Advancements in Polymeric Denture Lining Materials

Ghazal Khan, Khumara Roghani, Nawshad Muhammad*, Saad Liaqat, Muhammad Adnan Khan

Department of Dental Materials, Institute of Basic Medical Sciences, Khyber Medical

University, Peshawar, Pakistan

Corresponding Author

Dr. Nawshad Muhammad, Associate Professor, Institute of Basic Medical Sciences Khyber
Medical University, Peshawar, Pakistan Mob: +923339223834 Email:
[email protected]

Abstract:

Denture Liners are elastomeric materials that are applied on the fitting surface of a partial or
complete removable denture. They are mainly used to improve the fit of dentures and provide a
cushioning effect, to relieve pain and discomfort of the patient. Denture liners are broadly
categorized into three main groups (1) Soft liners (2) Tissue Conditioners and (3) Hardliners and
can be either heat cured, light cured, or self-cured. Although these materials have advantageous
properties each one of these has its disadvantages as well. Therefore, the selection of material for
a specific condition is of great importance and depends on the properties of the selected material.
In this chapter, we will discuss the different types of denture liners, their clinical application,
properties, limitations, and recent advances in these denture liners.

Keywords: Soft denture liner; tissue conditioner; adhesion; denture stomatitis

1. Introduction:

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Prosthodontics is as defined by Glossary of Prosthodontics as,” dental specialty pertaining to the
diagnosis, treatment planning, rehabilitation and maintenance of oral function, comfort,
appearance and health of patients with clinical conditions associated with missing or deficient
teeth and/or maxillofacial tissues using biocompatible substitutes(1)”
Over a wide variety of treatment options provided to patients by prosthodontists, one of them is
Denture. A type of dental prosthesis that is used to replace the lost teeth is known as Denture as
shown in fig 1. It can either be a partial denture that replaces some of the lost teeth or a
complete/full denture that is a removable replacement for all of the missing teeth. A typically
removable denture has two main parts; Denture Base and Artificial Teeth. Generally, denture
base is made from acrylic resin, though this material can last for years, they have certain
limitations. Leaching of monomer causes porosity and microbial adhesion causing denture
stomatitis. Another problem is ridge resorption in patients with time leads to loose dentures
which is the cause of pain for the patient. To overcome these problems Denture liners were
introduced.
Denture liners are the materials that are applied on the denture base of an already fabricated
denture for several reasons. It is mainly indicated for use in ill-fitting dentures to improve its fit
leading to even distribution of masticatory forces and to relieve pain due to soreness.
Sometimes the denture base can not be tolerated by patients and therefore a soft barrier is
required. In such cases, a type of liner is used that gives a cushioning effect and prevents
irritation due to denture. In some cases, it is required for producing a functional impression.
Denture lining is a less costly and less time consuming procedure compared to fabricating a new
denture thereby their use has increased considerably, but despite that these denture lining
materials still possess some major disadvantages like debonding from denture base, fungal
growth leading to stomatitis, and degradation in the oral environment. New preparations of
denture liners are being studied to limit the disadvantages of denture liners.
Denture liners are of various types (heat cured, light cured, and self-cured) and have a different
composition (silicone-based and acrylic-based) and are broadly classified into three main groups
that are soft lining materials, Tissue Conditioners and Hard relines.

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 Fig. 1 (Source: Google Images)

2. TYPES OF DENTURE LINERS:

2.1 Soft Liners:

A soft liner is a type of lining material that is most frequently used to reline a denture(2). The
term “soft liners” refers to a group of resilient dental materials that are applied on the fitting
surfaces of the denture (3) to form a soft padded layer between the hard denture base and the
contacting occlusal surfaces of the oral mucosa(4) (Fig.2). Application of a liner is relatively a
noninvasive and cheaper process than fabricating a new denture(5).

Fig.2 Soft liner application on the denture base

(Image Source: Google images)

Soft liners help to ease discomfort, soreness, and pain from dentures (6). They are known to
provide relief to denture wearing patients, who present with severe ridge resorption, bony
undercuts, and non-resilient or thin oral mucosa (4). Soft liners act as shock absorbers for the
underlying residual ridge and are effective in minimizing the impact forces compared with a hard
denture base alone.

