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COMPLETEDENTURE

THEORYANDPRACTICE
Mostafa Fayad
Lecturer of Removable Prosthodontic
Faculty Of Dental Medicine
Al-Azhar University
Cairo- Egypt
2011
2nded
COMPLETE DENTURE THEORY AND PRACTICE
Dr.mostafa.fayad@gmail.com
Table of contents
Subjects
1 introduction
2 Anatomy and Physiology in Complete Denture
3 diagnosis
4 ImpressionTrays and techniques
5 Relief Areasandpost dam
6 RecordBase and occlusion rim
7 JAW RELATION
8 Occlusion & articulators
9 SELECTION , arrangement of artificial teeth andWAXING-UP
10 try in
11 Processing Dentures
12 Denture insertion
13 Complaints
14 SEQUALAE OF WEARING CD
15 PREPARATION OF THE MOUTH
16 Management of Problematicpatients
17 FAILURE OF C. D
18 Nausea & gagging
19 SINGLE COMPLETE DENTURE
20 Combination syndrome
21 TEETH supported OVERDENTURE
22 Implant Overdentures
23 Geriatric Edentulous Patient
24 Duplication
25 Relining and rebasing
26 Repair
27 Biomechanics
28 Neutral Zone
29 Esthetics in Complete Denture
30 phonetics in Complete Denture
31 masticatory function
32
33
COMPLETE DENTURE THEORY AND PRACTICE Introduction to CD1
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Introduction
Prosthetics : It is the art and science of designing, supplying and fitting artificial replacement for
missing part of the human body.
Prosthesis : Is the artificial appliance which replaces a lost part of the human body.
Prosthodontics: It is a branch of dental science which deals with replacement of missing teeth
and associated structures by using artificial devices to restore function and esthetics.
Prosthodontics
1- Fixed prosthodontics.
2- Removable prosthodontics : a- complete denture b- partial denture
3- Maxillofacial prosthodontics.
Removable Prosthodontics is the art and science of replacement of missing teeth and oral
tissues with a prosthesis designed to be removed by the wearer. It includes removable complete
and removable partial prosthodontics.
Dentulous : A condition in which natural teeth are present in the mouth.
Edentulous : A condition in which all natural teeth are lost.
Partially Edentulous : A condition in which some of the natural teeth are lost.
Retention is a quality inherent in a prosthesis acting to resist dislodging forces along the path
of placement.
Stability is the quality of prosthesis to be firm, steady, or constant, to resist displacement by
functional horizontal or rotational forces.
Support is the quality of prosthesis to resist vertical tissue ward force.
Supporting area is the foundation area on which a dental prosthesis rests.
Complete Denture Prosthodontics : It involves the replacement of the lost natural dentition and
associated structure of the maxilla and mandible for patients who have lost all their natural teeth.
Objectives of Complete Denture Prosthodontics
1- Restoration of the masticatory function.
2- Restoration of the normal appearance.
3- Correction of speech defects resulting from loss of natural teeth.
4- Preservation of the alveolar bone and tempromandibular joints.
5- Satisfaction and comfort of the patient .
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Denture surfaces
Complete denture consists of denture base that rest on the supporting structure and to
which an artificial teeth attached to it.
It has three surfaces:
1-Fitting surface, (intaglio surfaces, impression surface) determined by the impression.
2-Polished surface; includes the facial (labial and buccal) and lingual and palatal
surfaces.
3-Occlusal surface that makes contact with the opposingdenture.
Denture borders: The margin of the denture base at the junction of the polished and
impression surface.
Denture flanges
The vertical extension of the denture base that extends from the cervix of the teeth to the
borders of the denture flanges; they are named according to location into:
Labial flange; the portion of flange that occupies the labial vestibule.
Buccal flange; the portion of flange that occupies the buccal vestibule.
Lingual flange; the portion of mandibular denture flange that occupies the alveololingual
sulcus.
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The differences between natural teeth and artificial teeth
Natural Teeth Artificial Teeth
Type of support
The teeth are supported by periodontal tissue
which gives support, positional adjustment of
teeth and proprioceptive response.
Area of support in both jaws
About 90 cm square.
Amount of masticatory forces
From 5 - 17.5 pounds.
Effect of masticatory forces
The masticatory forces are transmitted to the
bone in the form of tension through the
periodontal ligament. This tension is well
accepted by the alveolar bone and may even
service as stimulus for alveolar bone remolding
Effect of pressure on teeth
Each tooth receives individual pressure and
moves independently.
Effect of non-vertical components of forces
Well tolerated.
Incising forces
Not affect posterior teeth.
Proprioceptive response
The proprioceptive mechanism act as a useful
alarm protecting both the supporting structures
of the tooth and the substance of the crown
from the effects of excessively vigorous
masticatory movements.
All teeth are on bases and supported by mucosa
which is not created to be covered.
About 35 cm square of edentulous mouth.
About 10- 15% of its value in natural dentition.
The force is not directed to the entire alveolar
bone but is applied only on its surface in the
form of compression. This compression has
limited tolerance by the bone and may cause
alveolar bone resorption.
Teeth move as a unit on a base.
Cause trauma to the supporting tissue and
reduce stability to the denture.
Cause tipping of the denture base specially if
the teeth are not balanced articulated.
By the loss of natural teeth there is no
proprioceptive mechanism.
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Steps of Complete Denture Construction
Clinical Steps Laboratory Steps
1-History taking and examination of the
mouth.
-Preparing the mouth for dentures.
2-Taking of preliminary impressions
(in stock trays)
5-Taking of final impressions (in special
trays) and determining of the posterior
palatal seal.
8-Recording of jaws relations, face bow
transfer and selection of teeth.
11-Trying in the waxed denture.
15-Registration of new centric relation and
face bow transfer for clinical remount
(if needed).
17-Delivery of the finished denture and
instruction for their use.
18-Review of the denture (inspection and
aftercare).
3-Casting of the preliminary impression (using
plaster of paris).
4-Construction of special trays.
6-Boxing in and casting of the final impression
(using dental stone).
7-Construction of occlusion record blocks.
9-Mounting of the casts with the record blocks
on the articulator.
10-Setting-up of the teeth and waxing-up.
12-Processing of the denture (flasking, wax
elimination, packing, curing and
deflasking).
13-Laboratory remounting of the denture and
correction of occlusion by selective
grinding.
14-Finishing and polishing.
16-Remount of the denture on articulator for
adjustment of occlusion (if needed).
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Classification System for Complete Edentulism
The American College of Prosthodontists has developed a classification system for
complete edentulism based on diagnostic findings. These guidelines may help
practitioners determine appropriate treatments for their patients. Four categories are
defined, ranging from Class I to Class IV, with Class I representing an uncomplicated
clinical situation and a Class IV patient representing the most complex and higher-risk
situation.
Each class is differentiated by specific diagnostic criteria. This system is designed for use
by dental professionals who are involved in the diagnosis of patients requiring treatment
for complete edentulism.
Potential benefits of the systeminclude:
1)better patient care,
2) improved professional communication,
3) more appropriate insurance reimbursement,
4) a better screening tool to assist dental school admission clinics, and
5)standardized criteria for outcomes assessment.
Diagnostic Criteria
The diagnostic criteria used in the classification system are.
1. Bone height--mandibular
2. Maxillomandibular relationship
3. Residual ridge morphology maxilla
4. Muscle attachments
Bone Height: Mandible only
The results of a radiographic survey of residual bone height measurement are affected by
the variation in the radiographic techniques and magnification of panoramic machines of
different manufacturers.
To minimize variability in radiographic techniques, the measurement should be made on
the radiograph at that portion of the mandible of the least vertical height.
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A measurement is made and the patientis classified as follows:
Type I (most favorable): residual bone height of 21mm or greater measured at the least
verticalheight of the mandible
Type II: residual bone height of 16 to 20 mmmeasured at the least vertical height of the
mandible
Type III: residual alveolar bone height of 11 to 15mm measured at the least vertical
height of the mandible
Type IV: residual vertical bone height of 10 mm or less measured at the least vertical
height of the mandible
The continued decrease in bone volume affects:
1) denture-bearing area;
2) Tissuesremaining for reconstruction;
3) Facial muscle support/attachment;
4) Total facial height; and
5) Ridgemorphology.
Residual Ridge Morphology: Maxilla Only
Residual ridge morphology is the most objective criterion for the maxilla, because measurement
of themaxillary residual bone height by radiography is not reliable.
Type A (most favorable)
Anterior labial and posterior buccal vestibular depth that resists vertical and horizontal
movement of the denture base.
Palatal morphologyresists vertical and horizontal movement of the denture base.
Sufficient tuberosity definition to resist vertical and horizontal movement of the denture
base.
Hamular notch is well defined to establish the posterior extension of the denture base.
Absence of tori or exostoses.
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Type B
Loss of posterior buccal vestibule.
Palatal vault morphology resists vertical and horizontal movement ofthe denture base.
Tuberosity and hamular notch are poorly defined, compromising delineation of the
posterior extension of the denture base.
Maxillary palatal tori and/or lateral exostoses are rounded and do not affect the posterior
extension of the denture base.
Type C
Loss of anterior labial vestibule.
Palatal vault morphology offers minimal resistance to vertical and horizontal movement
of the denture base.
Maxillary palatal tori and/or lateral exostoses with bony undercuts that do not affect the
posterior extension of the denture base.
Hyperplasic, mobile anterior ridge offers minimum support and stability).-of thedenture
base.
Reduction of the post malar space by the coronoid process during mandibular opening
and/or excursive movements.
Type D
Loss of anterior labial and posterior buccal vestibules.
Palatal vault morphology does not resist vertical or horizontal movement of the denture
base.
Maxillary palatal tori and/or lateral exostoses (rounded or undercut) that intcrfere with
the posterior border of the denture.
Hyperplasic, redundant anterior ridge.
Prominent anterior nasal spine.
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Muscle Attachments: Mandible only
The effects of muscle attachment and location are most important to the function of a mandibular
denture .these characteristics are difficult to quantify.
Type A (most favorable)
Attached mucosal base without undue muscular impingement during normal
function in all regions.
Type B
Attached mucosal base in all regions exccpt labial vestibule
Mentalis muscle attachment near crest of alveolar ridge.
Type C
Attached mucosal base in all regions except antcrior buccal and lingual vestibules
(canine to canine).
Genioglossus and mentalis muscle attachments near crest of alveolar ridge.
Type D
Attached mucosal basc only in the posterior lingual region.
Mucosal base in all other regions is detached.
Type E No attached mucosa in any region.
Maxillomandibular Relationship
It characterizes the position of the artificial teeth in relation to the residual ridge and/or to
opposing dentition. Examine the patient and assign a class as follows:
Class I (most favorable): Maxillomandibular relation allows tooth position that
has normal articulation with the teeth supported by the residual ridge.
Class II: Maxillomandibular relation requires tooth position outside the normal
ridge relation to attain esthetics, phonetics, and articulation (eg, anterior or
posterior tooth position is not supported by the residual ridge; anterior vertical
and/or horizontal overlap exceeds the principles of fully balanced articulation).
Class III: Maxillomandibular relation requires tooth position outside the normal
ridge relation to attain esthetics, phonetics, and articulation (ie crossbitc-anterior
or posterior tooth position is not supported by the residual ridge).
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Factors Influencing the Outcome of Prosthetic Treatment
The successful outcome of prosthetic treatment depends upon
(1) The dentist who makes a diagnosis, prepares a treatment plan and undertakes the
clinical work.
(2) The dental technician who constructsthe various items which culminate in the
finished dentures.
(3) The patient who is faced with coming to terms with the loss of all the natural teeth
and then of having to adapt to the dentures and accept their limitations.
The patients contribution
Thepatient must:
Be able to come to terms with the loss of thenatural teeth and their artificial
replacement
Become accustomed to the sensation of the dentures, a process known as habituation
Learn to control the dentures
Accept and hopefully appreciate the new appearance.
Psychological effects of tooth loss
In an investigation of patients receiving prosthetic treatment, most having lost their
remaining natural teeth several years previously and seeking replacement dentures, 45%
admitted to having found it difficult to accept the loss (Davis et al. 2000).
Many of those who had difficulties took longer than a year to get over the loss, and more
than a third had still not accepted it by that time.
They expressed feelings of sadness, anger and depression and many felt that these last
extractions had made them feel prematurely old and lost a part of themselves.
There was loss of confidence, a restriction in choice of food and a lowered enjoyment of
that food. Relationships with others were affected and many patients avoided looking at
themselves without their dentures in place.
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Habituation
Habituation has been defined as: A gradual diminution of responses to continued or
repeated stimuli.
When new dentures are placed in the mouth, they stimulate mechanoreceptors in the oral
mucosa. Impulses arising from these receptors, which record touch and pressure, are
transmitted to the sensory cortex with the result that the patient can feel the dentures.
For the first-time denture wearer this bombardment of the sensory nervous systemalmost
inevitably results in pronounced salivation which, fortunately, only lasts for afew hours.
The continuing stimulation of these receptors does not result in a corresponding
continuous stream of impulses. The receptors adapt to this stimulation and as a
consequence the patient begins to lose conscious awareness of the new shapes in the
mouth.
Control of the dentures
The patients ability to control dentures involves a learning process that, initially, is a
conscious endeavour.
The learning process has come to the rescue. As aresult of repetition, new reflex arcs
have been set up in the central nervous system andthe conscious effort has been replaced
by a subconscious behaviour pattern.
The patients perception of appearance
Because a pleasing appearance is a subjective evaluation, there is obviously room for the
dentist and patient to have differing opinions. However, open disagreement does not
predispose to successful treatment and so it is vitally important that the dentist should
take careful notice of a patients views on appearance.
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Factors predicting treatment outcome
Age of the patient:
- In general, as patients grow older, it takes longer for them to adapt
successfully to new dentures
Quality of care provided and previous complete denture experience
- In cases where examination of the mouth indicates that the prognosis for
dentures is poor, it is essential for the dentist to warn the patient in advance of
the difficulties and to describe the steps that will be taken to minimize them.
The patients expectations and attitude towards dentures
- a patients attitude to dentures can be a useful predictor of satisfaction or
dissatisfaction.
Opinion of a third party
- Negative comments from friends and relationscan cause disappointment
and rejection of the prostheses, while positive comments can promote
cheerful acceptance of the treatment.
General health.
- Significant impairment of general bodily or mental health may affect the
learning process adversely, with the result that the patient becomes
discouraged because of major difficulties in mastering new dentures.
