SOFT LINERS

The nature of support of bone in natural dentition and in partial

or completely edentulous condition is different.

In natural dentition, the work load is transmitted through the

tooth to the periodontium and the axial work load is shared by all

major periodontal fibers in a suspensory fashion, providing a resilient

apparatus resistant to the functional forces. This mechanism allows

the teeth to adjust their position under stress. Mastication and

deglutition produce vertical and lateral forces which result in tensing

of the principle fibers from their resting state to their full length

pattern and this tensile force results in deposition of new bone. This

remodeling of bone is related with position and support of the tooth.

The innervation of the periodontium provides a keen proprioceptive

sense which localises external stimuli and acts as a defense

mechanism against excessive forces and thus is protective in nature.

In subjects, wearing dentures, the mucoperiosteum receives all

the masticatory load. In the absence of periodontium, this load

creates a compressive force which depends on factors like amount of

force, direction of force, duration, and frequency and force per unit

area. Anatomic factors which play an important role in transmitting

the load to residual ridges are type of bone, density of bone, blood

supply, nature of soft tissue and thickness of soft tissue. Due to

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absence of periodontium, only pressure is applied against vascular

covering of the periosteum and its blood supply is disturbed resulting

in resorption of bone.

The pattern of alveolar resorption after loss of teeth is not

uniform giving rise to undercuts, sharp bony spicules and the thin

mucosa is caught between the bone on one side and hard denture

base on the other, leaving the thin mucosa to get insulted.

Furthermore this condition is aggravated by systemic conditions like

diabetes mellitus, hypertension, malnutrition. This leads to reduced

dietary intake due to reduced masticatory efficiency and in turn will

affect the denture foundation. This can be reduced to some extent by

maximum extension of denture base within physiological limits,

selective pressure impression procedure, teeth with low cusp angles,

balanced occlusion.

The concepts of conservative dentistry have been recently

introduced in the form of overdentures, root submergence and

implants. These modes of treatment have their own advantages and

disadvantages and cannot be used in all different clinical situations.

For many years, the dental professional has felt the need of dual

function denture base i.e. the hard polished surface around the

artificial teeth, supporting them and the soft lining layer in contact

with the underlying tissues. Accordingly to Bouchers glossary,

resilience refers to energy absorbed owing to elastic deformation. The

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impression surface of a denture base that is lined with a resilient

material, therefore should partially absorb and provide for a more

advantageous distribution of imposed stresses to its basal seat. This

assumption implies that an ideal material will instantaneously recover

its original form after an external stress is removed and retain its

resilience for an indefinite period of time.

In 1945, Mathews reported that use of plasticised polyvinyl

chloride as a soft liner for a specific clinical situation. A summary of

observations on different soft liners was published by Lammie and

Storer. The development of silicones as resilient liners for denture

bases was pioneered in the United States by Barnhart and Robinson.

Thus evolved an era of resilient denture bases.

Some of the other uses of soft resilient liners are in

rehabilitation or ridge atrophy or resorption, where surgery is

contraindicated (bony undercuts, tuberosities), bruxomania, relief

areas (median palatal raphae, anterior nasal spine and rugae),

restoration of congenital or acquired oral defects, xerostomia, systemic

diseases (diabetes, scleroderma).

Soft liners can be classified as follows:

I) According to composition they are classified as:-

1. Natural rubbers

2. Vinyl copolymers

3. Hydrophilic polymers

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 4. Silicone based compounds

5. Acrylic based compounds

Different types of resilient soft liners are:-

I) Acrylic Based Resilient Soft Liners

A) Preformed sheets:

These consist of sheets of the copolymer poly(ethyl

methacrylate) and poly (ethyl acetate) bonded to the acrylic denture

base by means of an acrylic solvent.

Properties:

Although included here, this co-polymer, which becomes

resilient at mouth temperature, is probably best considered as a

temporary soft lining, as its high water uptake and loss of soluble

constituents leaves much to be desired in a permanent material.

Powder-liquid systems:

These can now be subdivided into :-

1) Systems containing leachable plasticiser.

2) Systems containing polymerisable plasticiser.

3) Experimental high molecular weight acrylics with low glass

transition temperatures.