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Soft liners are made resilient by co-polymerization with the monomer or by adding alcohol type
plasticizers to their composition(6). They can either be Heat polymerized when their processing
is carried out in a dental laboratory (7) or Self polymerized when they are processed in a dentist
clinic(8). They are available in different compositions, which determine the properties,
indications, and durability of the material(9).

2.1.1 TYPES OF SOFT DENTURE LINERS

O’Brien classified soft liners, based on their composition, as silicone-based or acrylic-based(10).

Based on their durability, soft liners can also be classified as short-term (30 days) and long-term
soft liners (more than 30 days)(11, 12). However, most of the literature supports the idea that
temporary liners can serve for 6 months while permanent liners can serve for a year. Long term
soft liners are further classified into four groups based on chemical structure:

1) Self-cured silicone 2) heat-cured silicone 3) Self-cured acrylic resin 4) heat-cured acrylic resin
(Fig.3)

The acrylic-based soft liners have viscoelastic properties while silicone-based soft liners show
elastic properties(13) and are comparatively long-lasting and mechanically superior to resin-
based liners(14).

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 AUTO-POLYMREIZED
SILICONE

HEAT-POLYMERIZED
SILICONE
LONG-TERM/ PERMANENT
SOFT LINERS
AUTO-POLYMERIZED
ACRYLIC RESIN

SOFT DENTURE LINERS

HEAT-POLYMERIZED
ACRYLIC RESIN

SHORT-TERM/ TEMPORARY
TISSUE CONDITIONERS
SOFT LINERS

Fig. 3 Classification of denture soft liners(11)

2.1.2 DRAWBACKS OF SOFT DENTURE LINERS

Failures in the physical properties of the soft lining material mainly result in its poor clinical
performance(15). Clinical limitations of soft liners include the presence of surface defects and
porosity(16), poor adhesion to acrylic resin(17), water uptake(18), a tendency to color
change(19), and difficulty in cleaning(20).

i. SURFACE ROUGHNESS

Rough surfaces facilitate microbial growth resulting in denture stomatitis and affect the
durability of the lining material(21). Surface roughness can be caused by certain denture cleaning
solutions. Such solutions are known to change the morphology of lining material by penetrating
the resin. Also, the concentration and immersion time can alter the polymer structure(22).

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Literature also suggests that the denture type, habits like smoking, nighttime denture wearing,
and pH of resting saliva cause worsening of acrylic soft liners(23).

To prevent the surface changes in soft liners, Singh K et al. suggested that coating can be done to
reduce the loss of surface integrity of soft lining material(24). Most of the literature suggests that
the type of coating material used can also affect their performance in maintaining surface
softness and preventing surface porosities (22, 25). The sealed soft liners are also preferred
because they stay resilient, clean and prevent the formation of biofilm and microbial growth for a
long time as compared to non-sealed materials(9, 26).

ii. ADHESION/ BOND STRENGTH

For the denture to function clinically, a strong bond between the denture base and soft liner is
necessary. To ensure strong bonding between the denture base and the lining material, the
monomer must enter and infuse the resin pores to form an interpenetrating polymeric
complex(27). Aging is also a common factor that adversely affects the interface between the
denture base and the lining material and changes its adhesive properties(28). Soft lining materials
absorb oral fluids and moisture which causes the material to swell up, resulting in stress
development between the bonding surfaces, hence leading to an adhesive failure(29). (Fig. 4)

Fig. 4. Bond failure between the denture base and lining material

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In literature, many procedures are suggested to increase the bond strength of the lining materials.
For this reason, different bonding agents have been used. Lassila et al. in 2010 used ethyl acetate
as a bonding agent and found better adhesion between denture base resin and lining material(30).
Primers and adhesives prevent bubble formation during denture reline procedures. Therefore,
they are also used to stick silicone liners to denture base resin(31). The use of organic solvents
(MMA and ethyl acetate) result in porosities that improve monomer penetration, hence
improving bond strength(32, 33). Lasers and alumina abrasion have also been tested to overcome
the clinical limitation of de-bonding(34).

iii. WATER SORPTION

Another common drawback of soft liners is their ability to absorb water and solubility. It is
related to the changes in morphology as well as the physical properties of the lining material.
These changes can lead to swelling, wear, fungal growth, and stress accumulation at the bonding
surfaces(35).