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Transition from the Natural to the Artificial Dentition
Methods of transition
The various methods of making the transition from natural to artificial dentition may be
considered under the following headings.
Transitional partial dentures
Transitional partial dentures restore existing edentulous areas. They may be worn for a
short period of time before the remaining natural teeth are extracted and the dentures are
converted accordingly.
Overdentures
Overdentures are fitted over retained roots and derive some of their support from that
coverage. Special attachments may be fi xed to the root faces to provide mechanical
retentionfor the denture. If, in due course, the roots have to be extracted, the overdenture
can be converted into a complete denture.
Immediate dentures
Immediate dentures are constructed before the extraction of the natural teeth and are
inserted immediately after removal of those teeth.
Clearance of remaining natural teeth before making dentures
This approach differs from all those mentioned previously in that, after the extractions,
time is allowed for initial healing and alveolar bone resorption to occur before providing
complete dentures.
It is common practice for a period of several months to be allowed for healing and initial
alveolar modelling. This delay before taking impressions will produce more stable
supporting areas for the dentures, although resorption will continue indefinitely but at a
slower rate.
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Disadvantages:
Loss of masticatory function and appearance during the healing period.
The undesirable mental and physical effects on a patient.
Tongue and cheeks may invade the future denture space, making adaptation to
subsequent dentures more difficult.
Difficulty in assessing vertical and horizontal jaw relationships when
constructing new dentures.
The difficulty in restoring appearance if all information on the natural dentition
has been lost.
Factors influencing the decision of remaining teeth extraction:
1. The condition of the teeth and supporting tissues
Useful teeth can be retained if:
It is feasible to undertake appropriate treatment to eliminate any disease present
If there is confidence in the patients ability to maintain good oral health.
The presence of gross caries or advanced periodontal disease, coupled with no patient response
to oral hygiene instruction, makes the decision of whether or not to extract the teeth a simple one
2. The position of the teeth
a)Natural teeth opposing an edentulous ridge
Thenatural teeth generate high occlusal loads onof the denture, which may result in:
Rapid destruction of the denture-bearing bone
The production of a flabby ridge
Complaints of a loose denture
A deteriorating appearance as the denture sinks into the tissues
Fracture of the denture base.
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Only in extreme cases should the dentist consider trying to reduce the occlusal loads by
extracting sound teeth in the opposing arch.
b)Over-eruption of the teeth
Extraction of over-erupted teeth may be required because they:
Excessively reduce the vertical space available for the opposing prosthesis
Have a poor appearance.
endodontic therapy followed by decoronation of over-erupted teeth
3. Age and health of the patient
It is truethat early extractions may reduce problems of adaptation to dentures, but this
advantage must be balanced against the immediate probability of reduced oral function
and comfort in a patient who may be happy with a few remaining natural teeth and,
perhaps, a partial denture.
One view that is regularly propounded is that every effort should be made to retain
useful, strategic teeth which may either help to stabilize a partial denture or which may
be converted into overdenture abutments.
4. The patients wishes
Thefollowing two scenarios occur occasionally and might cause the dentist some difficulty:
(1) Hopeless teeth that the patient wants to retain.
The dentist should carefully explain to the patient about the condition of the teeth and the
possible harmful consequences of retaining them.
(2) Sound, useful teeth that the patient wants extracted.
Thedentist explainsto the patient the nature of the clinical situation and to emphasise the
harm that unnecessary extraction of the remaining teeth would cause. If the patient still
need tooth extraction , the appropriate action by the dentist is most likely to withdraw
from the case, as to extract theteeth without clinical justification would be unethical.
COMPLETE DENTURE THEORY AND PRACTICE Anatomy and Physiology2
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Anat omy and Physi ol ogy I n Rel at i on t o
Compl et e Dent ur e Const r uc t i on
Effect of tooth loss
Anatomy
Anatomical Landmarks of Prosthetic Interest
Musculuture
Oral Mucosa
Salivary glands
Physiology
Physiology of bone
Physiology of muscles
Physiology of mucous membrane
Histology
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Tooth Extraction
Extraction of teeth may be indicated upon several lines of thought including:
Extensive caries,
Development problems i.e. hypoplastic enamel,
Periodontally compromised teeth with severe mobility and/or furcation involvement.
Such teeth have poor prognosis and the clinician may convey this unto the patient and offer
possible treatment alternatives that may include extraction.
Prior to delving into the concept of immediate dentures, one must understand what tooth
extraction entails. The dentist must understand possible sequelae, time taken for bone healing
and possible consequences. Below describes the pathological processes that take upon an
immediate precedent once extraction occurs.
Extraction of teeth emulates processes similar to fracture healing. The
large cavitation formed where the tooth used to be required a large amount
of epithelial migration, collagen deposition, contraction and remodeling
during healing; thus, due to the nature of the cavitation bone healing at the
socket undergoes secondary intention.
Immediately following injury, bleeding occurs from torn vessels with subsequent formation
of a haematoma with presenting accumulating granular leukocytes. Tissue damage signals an
acute inflammatory response insinuating five cardinal. Connective tissue changes that
accompany the inflammatory response cause a loosening of the periosteal attachment to the
bone; the haematoma attains a fusiform shape.
Two to three days later, macrophages invade the clot to remove fibrin, red cells,
inflammatory exudates and debris. Bone fragments undergo necrosis and are attacked by the
infiltrating macrophages. Post-demolition, ingrowth of capillary loops and mesenchymals
cells occurs; these cells have osteogenic potential contributing to the haematoma. Migration
of epithelium occurs at the bony crest and eventually migrates until it becomes level with the
adjacent gingiva.
Following one week post-extraction, young fibrous tissue has penetrated most of the
socket; the proliferating epithelium may be tenous with possible complete coverage. There
may be initial signs of osteogenesis on parts of the socket wall and trabecular bone.
After two to three weeks, the invading cellular infiltrate has reduced but continued
vascularity with development of new fibrous tissue and woven bone. Furthermore,
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osteoclastic activity occurs on the alveolar crests, labial plate and young bone in the base of
the socket; connective tissue beneath the surface epithelial layers matures.
After several months, the woven bone still undergoes remodeling while the overlying oral
mucosa has fully developed; the alveolar crests are being reabsorbed via osteoclasts.
Complete replacement by lamellar bone occurs after two to three years.
Effect of tooth loss
When natural teeth are present the occlusal forces are absorbed by the hydrodynamic
effect of the periodontal ligament. This complete mechanism is related to the maintenance of
integrity of the alveolar process. But the loss of teeth deprives these processes of the stimulus.
Under dentures all forces are transmitted to surface of the alveolar process as pressure.
Control of excessive pressure is an important consideration in CD construction.
After loss of Teeth
Alveolar bone resorbed
The orbicularis oris muscle loses its support
The amount of vermillion border shown on the
upper lip is reduced
The philtrum becomes flattened.
The Nasolabial Sulcus becomes more prominent
with aging due to loss of teeth and loss of vertical
dimension.
The mandible become closure to the nose .
Lack of support of the facial muscles
The shape and size of the alveolar ridges change when the natural teeth are
removed. The alveoli become mere holes in the jawbone and begin to fill up with
new bone, but at the same time the bone around the margins of the tooth sockets
begin to shrink away. This shrinkage, or resorption, is rapid at first, but it
continues at a resorbed rate throughout life.
The maxilla resorbs upward and inward while the mandible resorb downward and
out word so many patient appear pragmatic.
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Maxilla
The shape and size of the alveolar ridges change when natural teeth are removed.
The alveoli become mere holes in the jawbone and begin to fill up with new bone, but at
the same time the bone around the margins of the tooth sockets begins to shrink away.
This shrinkage or resorption is rapid at first, but continues at a reduced rate throughout
life.
The resorption of the alveolar process causes the foundation of the maxillary denture to
become smaller and otherwise change shape. If the denture is made soon after teeth are
removed, the apparent foundation may be large, but it also may be tender to pressure.
This is the result of in complete healing and a lack of cortical bone over the crest of the
residual alveolar ridge.
If teeth have been out for many years, the residual ridge may become quite small and the
crest of the ridge may lack smooth cortical bony surface under the mucosa.
There may be large nutrient canals and sharp bony spicules. These conditions limit the
amount of pressure that can be applied on the denture without creating pain.
Mandible:
When teeth are removed the bony foundation offer mandibular denture becomes shorter
vertically and narrower buccolingually.
The bony crest of residual ridge becomes narrower and sharper. Often sharp bony
spicules remain and cause tenderness when pressure is applied by denture.
The total width of bony foundation becomes greater in the molar region as resorption
continues; the reason being the width of inferior border of mandible from side to side is
greater than width of alveolar process from side to side.
Shrinkage of alveolar process in anterior region moves RR lingually first. Then as
resorption continues the foundation moves progressively further forward. Bone loss
continues on the mandible below level of alveolar process.
With resorption of alveolar process occlusal contours of RR often develop that make
them curved from a low level anteriorly to a high level posteriorly causing severe
problems in denture stability.
The total area of support from the mandible is significantly less than from maxillae. The
available denture bearing area for edentulous mandible is 14cm2 whereas for edentulous
maxillae its 24cm2. This means that mandible is less capable of resisting occlusal forces
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than the maxilla are and extra care must be taken if available support is to be used to
advantage.
The rate of resorption in the mandible is much higher (4X) than in the maxilla
The Dentition Function Curve
0
20
40
60
80
100
120
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Age
F
u
n
c
t
i
o
n

(
%
a
g
e
)
Dentate Partially dentate Edentulous
A model
for
understanding
dental
function
over time
The Dentition Function Curve
Ideal maxillary ridge:
Abundant keratinized attached tissue
Square arch
Palate U-shaped in cross-section
Moderate palatal vault
Absence of undercuts
High frenum attachments
Well-defined hamular notches
Ideal mandibular ridge:
Well defined retromolar pad
Blunt mylohyoid ridge
Deep retromylohyoid space
Low frenum attachments
Absence of undercuts
Abundant attached keratinized
mucosa
Adequate alveolar height
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A classification of jaw form following tooth loss
Zarb classified the edentulous anterior jawbone into shape (quantity) and quality.
Quantity, Shape (types A though E) reflects a range of resorptive patterns relative to the
demarcation of the alveolar and basal jawbone.
A: most of the alveolar ridge is present.
B: Moderate alveolar ridge resorption has occurred.
C: Only basal bone remains.
D: Some resorption of the basal bone has taken place
E: Extreme resorption of the basal bone has taken place
Quality (types 1 through 4) reflects a range of cortical and cancellous patterns:
1. Almost the entire jaw is comprised of homogenous compact bone.
2. A thick layer of compact bone surrounds a core of dens trabecular bone.
3. A thin layer of cortical bone surrounds a core of dense trabecular bone.
4. A thin layer of cortical bone surrounds a core of low density trabecular bone.
Both parameters have been employed frequently in planning oral implant treatment.
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Alveolar Ridge preservation
Residual ridge is the portion of the residual bone and its soft tissue covering that remains
after the removal of teeth
One of the most important objectives of prosthodontic restoration is the
preservation of the supporting structures rather than the restoration of the missing
parts.
The success or failure of a removable complete denture is dependent on many
factors, which include the condition of the alveolar ridge ,health of oral mucosa and
amount of the masticatory force of the opposing dental arch.
Causes of Alveolar Ridge resorption see flat ridge
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Alveolar ridge maintenance
1) Periodontal diseases prevention
2) Conservation of remaining teeth. Retention of residual tooth roots in key locations
3) Root submergence
4) A traumatic extraction
5) Alveolar ridge maintenance (ARM) deals with the placement of osteo promotive
materials at extraction sites in an attempt to maintain the physiologic and anatomic
integrity
6) The impression should allow the fabrication of denture base that will provide the best
distribution of physical forces by accurate impression
7) Role of vertical dimension
- High vertical dimension will increase stress on residual ridge leading to ridge
resorption
- Jaw relation technique
- Occlusal plane
8) The occlusal table play an important role in ridge preservation
9) Role of occlusal surface morphology
- anatomical teeth cause more stresses on the ridge
- Semi anatomical teeth cause less stresses on the ridge
- flat teeth cause the least stresses on the ridge
10) Role of selected teeth material
- Acrylic teeth less stresses
- porcelain teeth more stresses
11) Premature contacts need to clinical remounting to decrease stress on the alveolar ridge
12) Balanced occlusion - Different Occlusal schemes
13) Denture base material and Well adapted and properly extended dentures base
14) over denture to slow down or prevent the resorption of residual ridge
15) role of implant in ridge preservation
16) Alveolar Ridge Augmentation
17) alveolar ridge augmentation using autogenous bone grafts from the iliac crest
18) Vertical Ridge Augmentation Using Alveolar Distraction Osteogenesis
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Anatomical Landmarks of Prosthetic Interest
These are anatomical guides that help in denture construction. These landmarks are either bony
landmarks or soft tissue landmarks.
a- BONY LANDMARKS :
Some bony landmarks are difficult to palpate, while others are easily palpated and
identified.
The bony landmarks have the advantage of their being fixed in place.
The measurement produced by bony landmarks can be duplicated with more
accuracy than measurements between soft tissue landmarks .
b- SOFT TISSUE LANDMARKS
Easily identified
Have the disadvantage of changing their relation according to their mobility
[ I ] Ex t r a-or al Landmar k s Of Pr ost het i c I mpor t anc e
Landmar k Desc r i pt i on Si gni f i c anc e
1- I nt er -pupi l l ar y l i ne - Imaginary line running between the
two pupils of the eye when the pt. is
looking straight forward.
- Establishing the anterior Occlusal
plane of the artificial teeth of the
denture.
2- Al a-t r agus l i ne
(Camper's line)
- Imaginary line running from the
Inferior border of the ala of the nose
to the superior border of the tragus of
the ear.
- Establishing the posterior occlusal
plane of the artificial teeth of the
denture.
3- Cant hus-t r agus l i ne - Imaginary line running from the
outer canthus of the eye to the
superior border of the tragus of the
ear.
- Locating the position of the
condyles.
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4- Naso-l abi al sul c us - Depression that extends from the ala
of the nose in a downward and lateral
direction to the corner of the mouth.
The sulcus becomes more prominent
with aging and due to loss of teeth
and vertical dimension. It can be
modified by proper degree of jaw
separation and tooth positioning.
Plumpers (thick denture flanges)
improve the condition but it may
interfere with muscular activity.
5- Ver mi l l i on bor der - The transitional epithelium between
the mucous membrane of the lip and
the skin.
The amount of vermillion border
shown on the lips depends on
1-The bulk of the orbicularis oris
muscle.