Systems containing leachable plasticiser:

The powder is either poly(ethyl methacrylate) or poly(methyl

methacrylate) and the liquid either methylethyl or n-butyl

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methacrylate, sometimes with the addition of ethyl acetate. The liquid

also contains 25-50% of a plasticiser such as di-n-butyl phthalate,

butyl-phthalylbutyl glycolate or 2-ethylhexyl diphenyl phosphate. To

promote the initiation of the polymerisation of the monomer, the

powder also contains a small amount of di-benzoyl peroxide.

The powder and the liquid are mixed to form a dough and either

adapted against a clean acrylic denture base or processed against

acrylic dough at the flasking stage of denture production. Heating at

72oC for 6 hours and slowly cooling would be the ideal curing cycle.

Common brands of this type of system are Coe Super-Soft, Palasive

62, Verno-Soft and Virina.

Properties:

The plasticiser lowers the glass transition temperature and thus

the normally rigid acrylic becomes rubbery and resilient. As

poly(ethyl methacrylate) has a glass transition temperature of only

66oC, as compared with the 105oC of poly(methyl methacrylate),

systems based on the former polymer require less plasticiser than

those based on the latter. However, in both systems the plasticiser

eventually dissolves or leaches out into the oral fluids and the

resilience falls, until eventually the soft lining is almost as hard as the

denture base itself. The rate at which this occurs varies from patient

to patient, not only as a result of their disparate oral environmental

conditions, but because of differing eating habits and the varying

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enthusiasm with which they clean their dentures. The rate is

particularly affected by the temperature at which patients soak their

dentures, if this is their practice. However, as Davenport et al.

discovered, no changes took place in the resilience of such linings

when they were subjected to 100 simulated cleaning cycles in

commercial acid or alkaline cleaners added to water at 55oC.

The major property in their favour is their ability to form a

strong and durable bond with the acrylic denture base.

Systems containing polymerisable plasticiser:

In an attempt to utilise the strong bond which forms between

acrylic-based resilient liners and acrylic denture bases, considerable

effort has been put into the development of a plasticiser, which will

actually polymerise and thus resist dissolution whilst still acting to

lubricate the chains of acrylic polymer, thus retaining a good

resilience. The exact formulation of the one commercially-available

material has not been revealed, but the liquid component of

experimental systems developed by Professor Braden and his

colleagues are known to be mixtures of tridecyl methacrylate, 2-

diethylhexyl meleate and ethylene glycol dimethacrylate. These are

mixed with either poly(ethyl methacrylate) or copolymers of n-butyl

and ethyl methacrylate, prior to being applied to the denture base and

heat cured. A common brand of this type of material is Softic 49.

Properties:

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 The set commercial material is firm at room temperature, which

enables it to be readily finished. However, it becomes resilient when

raised to mouth temperature. Exposure to Candida albicans for

periods of up to 8 weeks have shown that the commercial material will

promote the growth of this type of flora, and the surfaces of

translucent, smooth specimens become chalky and rough. An

experimental version of this type of material underwent changes

during long-term use in vivo; its surface became rough and cracked,

leading to the loss of small pieces. This was followed by failure of

adhesion between the liner and the denture base.

Experimental high molecular weight acrylics:

The research of Professor Braden and his colleagues has now

moved on into alternative systems, namely those which have

inherently low glass transition temperatures, but still have the

methacrylate chemistry. This enables them to be handled as doughs

and to form durable bonds with the acrylic denture bases. As the

chemistry needed to prepare these materials gets more sophisticated,

the names of the polymers produced become more complex. We will

have to be able to get our tongues around such compounds as tetra-

hydropyran-2yl methyl methacrylate and isobornyl (1, 7, 7, trimethyl-

bicyclo (221)hepta-1-yl) methacrylate if these materials can be

perfected in the future. Fortunately, the generic name of these

materials is a little easier; they are known as heterocyclic monomers.

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 To conclude this section on acrylic-based materials, mention

should be made of another approach to producing resilience tried by

Professor Braden. This involves introducing powdered elastomeric

butadiene-styrene copolymer into a self-curing methacrylate cocktail.

As yet, this system does not seem to have the durability of bone to the

denture base when used in the mouth, although laboratory tests do

show good bonding. With dental materials, however, there is only one

place in which they can realistically be tested the mouth.

Silicone resilient soft liners:

Siloxane polymers, similar to those used in impression

materials have been used as resilient liners for denture bases since

the early 1960s. Their resilience at mouth temperature is not derived

from the use of plasticisers, but from an intrinsic property of this type

of polymer. Thus, they retain their resilience throughout their

working life. This is only shortened when they separate from the

acrylic denture base. The problem of getting the inert silicone rubber

to adhere to an acrylic base still has to be solved. The silicones are

available in forms which can either be heat processed or which self-

cure at room temperature.