Water sorption is due to the hydrophilic and porous nature of the material and is affected by the
presence of cross linking agents(36). The use of sodium perborate as a chemical denture cleaning
method can enhance the water sorption of soft lining materials(37). Barbara et al. concluded that
tissue conditioners coated with certain protective preparations such ass monopoly did not absorb
water in vitro(38). One of the studies claimed that the type of filler added in soft liner
composition causes water absorption(4). In 1996, Waters also proved from his research that heat
polymerization of silicone led to the production of a denser material which was lacking micro
pockets of fluid/water(39).

iv. COLOR STABILITY

Color stability is another property of the lining material for maintaining the quality of the
material(40). It can be compromised by a variety of denture cleansers and by immersion
time(41). Color changes may also result from aging, staining from nicotine containing beverages

7
like tea and coffee (Fig. 5), and microbial colonization (42).  Ideally, a denture soft liner should
not easily undergo color change or staining after long use(40).

Fig. 5 Nicotine Staining (43)

Color stability may vary from one material to another. Gulfem concluded that acrylic-based
liners are less color stable than silicone-based liners(44). Hashem proposed that fluorinated soft
liners showed improved color stability and better stain resistance(4). Beverages like tea and
coffee can also cause staining of the denture liners. Serra investigated and suggested that coffee
can produce more noticeable color changes than tea for the denture soft lining materials(45).

v. DIFFICULTY IN CLEANING

Soft liners are readily attacked by Candida albicans, which may lead to denture stomatitis and
later require professional prosthetic cleaning (46). Subsequently, the ultimate drawback of the
soft liner is the problem to keep it clean(47).

Several modifications have been made to prevent microbial overgrowth on the surface of a soft
liner. Silver has fungicidal and bactericidal properties. Therefore, the composition of the soft
liners has been modified by silver nanoparticles in an attempt to improve the material’s fungal
resistance (48, 49). Antifungal agents, such as chlorhexidine, fluconazole, and nystatin are also
incorporated into a soft liner to provide a slow but continuous release of the drug causing a
continued inhibition in the growth of candida Albicans(4).

2. Tissue Conditioners:

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Tissue conditioners (TCs) are a type of reliners that are intended for short term use and formed
by mixing polymer in a solution of ethyl alcohol containing plasticizer(38).

2.1. AVAILABLE PRODUCTS:

Following are the commonly available commercial tissue conditioners:

Visco-gel (De Trey), FITT (Kerr), GC Soft-Liner (GC Europe NV), SR-Ivo seal (Ivoclar),
Tissue Conditioner (Shofu), and Coe-Comfort ( GC America) are shown in Fig.(6).

Fig 6. Showing commonly available Tissue Conditioner Coe- Comfort (50)

2.2. COMMON PROBLEMS:

Loss of elasticity, water sorption, microbial growth, color change, and inadequate bond retention
to base resin are the common problems associated with the use of tissue conditioners. As a result,
the materials need to be replaced regularly at short intervals(51)

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 2.3. COMPOSITION:

Table 1: (50) Composition of Tissue Conditioners

Powder
Polymer beads polyethyl methacrylate
(PEMA)
Liquid
Solvent Ethyl alcohol
Plasticizer Butylphthalyl butyl
glycolate

Tissue conditioners are available as liquid powder systems and table: 1, lists the composition of
these conditioners. The plasticizers are low molecular weight liquid esters like dibutyl phthalate,
butyl phthalyl butyl glycolate, and butyl benzyl phthalate (52) and serves to decrease the glass
transition temperature of the polymer, which leads to softening of the polymer (51, 53).
Following the mixing of the polymer powder with liquid results, gel formation occurs that has
viscoelastic properties (54)penetration of PEMA particles into the large molecules of the ester-
based plasticizer occurs, the alcohol causes swelling of the polymer and accelerates plasticizer
penetration that results in gelation time that is clinically acceptable(51, 52). Certain factors affect
the process of gelation the gelation process. These include polymer molecular weight, powder
particle size, the ratio of liquid and powder, the plasticizer amount, and the temperature(54). A
decrease in gelation time was noted when polymer molecular weight was increased, a similar
result was obtained when powder liquid proportion was increased (51-53). Temperature
reportedly has been said to increase the gelation process and therefore in the oral cavity the
gelation time is less compared to that with room temperature. Ethanol, acting as a softener and
present in the liquid plays a crucial part in the gelation process, but, its rapid evaporation in the
oral cavity, causes the tissue conditioner to harden with increased porosity, which ultimately
results in the loss of elasticity. Therefore it is recommended to change the tissue conditioner
lining after 3-5 days (55). Ethanol in high quantity causes shrinkage of material in the oral
cavity(52) while the highest quantity of ethanol is released within the first 12 h(26).