2- The amount of the labial alveolar
bone.
3-The alignment of the anterior teeth.
After loss of teeth, the amount of
vermillion border shown on the
upper lip is reduced. The condition
can be corrected by thickening of the
labial flange of the denture and
proper positioning of the anterior
teeth.
6- Ment o-l abi al sul c us - Depression runs horizontally
between the lower lip and chin.
Its curvature indicates the character
of the maxillo-mandibular
relationship and the degree of over-
closure.
Class 1 normal ridge
relationship: The sulcus
shows a gentle curvature
with obtuse angle
Angle class II (retruded
mandibular relation): The
sulcus forms an acute angle
Angle class III (protruded
mandibular relationship):
sulcus forms an angle of
almost 180
7- Phi l t r um - It is a diamond shaped depression at
the center of the upper lip and base of
the nose.
After loss of teeth, the philtrum
becomes flattened. This condition
can be improved by construction of
proper denture with an appropriate
arch-form and tooth alignment .
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8- Modi ol us - The point of meeting of buccinator
and other facial muscles distal to the
angle of the mouth. The modiolus is
held in position by the arch-form of
the maxillary teeth.
With the loss of teeth the modiolus
drops. The appearance can be
improved by proper positioning of
the maxillary teeth.
Narrowing of the lower denture base
related to the modiolus is usually
necessary to avoid displacement
9- Angl e of t he mout h
(commissure of the lips)
- Point of meeting between the upper
and lower lip.
- (Angular Chilitis): Inflammation
and ulceration as a result of:
1- Prolonged edentulism.
2- vertical dimension of complete
denture.
3- Vitamin B deficiency.
10- The Angl e of t he
Mout h and t he Out er
Cant hus of t he Eye
The distance from the outer canthus
of the eye to the angle of the mouth
was used by Wills to determine the
vertical dimension of the edentulous
patient at rest by making the distance
from the base of the nose to the
lower edge of mandible equal to it.
A, The Philtrum, naso-labial sulcus, commissure of the lips& mento-labial sulcus.
B, Modiolus and Orbicularis Oris muscle.
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The muscles contributing to the modiolus (dotted circle)
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[ I I ] I nt r a-or al l andmar k of pr ost het i c i mpor t anc e
The denture base must extend as far as possible without interfering in the health or
function of the tissues. The amount of biting force an edentulous ridge will tolerate is directly
proportional to the amount of surface area covered
Force directed to a large bearing area is more equally distributed and much less per sq.
mm. than the same force directed against a smaller area. Consequently, if we hope to assist a patient
to achieve maximum biting force and preserve the supporting structure over a longer period of time, The
maximum amount of denture bearing area must be covered.
The denture foundation can be divided into:
Denture bearing/stress bearing areas. (denture foundation area) it is the surfaces of the
oral structures available to support a denture. or the tissues (teeth and/or residual ridges)
that serve as the foundation for removable partial or complete dentures.
Peripheral limiting or sealing areas
Anatomic Landmarks of the Denture Bearing Area (supporting structures):
I n t he Max i l l a I n t he Mandi bl e
1-The residual ridge and hard palate
2- The incisive papilla
3- The palatine rugae
4-Median palatine raphe
5- Maxillary tuberosity
6- Torus palatinus
7- Fovea palatinae
8- Incisive fossae
9- Canine eminence
10- Buttress of the zygomatic bone
11- Palatal gingival vestige
1- Residual alveolar ridge
2- Retromolar pad
- 3- Internal oblique ridge
(mylohyoid ridge).
- 4- External oblique ridge
- 5- Buccal shelf of bone
- 6- Mental foraman
- 7- Genial tubercles
- 8- Torus mandibularis
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Anatomic Landmarks that Limit the Periphery of the Denture (limiting structures):
I n Rel at i on t o Max i l l ar y Dent ur e I n Rel at i on t o Mandi bul ar Dent ur e
1- Labial frenum
2- Labial vestibule
3- Buccal frenum
4- Buccal vestibule
5- Pterygo maxillary notch (Hammular
notch)
6- Vibrating line.
1- Labial frenum
2- Labial vestibule
3- Buccal frenum
4- Buccal vestibule
5-Masseter muscle influencing area
6-Retromolar pad and inferior border of the
ramus
7- Pterygomandibular raphe
8- Plato glossal arch
9- Lingual pouch
10-Mylohyoid muscle influencing area
11- Lingual frenum
ANATOMY OF MAXILLARY DENTURE FOUNDATION
The maxillary denture is supported by two maxillae and the palatine bones. The palatine
processes of the maxillae are joined together at the midline in the median suture
The two palatine processes of the maxillae and the palatine bone form the foundation of the hard
palate and provide considerable support for dentures.
There are two maxillae, each consisting of a central body and three processes.
(a) The frontal process of the maxillae is directed upwards. It articulates anteriorly with
the nasal bone, posteriorly with the lacrimal bone and superiorly with the frontal bone.
(b) Zygomatic process of maxilla is short but stout and articulates with the zygomatic
bone.
(c) The alveolar process of maxilla bears sockets for teeth. The alveolar process arises
from lower surface of the maxilla. It consists of two parallel plates of cortical bone
buccolingual or labiolingual, which unite behind the last molar tooth to form the alveolar
tubercle. When teeth are present the cortical plates are connected by inter alveolar or
interdental septa.
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Zygomatic process or malar process which is located opposite first molar region is one of
the hard areas found in mouths that have been edentulous for a long time. Some dentures
requires relief over this area to aid in retention and prevent soreness of underlying tissues.
The crest of the residual alveolar ridge
covered with a layer of fibrous connective tissues,
Most favorable for supporting the denture because of its firmness and position.
The residual ridge and most part of the hard palate are considered the major or primary
stress bearing areas in upper jaw.
The resorption of residual ridge limits its ability to support unlike the palate which is
resistant to resorption, so the residual ridge may be considered as secondary supporting
area. (ZARB)
Factors that influence the form and size of supporting bone of basal seat include.
(1) Its original size and consistency.
(2) The patients general health and resistance.
(3) Forces developed by surrounding musculature.
(4) Severity and location of periodontal disease.
(5) Forces accruing from wearing of dental restorations.
(6) Surgery at the time of removal of teeth.
(7) The relative length of time the different parts of jaws have been edentulous.
Hard palate
It is a partition between oral and nasal cavities.
Its anterior two thirds are formed by palatine process of maxillae and its posterior
1/3 by horizontal plates of palatine bone.
The center of the palate may be very hard because the layer of soft tissue covering
the bone in the region of median palatal suture is extremely thin.
The soft tissue covering the hard palate varies considerably in consistency and
thickness in different locations even though the epithelium is keratinised
throughout. Antero laterally the submucosa of hard palate contains adipose tissue
and posterolaterally it contains glandular tissue. The tissues should be recorded in
a resting condition, because when they are displaced in the final impression, they
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tend to return to normal form within completed denture base creating an unseating
force on denture base or causing soreness in patients mouth. Proper relief of final
impression trays aids in recording these tissue in an undistorted form. In addition
the secretions from the palatal glands can be an important factors in selection of
final impression material.
The glandular region of either side of the mid line in the posterior part of the
hard palate should be covered by the denture so it can aid in retention, but it
should not provide significant support for the denture because of the relatively
higher resiliency at this site. The mucous glands in this region are relatively thick
and they cover the blood vessels and nerves coursing forward in the palate from
greater palatine foramen. These vessels and nerves anastomose with vessels and
nerves passing through the nasopalatine canal and into the region of basal seat of
incisive papilla.
Incisive papilla
It covers the incisive foramen and is located on the line immediately behind and
between the central incisions.
Its position varies with different patients. It is located on the centre of ridge after
resorption has occurred in mouths that have been edentulous for long time.
The location of incisive papilla gives an indication as to the amount of resorption
of residual ridge and thus is an aid in determining vertical dimension and proper
position teeth.
Incisive foramen (Nasoplatine foramen)
The Nasoplatine nerves and blood vessels in submucosa exit the palate at right angles to
the margins of this bony fossa or foramen. Therefore even though the foramen is covered
with protective pad of fibrous CT called incisive papilla, the denture base should be
relieved over this area. Failure to relieve the denture base will result in pressure on the
nerves and blood vessels with resultant decrease in blood supply to anterior part of palate
and nerve irritation with accompanying burning symptoms.
The location of incisive foramen gives an indication as to the amount of resorption of the
Residual ridge. It comes nearer to crest of the ridge as resorption progresses. thus aid in
determining the vertical dimension and the proper position of maxillary anterior teeth.
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Palatine rugae
The rugae in the anterior part of the hard palate are irregularly shaped rolls of soft tissue.
They should not be distorted in an impression technique since rebounding tissue tends to
unseat the dentures.
This area contributes to stress bearing role as well as retention, though in secondary
capacity.
Median palatine suture (mid palatal suture)
The two horizontal palatine processes of the maxillary bone fuse in the midline to form
the mid palatal suture.
The submucosa in this region is extremely thin and non resilient little or no stress can be
placed in this region during find impression making or the completed denture lest the
denture tend to rock over the center of palate when vertical forces are applied to the teeth.
In addition this part of mouth is highly sensitive and excess pressure can create
excruciating pain.
Proper relief in the impression tray or completed denture is essential for accommodating
this nature of tissue.
Posterior nasal spine, greater/lesser palatine nerves and vessels
The posterior border of the horizontal plates of the palatine bones unites in midline to
form the sharp posterior nasal spine. The posterior margins of the hard palate serve as the
anterior attachment for aponeurosis of soft palate.
On each side of the hard palate the greater palatine foramen is located medial to the
third molar at the junction of the maxilla and horizontal plate of palatine bone. A groove
extends anteriorly from the foramen and contains the anterior (greater) palatine nerve and
blood vessels. Because the nerve and blood vessels course though a groove, rarely must
the denture base over the area be relieved.
In some instance bony spines are located near the greater palatine foramen. If these bony
projection present problems, the denture base should be relieved over these areas, or the
spines should be surgically removed.
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Tuberosity region
The tuberosity region often hangs abnormally low because the maxillary posterior teeth
are retained after the mandibular molars have been lost and not replaced, the maxillary
teeth extrude bringing the process with them often the low lying tuberosity is complicated
by excess fibrous connective tissue.
This excess soft tissue can prevent proper location of occlusal plane if not removed. In
addition rough and irregular bone can be irritated by denture base.
Palatine fovea
They are ductal openings into which ducts of other palatal mucosal glands drain. They
serve no function. According to Lye the fovea palatine are located on average of 1.31mm
anterior to anterior vibrating line.
Sharp spiny process
There are sharp spiny processes on the maxillary and palatine bone, usually they have no
problem with complete denture but with resorption they can irritate the soft tissue lies
between them and denture base.
ANATOMY OF PERIPHERAL OR SEALING AREAS
The functional anatomy of the mouth determines the extent of basal surface of a denture.
The denture base should include the maximum surface possible within the limits of health
and function of the tissues it covers and contacts.
Labial frenum
The lip movement near the maxillary labial frenum is
vertical and thus the notch becomes long and narrow.
If the frenum is pulled too far laterally during border
molding, the notch will become too wide and the
peripheral seal will be lost.
In some cases depressions are recorded beside the labial frenum notch due to muscle
band consisting of the origins of the nasal septal depressor muscle and the orbicularis
oris. In these cases the denture must be adequately relieved as not to disturb the function
of these muscles.
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Labial vestibule
In region of labial vestibule, three objectives of an impression should be fulfilled.
The impression must supply sufficient support to the upper lip to restore the relaxed
contour (for appearance) of the lip. The thickness of labial flange must be developed
according to amount of bone that has been lost from labial side of ridge.
Secondly the labial flange of impression must have sufficient height to reach the
reflecting mucous membrane of the labial vestibular space without distorting it.
Thirdly there must be no interference of labial flange with action of lip in function.
Buccal frenum
The muscle movements around the buccal frenum are both vertical
and horizontal thus a wider notch should be formed compared with
the labial frenum. It will become a V-shaped notch.
Generally the frenum runs obliquely and posteriorly therefore its
anterior movement should be recorded by pursing the lips such as when whistling during
border molding.
Buccal vestibule
The size of the buccal vestibule varies with the contraction of the buccinator, the
position of the mandible and the amount of bone lost from the maxilla.
The thickness of the distal end of buccal flange of denture must be adjusted to
accommodate the ramus and coronoid process and the masseter as
they function. When mandible moves forwards or to the opposite
side the width of buccal vestibule is reduced. When masseter
contracts under heavy closing pressure it also reduces the size of
space available for distal end of buccal flange.
If border molding in the buccal space is inadequate, the denture will lose its seal because
of the ingress of air under the denture base when the buccal vestibule is opened during
situations in which the patient laughs and opens the mouth widely.
In the rare case when it is hard to determine the width of the vestibule and thus the width
of the denture border due to severe alveolar ridge resorption, the appropriate width of the
vestibule can be estimated by using the remnants of the lingual gingival margin as a
guide. [HAYAKAWA]
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The buccolingual breadth of the dentate alveolar ridge (the horizontal breadth of
the alveolar process from the lingual gingival margin to the maximal projection of
the buccal surface of the ridge) is remarkably constant for every tooth position. So
the remnants of the lingual gingival margin can be located in the edentulous
mouth, the cheek position can also deduced by using it as a landmark.
For example , the average measurement of the buccolingual breadth BLB in the
dentate molar region is 10-12 mm, However, after extraction of the teeth, the
remnant move outward 3-4 mm from the position in the dentate mouth, so the
width of the vestibule should be estimated by deducting this value from the mean
buccolingual breadth of dentate patient. [See Palatal gingival vestige]
Pterygoid process
It projects downwards from the greater wing and body of sphenoid behind the
third molar tooth. Inferiorly it divides into medial and lateral pterygoid plates,
which are fused anteriorly but separated posteriorly by the v-shaped pterygoid
fossa.
The fused anterior borders of the two plates articulate medially with the plate of
palatine bone and are separated laterally from the posterior surface of the body of
maxilla by pterygomaxillary fissure.
The medial pterygoid plate is directed backwards. It has medial and lateral
surfaces and a free posterior border. The upper end of this border divides to
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enclose a triangular depression called scapoid fossa. Medial to this fossa there is a
small pterygoid tubercle, which projects into the foramen lacerum. It hides from
view the posterior opening of the pterygoid canal. The lower end of the posterior
border is prolonged downwards and laterally to form the pterygoid hamulus.
