The denture was worn for 5 years after it was fractured.
‘7olume 10 ROLE OF LEARNING IN DENTURE RETENTION
Iv‘umher 3 471

forces usually credited with retaining a denture were not operative. In spite of this,
the denture had given trouble only on one occasion.
One day, 5 years previously, the denture fractured. It was repaired. A few days
‘later it fractured again (Fig. 3). But since speaking, laughing, chewing, swallow-
ing, etc., were not impaired and since the patient could even gnaw on bones with
the fragments, she saw no reason for a second repair. Not until the left central
incisor broke off did she want to have the denture repaired. She felt that the loss
of this tooth spoiled her looks (Fig. 4).
The patient wanted only the missing tooth replaced, but after being told that
a new complete upper and a removable partial lower denture were indicated,
she accepted the diagnosis. Before treatment began, her ability to juggle with the
broken denture was tested. During these experiments she never lost her grip on
the denture. When she was requested to bite with different degrees of force on
various instruments (cotton rolls, etc.) (Figs. 5 and 6), the denture fragments
sontetimes tilted on their foundation but remained against the upper jaw, partly be-
cause of the counterpressure from the instruments. Upon removal of the instru-
ments, however, the fragments did not fall down as might have been expected.
They were immediately and firmly reseated and kept in place by the tongue, upper

Fig. 4.-The patient’s chief complaint was the unesthetic effect of the loss of the upper left
central incisor.

lip, and cheeks. When gnawing on bone (Fig. 7), chewing cotton rolls, and smiling,
the patient displayed the same expert performance. It did not matter whether the
tests were carried out with both denture fragments simultaneously or with one
or the other separately (Figs. 8,9, and 10).
Fourteen days later, the right fragment and the part covering the hard palate
of the denture fractured (Fig. 11). With the two pieces carrying teeth remain-
ing, the tests were reapplied. No reduction in the capacity to stabilize the fragments
was observed. The patient stated that eating, speaking, and other activities of the
masticatory mechanism were performed as usual. She noted only that it was now
easier to manipulate the left fragment than the right. Otherwise the situation
was “normal.”
The new upper denture had good retention. In about 2 weeks, she became
fully accustomed to both new dentures. Four weeks later, she went through the
same tests with the remnants of the old denture as had been made previously. This
time she failed all of them. Her former skill in handling the fragments had been
completely lost.
 BRILL, TRYDE, AND SCHiiBELER J. Pros. Den.
May-June, 1960

REFLECTIONS ON REFLEXES
Any person who needs and is capable of acquiring purposeful, coordinated
muscle activity will develop it. This report is but one example of many. Being
an extreme one, however, it demonstrates the importance of muscle activity in the
retention of dentures. In the light of what is known about learning processes, some
points will be elaborated.
Being young and at a formative age when she acquired her first denture,
the patient had been able to adjust to its contingent inconveniences. Concomitant

Fig. 5. Fpig. 8.

Fig. 6. I rig. 9.

Fig. 7. F

Fig. 5.-The fragments of the denture remained in position when the patient closed on the
shaft of a mouth mirror.
Fig. B.-The fragments remained in position during closure with wide jaw separation.
Fig. 7.-The oatient could gnaw on bone with the old denture.
Fig. 8.-One-fragment of the denture could be controlled during closure.
Fig. 9.-The contraction of the left buccinator muscle helped to hold the left fragment in
place.
Fig. IO.-The left buccinator muscle contracted medially into the oral cavity with the right
fragment in place.
‘b’olume 10
Numlm 3
ROLE OF LEARNING IN DENTCRE RETENTION 473

Fig. Il.-The patient could stabilize the two remaining fragments with the palatal portion
missing.