10
Due to the differences in the composition and properties of different types of tissue conditioners,
it is recommended to choose the material that is best suited for that scenario.

2.4. CLINICAL APPLICATIONS:

Primarily used for the restoration of traumatized oral mucosa caused by denture inflammation,
recording functional impressions, as liners to improve the fit of the acrylic dentures, and for
prevention of irritation from the denture. They may also be used for the rehabilitation of cancer
patients who need obturation. The viscoelasticity and dimensional stability vary depending on
the type of tissue conditioner used (56, 57), therefore, a single Tissue conditioner is not able to
fulfill all requirements for applications. Ideally, a tissue conditioner should have high elasticity
during masticatory load and have viscoelastic properties to distribute forces evenly(53).
Maintaining denture hygiene with tissue conditioner lining is a major problem since liquid
cleaning agents and antiseptic cleansers have shown adverse effects on Tissue conditioners'
surfaces (58). It is recommended that the prosthesis with tissue conditioner should be cleaned
with a cotton cloth and disinfected in 0.2% solution of chlorhexidine. Fig 6. Shows a layer of
tissue conditioner covering the surface of an upper denture

Fig. 7. Tissue conditioner covering a fitting surface of a denture (50)

2.5. PROPERTIES:

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The release of ethanol and plasticizers from tissue conditioners in the mouth is a limitation of
tissue conditioner and requires the material to be replaced often (57). Studies reported a rise in
water sorption and solubility within 1 week time period of different tissue conditioners (59, 60).
Another major disadvantage specifically of silicone-based tissue conditioners is the lack of
bonding between tissue conditioner liner and the denture plate and is the leading cause of failure
of reliners since it creates a suitable growth environment for microbes and formation of plaque
and calculus (51, 61).

Adequate bonding between lining material and the denture base is vital for increasing its life in
the oral cavity (62). Improved bond retention can be obtained with roughness in the denture base
that can be increased with abrasives and laser treatment (51, 63).

Another important feature of the tissue conditioners is their dimensional properties. With time
there is a change due to water sorption and solubility of the conditioner in the mouth. A polymer
having greater acceptance for water uptake, there is a volumetric increase in the tissue
conditioner while leaching of plasticizers and solvent causes shrinkage in the material, leading to
dimensional instability (53). It is suggested that the time for recording functional impressions
should not be more than 24 h. Permaseal and Monopoly, maintain elastic properties for longer
durations, increasing its life in the mouth. To achieve these results formulations need to be
prepared that have decreased leaching of plasticizers and decreased water sorption (25). Coating
of tissue conditioner surface with Monopoly may prolong the life of the liners up to a year and
the smoothness on the surface due to coating also decreases the accumulation of microbial
growth.

2.6. ROLE OF TISSUE CONDITIONER IN DENTURE STOMATITIS:

Loss of the plasticizer and roughened surface of tissue conditioner leading to inflammation of the
oral mucosa that bears the denture or denture lining surface is a common problem (64).

A study by Okita et al.(65) reported that Coe-Comfort, FITT, Soft-Liner and Visco-gel, show
cytotoxicity in vitro, and is said to be greater than that of Polymethyl methacrylate. The release
of softening agents from tissue conditioners is a probable disadvantage of these materials.
Phthalates that act as softeners in tissue conditioners have reportedly been shown to have

12
estrogenic activity potential(66) new formulations are being tried with the addition of dibutyl
citrate or dibutyl sebacate as softeners to overcome the problem of toxicity caused by phthalates
(67).

Some of the plasticizers used in tissue conditioners have been shown to retard fungal growth.
Leaching of solvent and plasticizers from the surface of tissue conditioners causes it to harden
and become porous, hence becoming a good site for microbes to grow. The effectiveness of
adding antibacterial and antifungal drugs to TCs has been evaluated. Chow et al (68) study show
that when 5% of itraconazole is added to different tissue conditioners, the activity remains the
greatest within the first three days, after which reliners should be replaced for better healing.