The lateral pterygoid plate is directed backwards and laterally. It has medial and
lateral surfaces and a free posterior border. The lateral surface forms medial wall
of infra-temporal fossa. The medial surface gives origin to muscles. The posterior
border sometimes has a projection called pterygo spinous process, which projects
towards the spine of sphenoid.
Pterygo maxillary (hamular) notch
The pterygoid hamulus is a thin, curved process at the terminal end of medial
pterygoid plate of sphenoid bone. The exact position of hamular process is located
2-4 mm posteromedial to distal limit of maxillary residual ridge
Although the pterygoid hamulus does not help in support of dentures, the area
between the maxillary tuberosity of maxilla and the hamulus is critical to design
of maxillary denture. It is used as a boundary of the posterior border of maxillary
denture back of tuberosity.
The posterior palatal seal must be placed through the centre of the deep part of
hamular notch since no muscle or ligament is present at a level to prevent the
placement of extra pressure. The submucosa of mucous membrane is thick and
made up of loose areolar tissue.
Additional pressures also can be placed on this tissue at the centre of the notch to
complete the posterior palatal seal.
Posterior palatal seal
It is divided into two separate but confluent areas based on anatomic boundaries.
The posterior palatal seal extends medially from one tuberosity to another.
Laterally the pterygo maxillary seal extends through the pterygo maxillary notch
continuing for 3-4mm antero laterally approximating the mucogingival junction.
The pterygo maxillary seal occupies the entire width of pterygo maxillary notch,
which is defined as band o loose CT lying between the pterygoid hamulus of
sphenoid bone and distal portion of maxillary tuberosity.
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The notch is covered by pterygo mandibular fold, which extends from posterior aspect of
tuberosity posterior-inferiorly to insert into retromolar pad. This fold of tissue can influence the
posterior border seal if the mouth is in a wide-open position during final impression procedure.
Vibrating lines
The PPS lies between the anterior and posterior vibrating lines.
It is an imaginary line across the posterior part of the palate marking the division
between the movable and immovable tissues of the soft palate. This can be
identified when the movable tissues are functioning
It should be described as area not line
The anterior vibrating line located at the junction of attached tissues overlying
the hard palate and movable tissues of the immediately adjacent soft palate. This
should not be confused with anatomic junction of hard and soft palate.
It can be located by patient performing Valsalva Maneuver or instructing patient
to say Ah in short vigorous bursts. This places the soft palate inferiorly at its
junction with hard palate.
Due to projection of posterior nasal spine the anterior vibrating line is not a
straight line between the hammular processes. The anterior vibrating line is
always on soft palatal tissues. As soft palate extends posteriorly the action of
palatal muscles become more exaggerated.
The posterior vibrating line is an imaginary line at the junction of aponeurosis
of tensor veli palatini muscle and muscular portion of soft palate.
It represents the demarcation between that part of soft palate has limited or
shallow movement during function and the remainder of soft palate that is
markedly displaced during functional movements.
It can be visualized by instructing patient to say Ah in normal unexaggerated
fashion. The posterior vibrating line marks the most distal extension of denture
base. The vibrating line is located and marked using an indelible pencil or marker,
and the impression tray is trimmed to this line
The distal end of the denture : should extend at least to vibrating line and in some instances it
may extend 1 to 2 mm posterior to vibrating line .[ ZARB] Should cover the tuberosity and
extend to hamular notch.
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Techniques used in locating the vibrating line.
1- The clinician will often visualize the position of this line by having the patient say
"Ahh" and noting that the soft palatal tissues will usually lift while the hard palatal tissues
remain immobile. When the patient says "ah" the oft palate rises up and returns to its original
position when the patient relaxed
2- The Valsalva maneuver in which the patient is asked attempt to blow air through their
nose while the nostrils are gently pinched closed. While gently holding the tongue down with
a mouth mirror, the clinician will often easily visualize the line because the soft palate will
drop dramatically at the vibrating line using this technique. Blowing out through the nose
while closing the nostril causes a downward expansion of the soft palate
3- Other features indicating the position of this line may include a rather sharp color
change between the hard and soft palatal tissues at the vibrating line
4- Presence of the fovea near the line. According to Lye the fovea palatine are located on
average of 1.31mm anterior to anterior vibrating line.
5- Lastly, and often the easiest to visualize, may be the rather significant angular change
between the rather flat hard palate and the moderately to severely sloping soft palate. This
junction indicates the vibrating line.
A = "clinical" junction of hard and soft palates.
B=ah-line ,
C=fovea palatinae ,
D: anatomical junction of hard and soft palates.
The hard palate possesses a portion made up of a 4-5 mm thickness of submucosa which
contain muscle insertions a well as glandular tissue. Even though the hard palate is
supported by bone, it is affected by the Levator and tensor muscles of the velum palatini
and so it is considered to be movable.
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Clinically, from only inspection and palpation, it is difficult to
determine whether the palate is supported by bone or not. So, the term,
"clinical' hard and soft palates, should be advocated
In the posterior part of the submucosa of the palate, the palatine glands
extend anteriorly from the soft palate to the first molar region taking the
shape of a mountain on either side of the midline.
The thickness is 4-6 mm in the soft palate and 2-3 mm even in the anterior part on the
hard palate. Thus there is no need to be anxious regarding how far the posterior border can be
extended. If the border is placed only on these palatine glands which possess a cushioning
effect, this would be adequate for retention, even if it is placed slightly anteriorly. A little
more extension may not lead to much better retention. If it is overdone the situation will be
worse than that of under extension and will lead to a gag reflex and irritation of the movable
mucosa. Therefore it is recommended that the posterior border is determined by carefully
avoiding the portion moving around the vibrating line whilst saying "ah".
Some clinicians might extend the posterior border posteriorly so as to cover the foveae
palatinae by considering the anatomical junction of the two palates, but this concept is not re-
commended. [HAYAKAWA]
Classification of soft palate
Based on angle that soft palate makes with hard palate. The more acute the angle, the
more muscle activity that will be necessary to achieve velopharyngeal closure (closing
nasopharynx).
The more the soft palate is markedly displaced in function, the less that can be covered
by denture base.
The more resorbed the edentulous ridge, more difficult in determining the soft palatal
configuration.
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A Broad PPS
B - Medium width PPS
C Narrow PPS
Class I
Horizontal.
Minimal muscular activity.
Allows wide PPS but not very deep.
Since more tissue surface is covered it yields more retentive denture base.
Class III
The most acute contour.
Marked elevation of the musculature to create velopharyngeal closure.
Usually seen in conjunction with high v-shaped palatal vault.
Small area for posterior seal.
Deeper than class I
Class II
Designates those palatal contours that lie some where between class I and class III.
ANATOMY OF MANDI BULAR DENTURE FOUNDATI ON
The mandible is the movable membrane of the stomatognathic system. The body of
mandible is horse-shoe shaped. The distal portion of each site continuous upwards and
backward into the mandibular ramus.
The ramus divides superiorly into the condylar process and coronoid process. The
condyle (head) is the articular surface of the condylar process.
The connection of condyle with ramus is the slightly constricted mandibular neck.
Superior to the neck, the condyle is bent anteriorly so that the articular surface faces upward and
forward.
The coronoid process is a triangular bony projection that varies in size and shape. The
convex anterior border of coronoid process continues in to anterior border of ramus.
When the mandible is protruded the anterior border of ramus extends towards the
alveolar tuberosity, which is medial to ramus. If the distobuccal flange of denture is too thick, it
will cause discomfort when mandible is protruded and may dislodge denture during lateral
excursions.
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The total area of support from the mandible is significantly less than from maxillae. The
available denture bearing area for edentulous mandible is 14cm2 whereas for edentulous
maxillae its 24cm2. This means that mandible is less capable of resisting occlusal forces than the
maxilla are and extra care must be taken if available support is to be used to advantage.
Crest of residual ridge
The underlying bone of crest of RR is cancellous made up of spongy trabeculae.
Therefore crest of lower RR may not be favourable as primary stress bearing area for
lower denture.
Proper relief to be provided for crest of lower ridge during making final impression.
Retro molar region and pad
The distal end of mandibular denture region is bounded by the
anterior border of ramus, thus including the retro molar pad
posteriorly, which defines the posterior limit.
The retro molar which is triangular soft pad of tissue at distal end of
lower ridge must be covered by denture to perfect the seal.
It contains some glandular tissue, some fibers of temporalis tendon, fibers of superior
pharyngeal constrictor enter it from lingual and pterygo mandibular raphe enters the pad
at its supero posterior inside corner. The action of these limits the denture during
impression procedures.
The posterior half of the retromolar pad is filled with resilient glandular tissues. The
peripheral seal of the denture can be obtained when the denture border is placed on this
tissue. The distal end of the denture should be placed at a point 213 of the way up the
retromolar pad .
As the ternporalis muscle fibers attach to the distal portion of the retromolar pad,
stimulation from this muscle prevents the pad from resorption. So, the retromolar pad is
also used as a landmark for orientation of the occlusal plane. Therefore the retromolar
pad must be included in the impression. [HAYAKAWA]
Retromolar pappilea is small pear shape area just anterior to the retromolar bad it is
dense fibrois connective tissue. [HEARTWELL]
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Mylohyoid ridge
If the denture border is short of the mylohyoid ridge, it will dig into
the residual ridge and cause pain. The border is shortened to remove
this pain, but shortly after, the shortened border again impinges upon
the residual ridge. This repetition will make the denture into a cord-
like and has poorer retention and stability.
Border molding of the mylohyoid ridge area should be performed to
cover the ridge 4-6 mm beyond it. At the insertion appointment the
impression surface of the denture on the mylohyoid ridge is relieved so
that pain during mastication will be diminished.
In addition, when the lingual denture border is extended properly as
mentioned above, the lingual polished surface can be shaped into a
concave form(the concave shelf) which is important [or the retention and
stability of the denture]
When making an impression of this region, some think that the movement
of the mylohyoid muscle would be recorded by moving the tip of longue toward the
opposite side, However, tongue movement is due to the action of the genioglosus muscle,
The mylohyoid muscle contracts during swallowing.
The patient is instructed to slightly touch the corner of the mouth with
the tongue. A exaggerated tongue movements during impression making
will be the cause of under extended borders, excessive movements
should be avoided. If the tongue is protruded over the dental arch, the
lingual sulcus will become shallow and an extremely shortened border will be obtained.
During ordinary function like mastication the tongue is not protruded outside dental arch
The impression should be made to cover 4-6' mm beyond the mylohyoid ridge. This is
the length of the denture border in the mylohyoid ridge area. [HAYAKAWA]
The outline of the denture base can be determined easily and automatically by using these
indexes. It is just necessary to connect the index lines, namely lines placed 1 mm beyond
the external oblique ridge, 2\3 of the way from the anterior border of the retromolar pad
and 4 to 6 mm below the mylohyoid ridge. [HAYAKAWA]
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Lingual tuberosity
It is an irregular bony prominence on distal end of mylohyoid line.
When this area is excessively prominent or rough it may present an undesirable undercut
requiring surgical intervention.
External oblique ridge (line)
It is a ridge of dense bone extending from just above the mental foreman in a superior
and distal direction to become continuous with anterior border of ramus.
In most individuals the external oblique ridge is the anatomic guide for lateral
termination of buccal flange of mandibular denture.
Buccal shelf area
The area between the buccal frenum and the anterior edge of the masseter muscle. The
buccal shelf may be very wide and is at right angles to vertical occlusal forces, providing
excellent resistance to such forces.
Some buccinator fibers are located under the buccal flange because the mandibular
attachment of this muscle is close to crest of ridge in molar region. The inferior part of
buccinator is attached to buccal shelf of mandible and thus contraction of muscles does
lift the lower denture.
Mental foremen
It is located on the lateral surface of body of mandible between the first and second
bicuspids about halfway between the lower border of mandible and the alveolar crest.
If the loss of RR is extensive, the foramen occupies a more superior position and denture
base must be relieved over the foramen to keep the denture base from irritating the
mental neurovascular bundle failing which the pressure exerted will cause numbness of
lower lip.
Mental spines (Genial tubercles)
They are situated on lingual aspect of mandibular body in midline slightly above the
body. These bony elevations are often divided into a superior and an inferior section and
sometimes into right and left prominences.
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When loss of RR is extensive these spines are more superior position than crest of
existing ridge, requiring surgically intervention.
The denture flange covering the genial tubercles may be widely
eliminated in many dentures for fear that the tubercle would be
irritated by settling of the denture due to occlusal forces.
However, if the denture border ends on the hard tissues, no
peripheral seal will be possible. The denture border must be
extended over the genial tubercles (and proper relief is done) in favor of improving the
peripheral seal.
Lingual ledge
On side of genial eminence, a sharp bony ridge or crest which projects horizontally
toward the tongue and then falls off abruptly maybe palpated. This is a frequent source of
annoyance to denture. The ledge is a crescent shaped prominence located bilaterally
between genial tubercle and anterior end of mylohyoid ridge, which maybe continuous. It
exists in normal mandible as a slightly curved elevation but becomes more and more
prominent as the resorptive process reduces mandibular ridge and body.
In mouths containing moderately resorbed RR, the lingual ledge maybe palpated for
below the level of the floor of the mouth and is not involved in denture impressions
unless the impression tray is over - extended. Where slightly resorbed the high
mandibular ridges are present, the ledge is not palpable. The presence of soreness of
lesions in this region explains the denture border impinging on the thin overlying mucosa,
thus not covering the lingual ledge completely.
Labial frenum
Usually a single narrow band but may consist of two or more band. The activity of this
area tends to be vertical so the labial notch in denture should be narrow.
The mandibular labial frenum is usually shorter and often wider than maxillary labial
frenum.
Labial sulcus
The part of denture extending from labial frenum to buccal frenum is labial flange or
labial sulcus in edentulous mouth.
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This flange is limited in extension because the fibers of orbicularis oris and incisive labi
inferioris are fairly close to ridge crest. Muscles fibres are mainly horizontal. Mentalis
muscle originates from mental tubercles and inserts into lower lip (orb oris). It is a
vertical muscle and may be very active in some patients.
The orbicularis oris is the major muscle in this region. as its
muscle fiber run horizontally, care must be taken not to
overextend the impression border in cases with weak muscle
tension in this region.
The mentalis muscle is one of the muscles constituting the lower
lip. Its muscle fibers are vertical and the origin attaches high on
the mandibular alveolar process therefore the labial vestibule becomes narrow when this
muscle contract .
However, if the lip is pulled too much as a result of being over conscious about this
contraction during border molding, the vestibule will become too shallow because the
attachment of the muscle is higher than the base of the labial vestibule
Excessive activity in this area results in short flange which may not provided seal for
finished dentures.