The heat-curing material is supplied as a dough which can be

used either on new or old acrylic dentures, or for the construction of

obturators. Once cured, excess material can be ground away with

special stones or cross-cut burs. This leaves a rough surface which

can be smoothed with a varnish consisting of a self-curing silicone

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fluid. The bond between the acrylic denture base and the silicone

liners is aided by the use of a silicone polymer (such as methyl

siloxane) in a volatile solvent, or by the use of alkyl-silane bonding

agents. However, the bond still remains as the weak link in this

silicone/acrylic sandwich.

The self-curing material, which is generally presented as a

medium viscosity paste and a liquid catalyst, can be applied to an

existing denture whose fitting surface has been washed, dried,

roughened and cleaned with acetone or absolute alcohol in order to

remove any water it may have absorbed. It is then coated with a thin

layer of adhesive. This must be allowed to dry in air for an hour,

during which time atmospheric moisture brings about its

polymerisation.

Common brands of the heat-cured type are Molloplast-b.

Cardex-Stabon, Flexibase, Mollosil, Per-Fit and Simpa are all of the

self-curing type.

Properties:

These materials demonstrate good resilience but inferior

bonding to acrylic base. Abrasion resistance also leaves something to

be desired. There is also well-documented evidence that they support

the growth of Candida albicans, leading to denture stomatitis.

Overall, the heat-cured material is somewhat superior in its

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properties to the self-curing forms, and is the nearest we have, as yet,

to a permanent soft lining material.

Alternative soft polymers:

Many materials have been tried as resilient soft liners for

denture bases, including vinyl chloride and vinylacetate polymers, as

well as a range of copolymers of the two systems. In all cases,

plasticisers were used. One commercially available alternative is

based on polyurethane, and is called Petal Soft.

Properties:

This material suffers from gross absorption of water after only a

few weeks immersion. As a result, it has been observed to expand to

up to three times its original size. This instability is unacceptable. It

also appears to be even worse than the silicone liners in its support of

Candida albicans.

Experimental systems:

A number of other polymers have been reported as having been

tried or suggested as resilient soft liners. These include poly(hydroxy-

methyl methacrylate), known commercially as 'Hdron. This is the

polymer used to manufacture soft contact lenses. Water is absorbed

and acts as a plasticiser. However, there are problem associated with

this, in that its mechanical properties deteriorate and some

dissolution occurs, making it unsuitable as a permanent soft lining

material.

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 A brief mention has also been made of an experimental material

consisting of a fluro-ethylene copolymer, but no details are available

as yet.

Tissue conditioners (temporary soft liners):

Although these are based on acrylic resins; the do not undergo

cross-linking reactions causing them to set, as do the permanent soft

lining materials. Instead, they form a gel. They are generally based n

poly(ethyl methacrylate) which, in powder form, is mixed with a liquid.

It should be noted that this does not contain any methacrylate

monomers. Instead, it is a plasticising mixture of esters and ethyl

alcohol. When the powder is added to the liquid, it forms a cohesive

gel within a few minutes and this can be added to the clean, dry, rigid

acrylic denture base. It is then seated in the mouth of the patient,

and under occlusal loads, the gel distributes itself. It stiffens up in 5-

10 minutes to form an elastic, resilient layer. Examples of these

tissue conditioners include Coe Comfort, Coe Soft, Kerrs FITT, Soft

Oryl, Tempo, and Viscogel.

Properties:

The plasticisers and alcohol leach out from the gel, in most

cases within a few days. As a result, the gel stiffens until it becomes

hard. Under mouth conditions, when first placed, the gel acts as a

visco-elastic medium, flowing under a steady load, but acting as a

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resilient cushion under sudden loads. In this way, it has been

successfully employed as a functional impression material.

Tissue conditioners of this type are sensitive to denture

cleaners. The alkaline peroxides (such as Efferdent and Steradent)

can cause surface and sub-surface bubbling, and the hypochlorite

solution tends to leave its characteristic odour behind. They are

probably best cleaned with plain soap and water. Abrasive cleaners

are not recommended. Their use as resilient denture liners should

only be considered as temporary.