Studies have shown that surface roughness of dentures and resilient liners harbors microbial
growth by increasing the accumulation of microorganisms by enhancing the adhesion of
microorganisms and which in turn can lead to candida associated denture stomatitis(69). A study
by Radnai et al.(70) showed that chlorhexidine gluconate gel incorporated in tissue Conditioner
did not affect the candida Albicans growth, while the addition of miconazole showed a dose-
related inhibitory effect on candida growth.

It has been suggested for further studies silver zeolite be added to tissue conditioners since it has
reportedly shown to have a dose dependent inhibition on Candida albicans.

3. Hard Reliners:

Hard relines are non-resilient materials that contain an acrylic resin that is similar in composition
to the acrylic used in the fabrication of denture bases. These materials are mainly used in
chairside relining of the dentures in dental clinics. They are less comfortable but are famous for
their durability, stability in the oral environment, and easy cleaning(71). Fig. (8). shows a self-
polymerizing hard relining material.

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Fig.8 Shows a Commercially available Hard reliner (72)

3.1. COMPOSITION:

Table 2: Composition of Hard reliners

Powder:

Polymer beads: Polymethylmethacrylate

Initiator: Benzoyl peroxide

Liquid:

Monomer: Methylmethacrylate OR
Butyl methacrylate

Chemical activator: Tertiary amine

Table (2). Shows the

composition of hardliners that are available as powder liquids systems.

14
Following the mixing of polymer powder with monomer, the resin readily undergoes
polymerization at room/ mouth temperatures(73).

3.2. PROPERTIES

Viscoelasticity enables the lining material to absorb and evenly distribute the masticatory forces.
Sheridan in 2018, evaluated the viscoelastic properties of hard denture lining materials using
viscoelastometer. It was concluded that the hard reline transmitted less stress to the underlying
mucosa and alveolar bone. Therefore, these materials have far better able to absorb energy and
relieve stresses under masticatory force(74).

The lining materials applied must form a strong bond with the denture base to ensure the proper
functioning of the denture. In 2014, Mayank Lau tested the shear and tensile strength of the hard
relines and found that the strength values of the hard relines were significantly high making the
material more durable(75). Therefore, it was concluded that hard relines can be used safely in
high stress bearing areas.

3.3. BIOCOMPATIBILITY:

Due to direct contact of hard reliner with oral soft tissues. These materials should not be toxic or
irritating. In 2012, Ayse Atay assessed the cytotoxicity of the hard denture relines at different
incubation periods. The results concluded that all the test materials showed good
biocompatibility(76). Hard relines are the least cytotoxic and safe to use in clinical practice.

3.4. ADVANTAGES and DISADVANTAGES:

Table 3:

ADVANTAGES DISADVANTAGES:
1. More durable clinically 1. less comfortable
2. Better retention 2. Low glass transition temperature
3. Better adhesion with denture base 3. Dimensional instability
resin
4. less time consuming 4. Irritation due to direct contact
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 3.5. CLINICAL LIMITATIONS

Hard relines are made with a harder plastic therefore clinically, they are not preferred(77). Also,
they are not recommended in patients with sensitive gums. Unlike soft reline, these materials fail
to provide the cushioning effect, therefore their use is also contraindicated in thin mucosa or
resorbed ridges(74). The methacrylate monomer is a known irritant that may sensitize the oral
tissues after direct placement of the hard relines (73). Another problem associated with the hard
reline is the increased thickness of the palate for upper dentures. This increase in thickness is
often unpleasant for the patients(73).

Due to their limitations, the use of hard reliners is decreasing with time.

CONCLUSION:

The function of polymeric soft denture lining materials in the prevention and management of
chronic tissue irritation from dentures is an exceptional way to reduce patient discomfort and is
beneficial for preserving the health of the residual denture supporting tissue. However, the
limitations of these materials mainly including lack of adhesion between acrylic base and soft
liners, enhancing microbial growth, and leaching of plasticizers making them less durable.
Tissue conditioners that majorly act as cushioning material are intended only for short term use
and lose their advantageous properties when used for longer durations and cause irritation to the
mucosa, denture plaque accumulation leading to worsening of denture stomatitis. Therefore, the
tissue conditioner liners should be replaced within a specified period of 3-5 days. Since the
limitations outweigh the advantages of hardliners their use is diminishing with time. There’s a
hope that broader applications will establish in the future once the current drawbacks of the
available commercial materials are dealt with.

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