In patient exhibiting strong muscle tension of these muscles
in this region, this causes the lower up to fall inward and the
impression border becomes thin and short. As a result, the
completed denture might have an insufficient peripheral seal.
In general, the instruction is given to bite the operator's
fingers which are placed between the tray and the maxillary ridge. A the masticatory
muscles become tense and the lower lip becomes loose as a reflex, the impression is then
made in this situation
When ridge is fair to good the labial borders should be thin (1-2mm) since thicker border
will distort the lips. When ridge is flat a thicker border is needed for lip and checks
support and to provide better seal.
In general a thicker border creates better seal than thin border. Wider borders tend to
create favourable inclined plane and reduce the potential of losing peripheral seal.
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Thicker border should be used with discretion, since they may cause discomfort poor
esthetics or interference with normal muscle movements.
Buccal frenum
It is usually in the area of first premolar. It may be a single band but often two or more
bands.
The oral cavities in this are horizontal as well as vertical (i.e. movements such as
puckering, grinning etc) so wider clearance is usually needed.
The contour of denture will be little narrower in this area due to activity of depressor
anguli oris muscle.
Buccal vestibule
Extends from buccal frenum posteriorly to outside back corner of retromolar pad and
from crest of RAR to cheek.
The buccinator in cheek extends from modiolus (ant) to pterygomandibular raphe (post).
Labial and buccal borders are not as critical for borders seal because they shape of the
lips and checks create a facial seal. That is why it is possible to have a denture with open or short
flange (often used for immediate dentures) and still have good retention.
Masseter region
Pain may occur on the buccal side of the retromolar
pad region during mastication even though the de-
nture is properly designed. This is due to the
masseter muscle, a strong elevator, which is lateral
to the retromolar pad and covers the buccinator
muscle.
When the masseter muscle contracts, its
enlargement presses the denture border with the cramped buccinator muscle. As the
denture occludes it cannot move during function of the elevators. When the distobuccal
border of the denture base is extended into the functioning area of the masseter muscle,
the mucosa will be pressed against the denture base leading to pain.
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to avoid such a situation, the movement of the masseter muscle is recorded in the
impression by creating its reactive contraction through pushing the tray during the border
molding procedure. The tension of the masseter muscle will make a concavity in the
distobuccal outline of the impression. Another way is to reduce the over lengthened
border through observing the redness or displacement of the denture after insertion of
the new denture made by connecting the index line.
An active masseter muscle will create a concavity in the outline of distobuccal border.
The distobuccal border of mandibular impression encounters
the action of masseter to a greater or lesser degree depending on
the shape of the mandible and the origin of muscle.
If ramus of mandible has a perpendicular surface and origin of
muscle on zygomatic arch is medial ward; the muscle pulls
more directly across the distobuccal denture border, therefore it forces buccinator and
tissues inward, reducing the space in this region. If the opposite is true, greater retention
is allowed on distobuccal portion of mandibular impression.
The relative size of masseter will influence its action on the buccinator; a masseter that is
of smaller diameter will have less influence (perhaps none) on the border.
Distal extension of mandibular impression
The distal extent of mandibular impression is limited by the ramus of mandible, the
buccinator fibers that cross from the buccal to lingual as they attach to the pterygo
mandibular raphe and the superior constrictor and sharpness of lateral bony borders of
retro molar fossa (formed by continuation of external and internal oblique ridges
ascending the ramus).
If the impression extends on to the ramus, the buccinator and the adjacent tissues will be
compressed between hard denture border and the sharp external oblique ridge, which will
not only cause soreness but also limit the function of buccinator, which is a part of the
kinetic chain of swallowing.
The desirable distal extension is slightly lingual of these bony prominences and includes
the pear-shaped retro molar pad which forms a splendid soft tissue seal.
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Pterygomandibular raphe
The pterygo mandibular raphe or ligament originates from the pterygoid hamulus of
medial pterygoid plate and attaches to distal end of pterygoid ridge.
It is partly the origin of buccinator muscle laterally and the superior constrictor muscle
medially.
It is quite prominent in some patients and may even require and notch like clearance in
maxilla denture. A simple wide-open digital and visual inspection will usually determine
whether clearance is required or not.
If extreme opening is allowed in making the impression the pterygo mandibular ligament
make a notch distal to alveolar tubercle
Alveololingual sulcus
It is the space between the residual ridge and tongue. It extends posteriorly from lingual
frenum to retromylohyoid curtain. Part of it is available for the lingual flange of denture.
The alveololingual sulcus can be considered in 3 regions
1. The anterior region (Premylohyoid fossa)
This extends from lingual frenum to where the mylohyoid ridge curves down below the
level of sulcus.
This fossa results from the concavity of mandible joining the convexity of mylohyoid
ridge.
Lingual border of impression in anterior region show make definite contact with mucous
membrane of mouth when tip of tongue touches upper incisors.
Anterior lingual flange area
The border of the impression in this area is mainly influenced by the lingual frenum and
the genioglossus muscle. The genioglossus muscle and the Lingual frenum which lie over the
muscle move actively and are easily traumatized therefore their movement and tension must
be recorded exactly during border molding. Thus the patient must be instructed to make
appropriate tongue movements in order to record the exact depth and width of the notch
made by the lingual frenum.
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To provide adequate clearance in this area the patient is instructed to make some overactive
movement such a licking the Lower lip , by moving the tip of the tongue from side to side.
Inadequate clearance may result in pain or inflammation. Tongue movement is never
requested during, impression making. However this is the only area where functional
movement of the tongue is necessary.
Lingual frenum
Fibrous band of tissue that overlies the centre of genioglossus muscle. It is usually a
narrow single band of tissue but may be broad and exist as two or more frenums.
It is rather shallow, sensitive and resistant. It should be registered in function because at
rest the height of its attachment is deceptive. In function it comes quite close to crest of
ridge although at rest it is much lower.
It originates at midline from under surface of tongue and often terminates at the
sublingual (salivary) caruncles. In other instances it crosses and bisects the sublingual
crescent space and attaches to lingual aspect of mandibular ridge. Often it fans out to find
a broad insertion in alveolar mucosa.
This structure should be palpated for tension during tray adjustment procedure. Careful
clearance is needed in the denture because the lingual frenum is attached to tongue and
inadequate clearance may result in pain or displacement of denture.
They may be attached or near the crest of ridge. The lingual frenum maybe very short or
tongue-tie the patient can hardly protrude the tongue. Accessory frenums may occur in
almost any area of vestibule.
It is influenced by genioglossus muscle and some what by anterior portions of sublingual
glands. The action of these muscles may raise and protrude the tongue.
Frenums are basically fibrous connective tissue. They do not contract or expand like
muscles but rather are ligaments. They are accessory limiting structures for tongue, lips,
and muscles of cheek.
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2. The middle region
The part of alveololingual sulcus extends from premylohyoid fossa to distal end of
mylohyoid ridge curving medially from the body of mandible.
When mylohyoid muscle and tongue are relaxed, the muscle drapes back under
mylohyoid ridge.
If the lingual flange slopes towards the tongue, the tongue can rest on top of flange and
aid in stability of lower denture on RR it also prevents displacing the denture during
tongue movements and swallowing thus maintaining the seal.
The length and width of mylohyoid flange is determined by membranes attachment of
tongue to mylohyoid ridge and width of hyoglossus muscle and can only be determined
by skilful border molding and impression.
The lingual borders in mylohyoid areas are formed by contact with mylohyoid muscles in
a functional but not extreme contracted or elevated position.
As Blanchard pointed out these borders leave a space when mylohyoid muscles are at
rest. The average mylohyoid border is 4-6mm below mylohyoid ridge fair-good ridge-
width 2-3mm flat-ridge 4-5mm.
Sub mandibular fossa
It is a concave area in mandible that is inferior and distal to mylohyoid ridge. It is a bony
landmark and has little significance in impression making except it is necessary to be
aware of configuration.
SUBLINGUAL GLAND AREA
The relationship of sublingual gland to lingual border is
controversial and confusing.
They are located above mylohyoid muscle. They vary in
size and sometimes appear immense, that they seem higher
than RR. The position of gland is elevated when mylohyoid
muscles are in function (during swallowing) and they
appear to eliminate the lingual vestibules unless quite firm, which is rare, the sublingual
glands can be virtually disregarded during impression making.
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Similar to impression making in the mylohyoid ridge area the patient is never instructed
to perform any movements of the tongue, but asked only to relax the tongue comfortably.
The mouth is nearly closed and the tongue lies on the floor of the mouth completely. This
is the "impression position" of the tongue.
Tongue movements ate made by pressing the anterior portion
of the tongue with the forefinger. Such an amount of tongue
movement is recommended for those who want to make
tongue movement.
Through border molding, the depth of the Lingual vestibule
is recorded in this situation and this will in turn be used as the length of the lingual flange
in the sublingual gland area, so that the lingual border seal can be established effectively.
The lower denture will not be lifted up, even though the
sublingual gland is raised, as the upper and lower teeth are
in contact when swallowing.
On the other hand, the sublingual gland serves as a cushion
due to its soft and resilient nature and therefore it will
neither lift the denture nor will it covering mucosa be traumatized by the denture.
If the denture border is made short to relieve the raised
sublingual gland a space will occur between the denture
border and the mucosa when the mylohyoid muscle is at
rest and thus the peripheral seal will be lost.
3. The posterior region (Retromylohyoid fossa/space)
The space distal to the mylohyoid muscle is referred to as the
retromylohyoid fossa. It lies at the distal end of the alveolingual sulcus and
extends from end of mylohyoid ridge to retromylohyoid curtain
It is bounded medially by anterior tonsillar pillar. posteriory by
retromylohyoid curtain and superior constrictor, laterally by mandible .
Anteriorly by lingual tuberosity. inferiorly by mylohyoid muscle .
[HEARTWILL]
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It is bounded by the mylohyoid muscle anteriorly the retromolar pad laterally, the
superior constrictor muscle posterolaterally, the palatoglossus muscle posteromedially
and the tongue medially. [HAYAWAKA]
At this time, the posterior limit of the lingual border is defined by the palatoglossus
muscle[A] and the Lingual slip of the superior constrictor muscle[B]. This is called the
retromylohyoid curtain
The retromylohyoid curtain is formed posteriorly by superior pharyngeal constrictor. The
action of the muscle and the tongue determine the posterior extent of lingual flange.
In the retromylohyoid fossa the lingual flange not affected by mylohyoid muscle so the
flange can turn laterally toward the ramus to fill the fossa and complete the typical S form of
correctly shaped lingual flanges. ZARB
Pouch shaped retromylohyoid space is lined completely with loosely attached mucosa.
There are no supporting structures here since the medial surface of mandibular body
slope obliquely outward from mylohyoid ridge to mandibular border forming
submandibular fossa.
Distal to mylohyoid muscle the space dips toward and outward to permit formation of
retromylohyoid eminence of mandibular denture. However denture flange should not
completely fill this area. it is necessary that the lining mucosa maintain continuous
contact with basal surface of flange which should not inhibit the tongue movement. The
external surface of retromylohyoid eminence is in continuous contact with lateral and
ventral surface of tongue, which limits flange thickness in accordance
with size and functional movements.
During border molding, the border in this area is pushed into the
retromylohyoid fossa by the strong intrinsic and extrinsic tongue
muscles, it will show the so-called S-curve as viewed from the impression surface
Lateral throat form/ Distolingual vestibule/ Retromylohyoid fossa
This anatomical area is probably least understood and frequently mismanaged. It is
bounded by :
Anteriorly - by mylohyoid muscle Laterally - pear shaped pad
Postero-laterally - superior constrictor muscle
Postero-medially - palatoglossus muscle and Medially tongue
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The so called s- curve of mandibular denture as viewed from lingual results from the
stronger intrinsic and extrinsic tongue muscles which usually place the retromylohyoid
borders more laterally towards retromylohyoid fossa, as they appose weaker superior
constrictor muscle.
The posterior limit of mandibular denture is determined by palatoglossus muscle and
somewhat by weaker superior constrictor muscle. This area is called Retromylohyoid
curtain.
Classification of lateral throat form
Neil described that the denture could have three possible lengths, depending on tonicity, activity
and anatomic attachments of the adjacent structures.
Class III
minimum length and thickness
Border 2-3 mm below mylohyoid ridge or sometimes at the ridge
Thickness no more than approx- 2mm
Knife-edge border if border terminates at mylohyoid ridge
Class I
Wide and long and wide flange.
Thickness varies
The Retromylohyoid curtain area (most distal border )should be thinner
Class II
it is half as long and narrow as class I and twice as long as class III
Most edentulous mouths have class I and class II lateral throat from class III is rare.
Besides border seal, another important reason for extending the lingual flanges into lingual
vestibules as for possible within their anatomical and functional limits. These flanges present
favourable inclined planes to the tongue resulting in vectors of force that helps maintain the
mandibular denture in place.
Lingual flange affected
Distal extent - glossopalatine arch formed by glossopalatine and lingual extension of
superior constrictor.
Medially - influenced by mylohyoid muscle attached to mylohyoid ridge.
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The buccal surface of flange rests on soft tissue and not on mucous membrane in contact
with bone.
The mucolingual fold (the line of flexure of mucous membrane as it passes from tongue
to floor of mouth) is extremely flexible and mobile because of the type of tissue and due
to mobility of entire floor of mouth.
The anterior part of lingual flange over sublingual gland is shallow because of mobility of
tissues that are controlled indirectly by mylohyoid muscle. The mylohyoid muscle in this
region extends nearly to inferior border of mandible and yet the glandular and other
tissues move above it. The combination of typical arch form of lingual side is projection
of mylohyoid ridge toward the tongue and existence of a retro mylohyoid fossa at distal
end of alveololingual sulcus causes the border of lingual flange to assume its typical s-
shape when viewed from impression surface.
The mucous membrane lining the vestibular spaces and alveololingual sulcus is thin non-
keratinised epithelium. The submucosa is formed of loosely arranged CT fibres mixed
with elastic fibres. Thus the mucous membrane is freely movable. Anteriorly the
submucosa of mucous membrane lining the alveololingual sulcus contains components of
sublingual gland and is attached to genioglossus muscle. In molar region, the submucosa
attaches to mylohyoid muscles and the mucous membrane of retromylohyoid curtain is
attached by its submucosa to superior constrictor. Posterior to superior constrictor, which
runs in horizontal direction is medial pterygoid muscle running in vertical direction.