with occasional extractions of lower teeth and progressive atrophy of the upper
ridges, the denture lost retention and stability. Provoked by these handicaps, she
gradually learned to utilize her muscles, especially those of the tongue, lips, and
cheeks, so that she was able to stabilize the denture when smiling, speaking, chew-
ing, and swallowing. New reflex patterns of her musculature were established.
These patterns were so successful that they completely replaced the “classic”
forces effective in denture retention, and she never found cause to complain.
When the denture fractured the first, second, and third times, she mastered
the situation easily. However, we should not be misled into believing that she
has retained her former capacity for learning to this day. The correlation be-
tween age and this capacity to learn suggests that her accomplishments in handling
the denture fragments were like variations performed by a virtuoso who has been
forced to practice for many years.
Another aspect of learning was illustrated also by this patient. The new
upper dentlure did not require any muscle activity for its retention, and, there-
fore, her acquired reflex patterns were not called into action. They became disused,
and in a matter of weeks the patient could no longer control the movements of the
fragments. This was expected, because acquired patterns, like conditioned re-
flexes, are easily unlearned. The reason for this is suggested by the findings of
Eccles and McIntyre.g They have shown that disuse of nervous pathways pro-
duces an increased synaptic resistance to impulse transmission in the pathways
concerned, that is, muscular activity patterns may be forgotten transitorily or
permanently. They can, however, be retained by constant repetition because, con-
versely, synaptic resistance decreases in a pathway which is used frequently.”
The important features put forward in this article are: (1) in advancing
age, there is loss of functional elements in the central nervous system, (2) aging
places limitations on the capacity of acquiring new muscle activity patterns, (3)
adaptation in aged patients is achie\,ecl slowly, if it is achieved at all, and (3)
young patients, who are not yet incapacitated, can readily learn to use even
crude dentures skillfully. This report is a demonstration of potentialities in the
young in this respect.
 J. Pros. Uen.
474 BRILL, TRYDE, AND SCHiiBELER May-June, 1960

REFLECTIONS ON CONSEQUENCES

TWO conclusions concerning relevant therapy follow from these statements.

The first is that complete dentures should be made preferably for young people,
and, for such patients, it would be reasonable to make the dentures with a limited
balanced occlusion which should be restricted to the muscular position of the man-
dible.lOJl If a denture is devoid of balanced occlusion outside this position, it will
be inconvenient for the patient to make lateral excursions because the occlusal
forces applied will be concentrated at single points and pain -may be produced.
Moreover, the denture may slide or tilt and may even momentarily lose its re-
tention. These effects will act as punishment and teach the patient to limit move-
ment patterns of the mandible to pure “hinge” movements and, at the same time,
reduce the forces applied. Thus, a decrease of horizontal forces may be expected.
These forces are supposed to be more destructive to residual ridges than vertical
forces. As yet, no scientific proof of this has been established. However, experienced
prosthodontists know of innumerable oIder persons who were fitted with com-
plete dentures while they were young and have not suffered a severe loss of their
denture foundations. In contrast, older people often show rapid ridge resorption fol-
lowing denture insertion, and often their denture foundations are in poor shape
because periodontal disease has destroyed the alveolar bone.
These observations lead to the second conclusion. By fluoridation projects,
pedodontic treatment, extensive periodontal treatment, and various other dental
health measures, modern dentistry combats caries and periodontal disease energetic-
ally. The eventual outcome of this fight is unknown. The results to date are in-
adequate in that these diseases and their sequelae have not been completely
controlled.
In civilized countries, therefore, where life expectancy is increasing and where
teeth are carefully preserved, the end result will be questionable in some instances.
More and more patients will save teeth, and this will allow them to chew food
adequately for several years. Thereby, these patients will advance into age groups
where adaptation occurs only with difficulty. Some patients will be carried beyond
the point where new muscle activity can be learned. Thus, in those people who ulti-
mately must wear complete dentures and who are disabled because of bone de-
struction and atrophy of the central nervous system, dentistry has created a
problem it cannot solve. This is a provocative statement, but the simple background
to it is that the human masticatory mechanism is not built to stand the impact of
civilization. Therefore, when therapy is formulated, the arguments presented must
receive their proper consideration.

SUMMARY

The clinical importance of learning and the capacity of learning relative to age
are discussed and therapeutic aspects of wearing dentures are considered. Com-
plete dentures are usually successful in young people, and, in such patients, dentures
should be made with a balanced occlusion confined to a limited area in the muscular
position of the mandible. Treatment with complete dentures in debilitated and
cerebrally incapacitated older people is often irrelevant therapy.
y$ly;r 130 ROLE OF LEARNING IN DENTURE RETENTION 47.5

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of Psychiatry, Springfield, 1958, Charles C Thomas, Publisher, pp. 22-38.
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167:466-468, 1951.
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