As yet, neither the permanent soft liners nor the tissue

conditioners are covered by any national or international standards.

Under these circumstances, it is not possible to indicate which brands

are acceptable and which are not.

II) According to processing techniques, soft liners can be

classified into the following:

1. Heat cure

2. Cold cure

3. Light cure

Requirements of an ideal soft liner are:-

1. Compatibility with oral tissues.

2. Compliance and resilience.

3. Dimensional stability.

4. Rupture properites.

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 5. Adhesion to polymethyl methacrylate.

6. Wettability

7. Effect on growth of Candida albicans.

No ideal soft liner material is available as on today. Several

deficiencies are observed with the materials in use, such as;

1. Loss of softness.

2. Colonization by Candida albicans.

3. Porosity

4. Poor tear strength

5. Bad odour

6. One of the more serious problems with soft liners is the failure of

adhesion between soft denture liners and the denture based.

Ideally, the soft denture liner should bond sufficiently well to

polymethyl methacrylate denture based resin to avoid failure of the

interface during service. However, the bond strength between the soft

liner and PMMA denture base resins is often weak and debonding of

lining materials is commonly observed even before the materials have

lost elasticity. Bond failure creates a potential surface for bacterial

growth, plaque and calculus formation. Either the lining just peels off

the denture base or it becomes unhygienic to be hardly tolerated by

the patient and requires frequent relining. In the absence of any

specifications for an ideal soft liner, it becomes necessary to base

research for providing guidance for the clinicians to opt for the soft

liner depending upon its properties.

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 Several tests have been developed to determine the tensile bond

strength which include tensile, shear, fatigue, creep, impact and

cleavage. The most commonly used methods to measure the bond

strength have been peel, tensile and shear tests. In vitro tensile bond

test is taken as a more reliable test.

There are a number of problems associated with all these

liners; for example, inadequate bonding to the denture base,

especially for the silicone liners. The high rate of water diffusion

through the silicone as compared with the diffusion rate through

acrylic may be partially responsible for loss of adhesion.

Some, but not all, silicone liners also undergo a high volume

change (up to 40 per cent) with gain and loss of water. The

hydrophilic acrylics behave similarly.

The heat-cured soft acrylics bond well to the hard denture base

but lose their softness as plasticizer is leached from the liner. The

considerable difference in hardening rate for these acrylic liners may

be associated with the manner in which a low Tg is achieved. A

polymer that in itself has a lower Tg would require less plasticizer and

should therefore retain softness for a longer period of time.

The apparent softness of the liner depends upon its thickness

as well as its hardness and elastic modulus. A liner thickness of 2 to

3 mm is generally recommended. A further increase in thickness

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would have less effect in increasing apparent softness. For many

dentures this is physically impossible.

The soft liner decreases the denture base thickness but also by

solvent action of the silicone adhesive and the soft acrylic monomer.

Loss in the base strength can result in fracture in clinical service.

Trimming, cutting, adjusting, and polishing of a soft liner are

difficult. The silicone surface, in comparison with that of a hard

acrylic resin, is abrasive and irritating to the oral mucosa.

The permanent soft liner, as well as the tissue conditioner,

often has a characteristic and disagreeable taste and odor. Perhaps

the greatest disadvantage of the soft liner is that it fouls more readily

than the hard denture base resin, and it cannot be cleaned as

effectively. Both the oxygenating and the hypochlorite type of denture

cleaners will damage soft liners, especially the silicone type.

Although the silicone liner itself does not support mycotic

growth, debris that accumulates in pores in the liner does. The most

common fungal growth is Candida albicans. Immersion in a

fungicidal solution for 20 minutes each day can help control the

growth, which in one report was occurring on 81 per cent of the

silicone liners.

One of the room temperature curing silicone liners is supplied

as a three-component system, one of the components being a

dibutyltin dilaurate catalyst that will inhibit the growth of C.albicans.

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This growth-inhibiting activity undergoes exponential decay as the tin

compound is washed from the liner.

Mechanical cleaning of the soft liner can easily lead to damage

but is often necessary. A soft brush and detergent or a mild non-

abrasive dentifrice may be used.

Thus, it can be seen that none of the soft denture reliners can

be considered entirely satisfactory. Few of the materials will remain

soft indefinitely, although some of them harden more slowly than

others. Also, all of them stain with use and are difficult to clean. It

must be concluded that at the present time these materials should be

used only as a temporary expedient and not for an extended period.

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