FLAT MANDIBULAR RIDGES
On the labial surface of anterior region of the mandible several muscles are close to the
crest of ridge especially in badly resorbed ridges. This proximity accounts for the short
flanges necessary in this region. The muscles should not be impinged on since their
action is nearly at right angles to the flange. Many edentulous mandibles are extremely
flat because of loss of cortical bone.
The surface is weakened and changes in form by the more rapid resorption of cancellous
portion of mandible. The denture-bearing surface often becomes concave, allowing the
attaching structures, especially on lingual side of ridge to fall over the ridge surface. Such
conditions require displacement of these tissues by the impression, which will gradually
establish a suitable bearing surface. The crest of greatly resorbed ridges is often at the
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level of mental foramina and the nerves and blood vessels are easily compressed unless
the area is palpated and relieved on impression.
Insufficient space b/w maxillary tuberosity and mandible
The maxillary sinus enlarges throughout life, if it is not restricted naturally by presence of
teeth or dentures.
The angle of mandible becomes more obtuse by early loss of posterior teeth with
retention of anterior teeth. This destroys the necessary counterbalance against muscle pull
at angle of mandible. Such straightening of mandible reduces the maxilla mandibular
space in posterior region and creating lack of space for teeth and denture bas causing
denture failures.
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ANATOMIC LANDMARKS OF THE MAXILLA
A] The Denture Bearing Area (Supporting Structures)
Landmar k Desc r i pt i on Si gni f i c anc e
1- Resi dual r i dge - The portion of the alveolar
process& it's soft tissue
covering that remains after
extraction.
- It covers by a dense connective
tissue fibers so, it can be act as a
1
ry
stress bearing area.
vaul t of t he pal at e The vault of the palate has
different forms according to the
pattern of development of the
maxillary processes. The palatal
arch may be V-shaped, U-
shaped or flat.
The moderately high U-shaped
vault is the more common and is
more desirable for denture
stability.
2- I nc i si ve papi l l a - Pear-shaped elevation present
in the midline behind the 2
centrals.
- After extraction of teeth it
migrates to the crest of the ridge.
- It should be relieved to avoid the
burning sensation of the palate.
3- Pal at i ne r ugae ar ea - It is irregular elevations
radiates from the midline of the
anterior part of the palate.
- 2
ry
stress bearing area.
- Prevent forward movement of
the denture.
- If it is sensitive or prominent it
should be relived.
4- Medi an pal at i ne r aphe - The mucoperiostium that
covers the median palatine
suture.
- When it is prominent it should
be relieved.
- Lack of relief cause:
1- rocking of the denture due to
bone resorption.
2- Tissue ulceration.
3- Mid-line denture fracture.
5- Max i l l ar y t uber osi t y - Bony prominence located
posterior to the upper 3
rd
molar.
- Aid in support, retention and
stability of the complete denture.
- When it is large:
1- Relieved.
2- Modify the path of insertion.
(unilateral enlargement).
3- Surgical removal.
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6- Tor us pal at i nus - Bony prominence present at
both sides of the midline of the
palate.
- present in 20% of the
population.
- It should be:
1- Relieved.
2- Surgical removal.
- Fovea pal at i nae
10-
- Two openings of minor
salivary glands present in both
sides of the midline posterior to
junction of hard and soft palate.
- It determines the posterior
extension of the upper complete
denture to be 2mm posterior to it.
8- I nc i si ve f ossa It is a slight depression in the
labial surface of the maxilla
opposite the region previously
occupied by the root of upper
lateral incisor.
9-Cani ne emi nenc e It is found in the labial surface
of the maxilla. It is a rounded
bulge at the corner of the mouth
opposite the region previously
occupied by the root of the
maxillary canine.
10-But t r ess (r oot ) of t he
zygomat i c bone
It is formed by the lower portion
of the zygomatic process of the
maxilla which flares upward
and outward from the area
above the first molar
This area provides excellent
resistance to vertical forces as its
almost at right angles to the
occlusal forces.
- avoid vertical over-extension
in the first molar region, as
mucosal injury may result from a
sandwiching of the soft tissues
between the denture border and
the zygomatic process of the
maxilla.
With resorption the denture may
require relief over it
Pal at al gi ngi val vest i ge It is the remains of the palatal
gingivae. After tooth extraction
the position of the vestige
remains relatively constant, the
same as the incisive papilla
This can be a very helpful pointer
for posterior tooth positioning
during complete denture
construction. See buccal vestibule
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B] Border structures that limit the periphery of maxillary denture
Landmar k Desc r i pt i on Si gni f i c anc e
Max i l l ar y l abi al f r enum It is a fibrous band covered by
mucous membrane that extends
from the labial aspect of the residual
alveolar ridge to the lip. It may be
single or multiple and may be
narrow or broad.
It contains no muscle so it can be
surgically exiseced if it attach near
the crest of the ridge.
A labial notch must be
provided in the midline of the
denture border opposite to the
frenum. This notch prevents
ulceration of the frenum or
displacement of the denture.
A shallow bead can be formed
in the denture base around the
notch to help perfect the seal.
Labi al vest i bul e The labial vestibule extends in both
sides between the labial frenum and
the buccal frenum.
The labial flange of the
maxillary denture occupies the
space bounded by the residual
alveolar ridge, and the lip.
The major muscle in this area
is orbicularis oris.
Buc c al f r enum It is a fold or folds of mucous
membrane extend from the buccal
mucous membrane reflection
towards the slope or crest of the
residual ridge. They vary in size,
number and position.
Associated muscles are:
Buccinator
Orbicularis oris
Levator anguli oris
It requires more clearance in
the denture flange for its
action. Inadequate provision
for the buccal frenum or
excess thickness of the flange
distal to the buccal notch can
cause dislodgment of the
denture.
Buc c al vest i bul e It extends from the buccal frenum to
the hamular notch.
It houses the buccal flange of
the denture between the ridge
and the cheek.
the distal end of the buccal
flange of the demure must be
adjusted to accommodate the
coronoid process of the
mandible
Pt er ygomax i l l ar y (hamul ar )
not c h
It is a depression lies between the
pterygoid hamulous posteriorly and
the maxillary tuberosity anteriorly
It is a displaceable area about 2mm
wide
It is used as a boundary of the
posterior border of the
maxillary denture. The tissue
in this notch is easily
compressed and the post dam
line of the upper denture
should be carried into this
region to ensure an adequate
peripheral seal.
Bases short of the hamular
notch will end on the thin -
nonflexible tissue of the
tuberosity and will
consequently lack retention.
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Vi br at i ng l i ne of t he pal at e The vibrating line is an imaginary
line drawn across the posterior part
of the palate that marks the
beginning of motion in the soft
palate when the patient says "ah."
may also be identified by Valsalva
maneuver by asking the patient to
close his nose using his fingers and
asking him to blow gently through
the nose .
It extends from one
pterygomaxillary notch to the other
notch on other side
A, Diagram of the upper arch.
B, Diagram of the lateral surface of the maxilla.
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ANATOMI C LANDMARKS OF THE MANDI BLE
A] t he Dent ur e Bear i ng Ar ea (Suppor t i ng St r uc t ur es)
Landmar k Desc r i pt i on Si gni f i c anc e
1- r esi dual r i dge - The portion of the alveolar
process& it's soft tissue
covering that remains after
extraction.
- Don't used as 1
ry
stress
bearing area Covered by
movable fibrous connective
tissue.
- Don't Provide stability or
support.
2- Ex t er nal obl i que r i dge - Bony ridge running
downward and forward from
ramus to reach mental
foramen.
In the impression, the external
oblique ridge shows a groove.
The impression should record
the ridge
- It is a limiting structure to
the complete denture and not
extend to it.
if the denture border is over
extended beyond the external
oblique ridge (over 1-2mm),
the denture will be widened
over the buccinator muscle
attachment and thus located on
the buccinator muscle fiber .
If the denture border is under
extended in this area, it is dif-
ficult to mould the convex
buccal flange correctly leading
to food accumulation in the
buccal sulcus and under the
denture base [HAYAKAWA]
3- Buc c al shel f ar ea - Bony area extends between
the external oblique ridge and
the residual ridge.
The buccal shelf area can
range from 4-6 mm wide on an
average mandible to 2-3 mm
or less in narrow mandible.
- Used as 1
ry
stress bearing
area:
1- Perpendicular to the vertical
masticatory force.
2- Formed from compact
bone.
3- provide support.

4- Ment al f or amen - It's located on the Buccal
surface of the mandible
between the roots of 1
st
and 2
nd
premolar.
- Lack of relief numbness
of the lower lip.
5- Ret r omol ar pad - Pear-shaped area located
distal to the lower 3
rd
molar.
It consists of mucous glands ,
temporal tendon , fibers of the
buccinators and superior
constrictor muscle .
- Shock absorbent.
- Gives retention not support.
- Determine the level of the
Occlusal plane.
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6- Tor us mandi bul ar i s - Bony prominence located at
the inner surface of premolar
area.
- It should be:
1- Relieved.
2- Surgical removal.
7- I nt er nal obl i que r i dge
(Mylohyoid ridge)
- Irregular bony ridge of
median surface of the
mandible which the
Mylohyoid muscle attached.
- It should be relieved during
complete denture construction.
11- Geni al t uber c l e (Mental spine) - Two bony projections present
at the median surface of
mandible at midline of each
side of symphesis.
- Represent the attachment of
geniohyiod and genioglossus
muscles.
- If it's prominent, it should be
relieved.
9-Li ngual f or amen Radiolucent hole in center of
genial tubercles.
Lingual nutrient vessels pass
through this foramen.
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B- Bor der st r uc t ur es t hat l i mi t t he per i pher y of mandi bul ar dent ur e
Landmar k Desc r i pt i on Si gni f i c anc e
1-mandi bul ar l abi al
f r enum
It is a fibrous band covered by
mucous membrane that extends from
the labial aspect of the residual
alveolar ridge to the lip. It may be
single or multiple and may be narrow
or broad.
A labial notch must be provided
in the midline of the denture
border opposite to the frenum.
This notch prevents ulceration of
the frenum or displacement of the
denture
2- Labi al vest i bul e The labial vestibule extends in both
sides between the labial frenum and
the buccal frenum.
The labial flange of the
mandibular denture occupies the
space bounded by the residual
alveolar ridge, and the lip.
3- Buc c al f r enum It is a fold or folds of mucous
membrane extend from the buccal
mucous membrane reflection towards
the slope or crest of the residual ridge.
Like the labial frenum it contains no
muscle fibers. They vary in size,
number and position.
It requires clearance in the
denture flange for its action.
Inadequate provision for the
buccal frenum or excess thickness
of the flange distal to the buccal
notch can cause dislodgment of
the denture.
4-Buc c al vest i bul e It extends from the buccal frenum to
the hamular notch.
It houses the buccal flange of the
denture between the ridge and the
cheek.
5-Masset er musc l e
i nf l uenc i ng ar ea
The distobuccal comer of the
mandibular denture must
converge rapidly to avoid
displacement due to contracting
pressure of the masseter muscle
Li ngual Vest i bul e: It can be divided into three areas
Anterior vestibule/ sublingual
crescent area/ anterior
sublingual fold
the middle vestibule/
mylohyoid area
the distolingual vestibule/
lateral throat form/
retromylohyoid fossa
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12- 6- The l i ngual pouc h \
r et r omyl ohyoi d
f ossa \ c ur t ai n \ spac e
lies at the distal end of the
alveolingual sulcus.
The lingual pouch boundaries:
Medially; the tongue.
Laterally; the mandible;
Posteriorly; the palatoglossus
arch, which is formed in part by the
palatoglossus muscle, and in part by
the lingual extension of the superior
constrictor muscle.
Anteriorly; the posterior 3 mm of
the mylohyoid muscle.
- The so called s curve of the
lingual flange of the mandibular
denture results from stronger
intrinsic and extrinsic tongue
muscles, which usually place the
retromylohyoid borders more
laterally and towards the
retromylohyoid fossa, as the oppose
weaker superior constrictor muscle.
- Over extension of the
distolingual border of the lower
denture will cause sore throat due
to the pressure on the
palatoglossus arch muscles.
- The posterior limit of the
mandibular denture is
determined mainly by the
palatoglossus muscle and
somewhat by weaker superior
constrictor muscle this is area is
called posterior/ retromylohyoid
curtain.
the denture could have three
possible lengths, depending on
the tonicity, activity, and
anatomic attachments of the
adjacent structures-
Class I throat form: The
horizontal border is usually 2-3
mm thick, but a thicker border of
4-5 mm should be used for better
seal if the ridge is flat. The
retromylohyoid curtain area
should be thinner, about 2-3 mm,
and very rounded and smooth.
Class II throat form is about half
as long and narrow as class I and
about twice as long as class III.
Class III lateral throat form has
minimum length and thickness.
The border usually ends 2-3 mm
below the mylohyoid ridge or
sometimes just at the ridge.
7- Subl i ngual sal i var y
gl and ar ea \ Subl i ngual
f ol ds
Formed by the superior surface
of the sublingual glands and the
ducts of the submandibular glands.
The lingual flanges of the lower
denture should not extend in
this area
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8- Li ngual f r enum It is the anterior attachment of
the undersurface of the tongue to the
floor of the mouth in the midline. It
is very resistant, active and often
wide.
The denture borders should be
well rounded in this area. A
notch should be provided in the
lingual flange to avoid
displacement of the lower
denture.
9-pt er ygomandi bul ar
Raphe
It is a raphe formed by the buccinator
muscle fibers and the superior
constrictor muscle of the pharynx.
The distal extension of the
mandibular denture is limited by
the Pterygo-mandibular Raphe
10- Pl at o gl ossal Ar c h The palato glossal arch is formed
mainly by the palato glossus muscle.
The distal end of the lingual
flange is related to the palato
glossal arch.
Over-extension of the lingual
flange in this area will cause sore
throat.
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Diagram showing the mandible: A, Buccal view. B, Lingual view.
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Musculature
Muscles of facial expression
Muscles of mastication
Suprahyoid and Infrahyoid muscles
Muscles of the neck and throat
Extrinsic and intrinsic tongue muscles
Palatal muscles
Tendons: Attach muscles to bones
Aponeurosis: A very broad tendon
Muscles Origin or head: Muscle end attached to more stationary of two bones
Insertion: Muscle end attached to bone with greatest movement
Belly: Largest portion of the muscle between origin and insertion
Isotonic contraction: It is shortening of the muscle under constant load. It is used to produce
movement. Elevation of the mandible is an example of isotonic contraction of Masseter muscle
Isometric contraction: It is contraction of muscle without shortening It is used to produce
tension within the muscle to resist an external
force. Elevator ms. Contract isometrically to keep
the mandible at rest (tension without shortening)
Classes of Levers
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A- MUSCLES OF FACIAL EXPRESSION
Zygomaticus major, zygomaticus minor, levator labial superioris alaque nasi, levater labi
superioris, levater anguli oris, mentalis, depressor labi inferioris, depressor anguli oris, r[soris,
platysma, orbicularis oris and buccinator muscles are responsible for expressions seen in lower
half of face.
The actions of these muscles
are responsible for various facial
expressions including smiling,
laughing and frowning. The actions
of these muscles reflect the
emotional status and mood of an
individual.
The perioral muscles do not insert
into bone and need support from
natural or artificial substitutes for
proper function.
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The insertions of these various muscles around the oral cavity both superficially and
deep are important. These muscles insert partly into CT of skin and partly into mucous
membrane of lips.
In an area situated laterally and slightly above the corner of mouth is a concentration of
many fibres of this muscle group called muscular node or modiolus and represents an area
where the extrinsic perioral muscles decussate with intrinsic fibres of orbicularis oris muscle.
The origins of several muscles of facial expression are near enough to the denture
bearing areas that their actions must be considered as definitely influencing the denture borders.
The higher the residual ridge, the less influence these muscle attachments will exert.
1- Mentalis
This muscle is found around the chin
It raises the lower lip, causing the chin to wrinkle
It will give a doubt facial expression
Importance of MENTALIS muscle in relation to complete denture construction
Contraction of the mentalis m. raise a soft tissues of the chin, thus reducing the width and
depth of the lingual sulcus.
If there has been marked resorption of the underlying bone , this muscle can exert
considerable pressure on the labial flange of the denture, resulting in posterior and
upward displacement
Because it raises the lower lip, causing the chin to wrinkle its Contraction indicates high
V.D. of the denture
The mentalis muscle renders the lower vestibule shallower when it contracts; dislodging the
denture, with residual ridge is same height as the fornix of vestibule, dictating the extension of
lower denture flange
2- Incisive labi superioris and inferioris
They arise from maxillary and mandibular alveolar process respectively. They coarse laterally to
blend with orbicularis oris muscle. Their action is similar to mentalis muscle on vestibular
fornix. They are small muscles, their actions alone may not influence the denture.
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3- Buccinator
Buccinator: from L. n. bucina = trumpet,[ bucinator = trumpeter]
It is an accessory m. of mastication , occupy the gap between
mandible and maxilla forming important part of the cheek.
Origin: alveolar bone of the upper and lower three molars and
pterygomandibular ligament . The ligament serves as a function
between the buccinator and superior constrictor of pharynx.
Course and insertion ;
Upper fibers inserted into upper lip,
Lower fibers inserted into lower lip,
Middle fibers decussate at the angle of the mouth, the upper fibers pass to lower lip while
the lower fibers pass to the upper lip .
Nerve supply Motor enervation is the buccal branch of facial nerve
Sensory impulses: carried by mand. branch of trigeminal nerve
Blood supply ; Facial artery .
Action : Prevents the accumulation of food in the vestibule of mouth
Importance of BUCCINATOR Muscle In Relation To Complete Denture
Construction
The buccinator muscle is divided into:
Superior fibres : act to seat the maxillary denture
Middle fibres :control the bolus of food
Inferior fibres:contribute to the stability of the mandibular denture
While the middle fibres contract, controlling the bolus, the inferior fibres relax to form a
pouch capable of storing food until needed to form another bolus.
Extension of a concave denture base into this pouch allows the cheek to lie over the
flange.
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The nature of buccinator was not able to changes to contour of the denture base.
Because learning and adaptation appear to be limited, the denture contours should be
designed to harmonise with exiting buccinator muscle function.
The neutral zone concept is based on the belief that the muscles should functionally
mold not only the border and the artificial teeth but also the entire polished surface.
facial and lingual forces generated by the musculature of the lips, cheeks and tongue are
balanced
Contraction of the buccinator m. raise a soft tissue band at about the level of the
occlusal plane. The polished surface of the buccal flange should be shaped so that the
pressure falling on it from B. activity will have a component of force which is directed
towards the ridge and which will therefore help to retain, rather than dislodge, the
denture.
In lower jaw due to extreme resorption of the RR, the buccinator and mylohyoid cover
the bony support from area of first molar to retromolar pad. Fortunately the action of
buccinator does not dislodge the denture as its fibres run parallel to plane of occlusion,
but run at right angles to masseter. When masseter is activated it pushes buccinator
medially against denture in area of retro molar pad.
The position and attachment of buccinator muscle in upper jaw determines the vertical
height of distobuccal flange of maxillary denture. The fibres attach to the thin
periosteum and possibly into bone proper.
4- Orbicularis oris
It is the sphincter muscle of the mouth. It has no skeletal attachments except through the
attachments of incisivus labii superioris and inferioris muscles and nasolabialis muscles.
A Intrinsic part deepest strata very thin sheet: Originates from superior incisivus in maxilla,
inferior incisivus in mandible Insert into angle of mouth
B Extrinsic part, two strata formed by converging muscles: Originates from thickest middle
strata derived from buccinators thick superficial stratum from elevators and depressors of lips
and angles of mouth. Insert into lips and angles of mouth
This muscle surrounds the mouth constitutes upper and lower lips and is continuous with
buccinator on either sides.
It is used to purse the lips, and closes the mouth
It is used to pout and kiss
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Importance of ORBICULARIS ORIS muscle in relation to complete denture
construction
Proper contouring of the labial and buccal flange is necessary to support the lips and cheeks.
Proper shaping of the denture flanges to be concave rather than convex, will allow the lips,
cheeks and tongue to seat the denture.
5- Risorius
This muscle extends diagonally from the corners of the mouth
It draws the mouth corners outwards
Used when smiling
6- Zygomaticus :
This muscle extends diagonally from the corners of the mouth
Lifts the mouth corners, upwards and outwards
Is used when smiling and laughing
Importance of REZYOMATIC SPACE In Relation To Complete Denture
Construction
The buccal space or REZYOMATIC SPACE
A region that often causes problems in
maintaining border seal
When the mandible is moved laterally, the cronoid
process on the non-working side comes into close
relation to the buccal aspect of the maxillary
tuberosity.
The buccal sulcus in this region is thus reduced in width, limiting the space available for
a buccal flange.
But must be filled to avoid ingress of air beneath the denture base
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7- Depressor labii
This muscle extends over the chin
It draws down the mouths corners
Is used when sulking
8- Platysma
This muscle is found at the sides of the neck
It draws down the mouths corners downwards and backwards
It is used when we are scared frightened (fear, horror)
9- Orbicularis oculi
This muscle surrounds the eyes
It closes the eyelid
Used when winking
10- Corrugator
This muscle is found between the eyebrows
It draws the eyebrows together
Making your frown
11- Occipital-frontalis
This muscle is found at the forehead, and runs to the
occipital region
This muscle raises the eyebrows
Giving a surprised facial expression
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12- triangularis muscle
The triangularis muscle, which attached in the region of the mandibular buccal frenum,
and the mentalis m. which may be active in the region of the labial flange.
Both should accompany any border molding procedure
IMORTANCE OF FACIAL MUSCLES IN RELATION TO COMPLETE DENTURE
CONSTRUCTION
Modiolus:It is a node or depression, below and distal to the corner of the
mouth, contributed to The union of the lip and cheek muscles. Because.
These ms. have more than one bony attachment. they depend on
fixation of the modiolus to allow isometric contractionthat allowing the
buccinator to control the food bolus
The denture base must be contoured to permit the modiolus to fnction freely.
The premolar region of the mand. Dent, should exhibit both a shortened and narrow flange to
permit the action that draws the vestibule superiorly and the mod. Medially against the denture .
With loss of teeth the Modiolus will become flattened . the replacement of teeth should restore
its normal shape
B: buccinator m.
DAO: depressor anguli oris m. (triangularis)
II: Incisivus inferior m.
IS: incisivus superior m.
LAO: levator anguli oris m. (caninus)
OO: orbicularis oris m.
ZM: zygomaticus major m.
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Muscles that influence the border of complete denture
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B- Muscle of mastication
They are masseter, medial pterygoid and lateral pterygoid and temporalis. As a group, the
muscles of mastication are very powerful only one of these muscles directly influences the
contour of the denture base. The contraction of masseter forces the buccinator muscle medially
towards the retro molar pad.
the muscles of mastication is a collective term reserved for four pairs of muscles involved : -
Prime movers: TEMPORALIS AND MASSETER
- Grinding movements: PTERYGOIDS AND BUCCINATORS
Muscles of mastication develop from the mesoderm of the first pharyngeal arch.
They are innervated by the Mandibular division of the trigeminal nerve (all from the anterior
division except the medial pterygoid from the main trunk) .
They are functionally classified as:
Jaw elevators:
Masseter
Temporalis
Medial pterygoid
Upper head of lateral pterygoid
Jaw depressors
Lower head of lateral pterygoid
Anterior digastric
Geniohyoid
Mylohyoid
- Other muscles that play an important role in mastication include
Orbicularis oris: Anterior oral seal
Buccinator and Tounge: Help to keep the bolus of food on the occlusal
Surface of teeth
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Masseter muscle : Masseter muscle influencing area:
1. The distobuccal corner of the mandibular denture is in relation to
the masseter muscle .
2. In this area the buccal flange must converge medially to avoid
displacement due to contraction of the masseter muscle because the
muscle fibers in that area are vertical and oblique .
MEDIAL PTERYGOID
The medial pteregygoid contraction influences the contour of the distolingual flange by
causing a bulge in the posterior wall of the retromylohyoid space.
Adequate seal can be obtained by gently compressing the tissues on the lateral wall of the
retromylohyoid fossa lingual to the retromolar pad and tucking the distolingual flange
laterally against the mucosa overlying the Sup. Cons. M. superiorly and the loose C.T.
Of the mandible inferiorly.
Maximum posterior extension into the fossa is not necessary. ( The inf. Ling. ext. is
dependent on the mylohyoid muscle.)
Lateral Pterygoid
The Lat. Pterygo. advance the condyles, thereby opening the mouth (depressing the mandible),
with the assistance of the Digastric.
The oblique orientation of the Masseter and Med. Pterygo. create a sling. The non-working side Med.
Pterygo. contracts simultaneously with the opposite side working Masseter
In normal chewing function, the mandible opens, and then, while initiating closing, there is a shift slightly
to the side of the bolus, due to the orientation of the masseter and medial pterygoid.
Due to the orientation of the Lateral Pterygoids and the oblique alignment of the condyles in relation to
each other, contraction of the Lat. Pt. initiates an instantaneous translation of the condyles. The slope of
the eminence provides for immediate mandibular depression and disocclusion of the teeth
Although Lat. Pt. are intended to work together to depress the mandible, a voluntary unilateral activity
results in an excursive movement to the contralateral side
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C- Suprahyoid and Infrahyoid muscles :
Hyoid Bone: Only bone not directly articulated with other bones
Attaches via ligaments to temporal bone, larynx
Functions Moveable base for tongue , Attachment for
sternohyoid, thyrohyoid and Superior attachment for larynx
Suprahyoid muscles
These muscles attach the hyoid bone to the mandible
and are partly attached to the base of the skull.The
functions of suprahyoid muscles are to elevate the hyoid
bone and larynx and depression of mandible they are: Digastric,
mylohyoid, stylohyoid and geniohyoid muscles. The mylohyoid
and geniohyoid muscles may influence the borders of mandibular
denture.
Infrahyoid Muscles
These muscles attach the hyoid bone to the sternum. They pull the
hyoid bone downward
Mylohyoid muscle
It is a thin sheet that arises from the whole length of the mylohyoid
line. The posterior fibres are inserted into body of hyoid bone. The
remaining fibres are inserted into a median fibrous raphe extending
from symphysis of mandible to hyoid bone. It constitutes the muscular floor of mouth. It
elevates hyoid bone, the tongue and the membranous floor of mouth during swallowing.
If denture flange is extended below and under mylohyoid line, it will impinge on this
muscle and can affect its action adversely or conversely its action can unseat the denture.
Because the fibres are directed downward, the denture flange can extend below but not
under the mylohyoid line. This places the inferior border of denture in a compatible
position with the tongue. In instances of extensive bone loss, the mylohyoid can be
surgically detached from its periosteal attachment and reattached more inferiorly on body
of mandible without apparent impairment in function.
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Mylohyoid muscle influencing area [internal oblique ridge]
The mylohyoid muscles anatomically and functionally form the floor of the mouth.
They elevate the tongue and depress the mandible.
Their O is the mandible and I is the upper border of the hyoid bone.
Problems
Movable floor of the mouth difficulty in establishing a lingual border seal
problem with retention
Lack of ideal ridge height and conformation minimize denture stability
The mylohyoid muscle act anteriorly as well as posteriorly to raise the floor of the mouth.
The lingual flange should extend to the mucolingual sulcus as determined by the extent of
the functional movement of the muscle .
The contour and inferior extension of the lingual flange are dependent on the action and
anatomy of the Mylohyoid muscle
The lingual flange slopes medially away from the mandible to allow for the action of the
Mylohyoid muscle
This inclination also enhances the ability of the tongue to control the mandibular denture,
providing a seating force to the denture.
The mandibular attachment of the Mylohyoid muscle extends anteroinferiorly along the
mylohyoid ridge in the molar region to the genial tubercle in the midline.
Posterior fibres extends vertically to attach to the hyoid bone while the anterior fibres
extend horizontally to meet the fibres of the contralateral side to form a midline tendinous
raphe.
This explains why the lingual flange can be made longer posteriorly despite a more
superior mylohyoid muscle attachment.
The inferior extension of the posterior lingual flange is determined by the displaceability
of the soft tissue and underlying Mylohyoid muscle when the floor of the mouth is at its
most superior position.
At rest The level of the floor of the mouth may be inferior to the lingual flange.
The tongue, by contacting the lingual denture surface is able to promote seal in this
region and enhance retention
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Accurate border molding and imp. Procedures ensure adequate border seal.
The mandibular attachment of the Mylohyoid muscle extends anteroinferiorly along the
mylohyoid ridge in the molar region to the genial tubercle in the midline.
Posterior fibres extends vertically to attach to the hyoid bone while the anterior fibres
extend horizontally to meet the fibres of the contralateral side to form a midline tendinous
raphe.
This explains why the lingual flange can be made longer posteriorly despite a more
superior mylohyoid muscle attachment.
Geniohyoid muscle
It arises from inferior mental spine (genial tubercles) which is located on inner aspect of
symphysis menti just above anterior attachment of mylohyoid muscle. This muscle presents no
problem in CD construction unless there is extensive loss of RR.
In this situation the attachments of paired genioglossus and geniohyoid muscles to
mental spines maybe problematic. Like mylohyoid, the geniohyoid can be surgically detached
from periosteum and reattached more inferiorly on mandible without apparent impairment of
function.
The geniohyoid muscles are found next to each other, on each side of the midline,
directly on top of the mylohyoid muscle. They have the same origin and function as the
mylohyoid muscle.
Digastric muscles
Digastric muscles is not a muscle of mastication but it play an important role in mandibular
function
The combined efforts of the Digastrics and Lateral Pterygoids provide for natural jaw opening
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D- Muscles of the neck and throat
Pharyngeal muscles
Of the several pharyngeal muscles, the
superior constrictor is one of most interest
in CD construction. It has four sites of
origin
The posterior border of
medial pterygoid plate and
pterygoid hamulus.
The pterygo mandibular
raphe.
The posterior end of mylohyoid line.
The side of the tongue.
I: posterior medial raphe of pharynx
Importance of THE SUPERIOR CONSTRICTOR MUSCLES in relation
to complete denture construction
Collaborated in The border seal of the distal extension of the lingual flange
The action of part of this muscle exerts pressure against the distal extremity of the mandibular
denture. Over extension in this area is very painful to the patient, as the denture will perforate the
tissue and create a painful lesion.
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The anatomy of the Retromylohyoid space
More posteriorly the lingual flanges are related to the lingual pouch with its boundaries which
are :
Posteriorly : The palatoglosssus muscle and Superior constrictor muscle
Anteriorly : The Mylohyoid muscle.
Medially : The tongue .
Laterally : The medial aspect of the mandible.
The posterolateral portion of the retromylohyoid curtain overlies the superior constrictor
muscle and the posteromedial aspect covers the palatoglossus m. and lateral s. of the
tongue.
the inferior wall of the retromylhyoid fossa overlies the submandibular gland, which fills
the gap between the superior constrictor and the most distal attachmrent of the mylohyoid
muscle
Border molding must allow for the muscular function of this region.
Denture overextension in this area will cause sore throat.
The medial pteregygoid contraction influences the contour of the distolingual flange by
causing a bulge in the posterior wall of the retromylohyoid space.
Adequate seal can be obtained by gently compressing the tissues on the lateral wall of the
retromylohyoid fossa lingual to the retromolar pad and tucking the distolingual flange
laterally against the mucosa overlying the Sup. Cons. M. superiorly and the loose C.T.
Of the mandible inferiorly.
Maximum posterior extension into the fossa is not necessary.
( The inf. Ling. ext. is dependent on the mylohyoid muscle.)
Sublingual salivary gland area
The lingual flanges of the lower denture should not extend in this area because with excessive
resorption of the mandible the gland may bulge superiorly above the body of the mandible.
Sublingual Folds
When the tongue is elevated, the sublingual folds raised and may greatly reduce the depth and
width of the lingual sulcus. This phenomena is most marked when advanced resorption of the
ridge has occurred.
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Snoring is a rough, raspy noise that can occur when a sleeping person inhales through the mouth
and nose. The noise usually is made by vibration of the soft palate but also may occur as a result
of vocal cord vibration.
Laryngospasm is a tetanic contraction of the muscles around the opening of the larynx. In
severe cases, the opening is closed completely, air no longer can pass through the larynx into the
lungs, and the victim may die of asphyxiation. Laryngospasm can develop as a result of, for
example, severe allergic reactions, tetanus infections, or hypocalcemia.
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E- THE TONGUE
The Oral Cavity
The boundaries of the mouth are:
1. vestibule
2. hard palate
3. soft palate
4. uvula
5. palatoglossal arch
6. palatine tonsil
7. palatopharyngeal arch
8. posterior wall of oropharynx
9. pterygoid hamulus
Tongue elevated:
1. Frenulum of tongue
2. Ridge formed by deep lingual vein
3. Sublingual fold
4. Sublingual caruncle
5. Opening of submandibular duct
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Primary functions of tonuge include:
1.Mechanical processing: Compression, abrasion, and distortion
2. Assistance in chewing and swallowing
3. Speech production
4. Sensory analysis by touch, temperature, and taste receptors (Houses taste buds =
gustation)
5- Secretion: - mucins - enzyme lingual lipase
Innervation
Motor = Hypoglossal (CN XII)
Sensory = Mandibular (CN V3), Facial (CN
VII), Glossopharyngeal (CN IX)
Structure of the Tongue
Anterior body (oral portion)
Posterior root (pharyngeal portion)
Five taste sensations
Sweet front middle
Sour middle sides
Salty front side/tip
Bitter back
umamiposterior pharynx
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Muscles of the tongue
A- Extrinsic muscles :
Genioglossus
Hyoglossus
Palatoglossus
Styloglossus
Mylohyoid

The extrinsic muscles attach the tongue to the hyoid bone, mandible, soft palate, and
the styloid process of the temporal bone.
These muscles are in contrast to the intrinsic muscles of the tongue which lie entirely
within the tongue.
The extrinsic muscles reposition the tongue, while the intrinsic muscles alter the shape
of the tongue for talking and swallowing.
B- Intrinsic muscles
Inferior and Superior Longitudinal Muscle:
Go the length of the tongue
moves tip up and down
Transverse Muscle:
Go across the tongue
narrows and lengthens the tongue
Vertical Muscle:
Go up and down in the tongue
flattens and depresses the tongue
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Importance of PALATOGLOSSUS MUSCLE in complete denture construction
The palatoglossus m. originates from the palatine aponeurosis; it depresses the soft palate,
moves the palatoglossal fold towards the midline, and elevates the back of the tongue.
The palatoglossus is the only muscle of the tongue not innervated by the hypoglossal
nerve, instead it is innervated the pharyngeal branch of vagus nerve.
The ever active tongue can be easily displace even best fitting denture and the dental
acrobat can manipulate ill-fitting dentures with greatest of ease.
Wright, Swartz and Godwin have shown that tongue position is very important. To
evaluate the tongue position, instruct patients to open just wide enough for a small portion of
food and observe the different positions of tongue. In normal position, the tongue appears
relaxed and completely fills the lower arch with its apex lightly contacting the lingual of lower
teeth. This position is important for lingual border seal.
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MISCELLANEOUS ANATOMIC STRUCTURES
The styloglossus muscle is inferior to and medial to lingual flange. The geniohyoid is under
genioglossus muscle and inferior to lingual flange. The medial pterygoid is a powerful and active
elevator but is normally too distal to affect the lingual flange, only if it is over- extended.
Lingual nerve is closely related to lingual flange but problems due to denture irritation have
not been identified.
Submandibular (Whartons) duct can be blocked by over extended lingual flange but this
rarely occurs. When it does patient returns with large swelling under mandible, normal
temperature and little if any pain but usually with great anxiety patients is instructed to leave the
denture out for few days and retained saliva is quickly drained. Over extended border is carefully
adjusted.
Other structures such as facial artery, hypoglossal nerve, platysma and digastric muscle
all have little or no effect on denture borders but have been included for better orientation and
understanding.
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F- Palatal muscles
Palate
Hard palate (anterior): Tongue pushes food against it during chewing, made of
bone
Soft palate (posterior): Closes nasopharynx during swallowing; made of muscle
Palatal muscles
Levator veli palatini
Tensor veli palatini muscle
Musculus uvulae
Palatoglossus muscle
Palatopharyngeus muscle
Musculus uvulae
The Musculus uvul (Azygos uvul)
arises from the posterior nasal spine of
the palatine bones and from the palatine
aponeurosis; it descends to be inserted
into the uvula.
Origin:hard palate
Insertion: palatine aponeurosis
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Oral Mucosa
Lining of oral cavity
Stratified squamous Keratinized Epithelium Covers only regions exposed to severe
abrasion
Nonkeratinized, and delicate Epithelial Lining of cheeks, lips, and inferior surface of
tongue is relatively thin,
Salivary glands
Functions include:
Lubrication, moistening, and dissolving food to taste
Initiation of digestion of complex carbohydrates (starch)
Bind food together
Neutralize mouth acid
Kill harmful microorganisms
Promote beneficial bacteria
Types
- Major
Parotid,
sublingual,
submandibular
- Minor In mucosa of tongue, lips, palate, cheeks
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Muscles that influence the border of complete denture
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Physiology
The requirements of a successful complete denture are demanding and include
Compatibility with the surrounding oral environment.
Restoration of masticatory efficiency within limits.
Ability to function in harmony during mastication, speech, respiration, and speech and
deglutition.
Esthetic acceptability.
Preservation of that which remains.
To fulfill these requirements, the prosthodontist needs to have knowledge of the
functions and vital processes of the body although a denture is not living tissue, it must
function with and become a part of the body.
A- Physiology of bone
Although considerable study has been devoted to the physiology of bone, the functions
and vital processes of osseous RR supporting a denture need further study. Much of the
knowledge pertaining to all bone is applicable because the RR is bony tissues covered by oral
mucous membrane.
It is easy to understand why a study of bone supporting dentures is extremely difficult.
Vivisections reveal only the reaction of one section of bone to one denture.
Bone responses vary among individuals sometimes in paradoxic ways.
Roentogenographic studies are inconclusive as related to stress bearing potential of bone.
Bone is one of the most unstable tissues of the body.
Alveolar process
The alveolar process appears to be the bony support most affected by dentures. The
alveolar processes support natural teeth and provide most vertical support for dentures. When
natural teeth are present, the roots occupy most of space between the compact bony plates.
This is particularly true in anterior regions of the arches.
Healing of bony sockets after tooth extraction is similar to that of bone fractures:
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Primary clot formation in the socket.
Organisation of clot by proliferating young CTs.
Gradual replacement of young CTs by coarse fibrillar bone.
Reconstruction by resorptive activity on one side and replacement of immature bone by
mature bone on the other and ,
Epithelialisation and healing of the surface occurring simultaneous with other reparative
processes.
The reconstructive process leads generally to loss of alveolar bone in the area. This loss in
quantity during normal healing after extraction is one of the reasons awaiting period of 6 weeks
to 2 months is often advocated before placement of dentures. To allow the immature bonevto
replace the young CT is another reason.
Bone tissue
It is continuous flux throughout life. The remodeling of bone is the result of destruction
of old bone by action of osteoclasts and other processes and the formation of new bone by
osteoblasts. This regenerative reconstruction, although continuous throughout life is not constant.
During the period of general body growth, the rate of bone formation exceeds the rate of
bone resorption. In the adult, the two processes are more nearly balanced. In the aged or in any
person with local or systemic disease, the rate of bone resorption exceeds that of formation. This
is only one of the many reasons some dentures appear to be physiologically tolerated over a
period of time and then seem to fail.
Change in function
According to Wolffs Law - that change in form follows change in function owing to alteration
in internal architecture and external conformation of the bone, in accordance with mathematical
laws.
Newheld found In some specimens studied, the trabecular pattern was arranged in such a way
that it indicated that there was some adaptation of the structure of bones to presence of an
appliance in region near superior surface of alveolar process.
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Blood supply
The blood supply to bone of maxillae and mandible is derived principally from medullary and
periosteal vessels that form plexuses, which anatomize with one another.
When teeth are present, intra-osseous vessels supply pulpal, periodontal and alveolar
branches. These various vessels anastomose with periosteal, gingival and other vessels supplying
the surrounding soft tissues.
However, in edentulous patient, the pulpal, periodontal and depending on extent of
alveolar bone resorption the alveolar branches are lost.
Broadly suggested that with age the inferior alveolar artery often becomes blocked which
changes the blood supply from centrifugal to centripetal in nature. In other words the blood to
the mandible comes from branches facial, buccal and lingual arteries instead of inferior alveolar
artery. The relationship between these and other changes in the blood supply to RR may
influence the biologic responses of denture supporting tissues to preprosthetic surgery and to the
success of subsequently fabricated dentures.
Reaction to pressure
The continuous presence of dentures can exert pressure of sufficient intensity to produce
resorption. This is particularly true in mandibular arch, because gravity exerts a steady pull on
the denture. When pressure diminishes or destroys the blood supply of bone tissue or interferes
with its venous drainage resorption results. A denture is potentially capable of exerting steady
pressure and intermittent heavy pressure that can interrupt the blood supply.
The dentures must therefore be removed at least and 8 of every 24 hours. With a limited
knowledge of physiology of bone it is possible to institute procedures in impression making,
selection of teeth, management of teeth, extension of denture base and instructions to patients
that will help ensure a denture that should be more acceptable to bony support. The following
represent some ways the dentist and patient can help make a denture better tolerated by bony
support.
1. Record tissues in impression at their rest position.
2. Decrease the number of teeth.
3. Decrease size of food table.
4. Develop and occlusion that eliminates, as much as possible horizontal and torque
forces.
5. Extend denture base for maximum coverage within tissue limits.
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6. Eat by placing small masses of food over the posterior teeth where supporting bone is
best suited to resist forces.
7. Remove dentures for 8 hour of every 24 hour.
B- Physiology of muscles
A muscle is made up of large number of fibres bound together by CT into bundles or fascicles.
These bundles are surrounded by CT sheaths and grouped together into still larger bundles. The
whole muscle is enveloped by a CT sheath, the epimysium. Blood vessels enter a muscle and
branch into smaller vessels that course through these CT to reach the individual muscle fibres,
which are also muscle cells.
The effectors of body are muscles and glands. The muscles that are intimately involved in CD
function are skeletal muscles controlled by sensory nerves system. When a sensory nerve ending
is stimulated, an afferent nerve carries the impulse to the CNS, where after one or more
synapses, an efferent nerve will be activated, which will ultimately result in muscle contraction.
This is called reflex action as opposed to voluntary action.
Muscle is of primary interest because it performs mechanical work. Resting muscle is relatively
firm but extensible. Like most tissues, it does not obey Hooks Law but becomes less extensible
the greater the elongation. On stimulation there is sudden change in its properties, it becomes
hard, develops tension, resists stretching and can shorten and lift a weight. The contraction
occurs in direction of long axis of muscles.
Many of skeletal muscles involved in CD construction have a bony origin but insert in to an
aponeurosis, a raphe or another muscle. The orbicularis oris has no bony origin or insertions, and
its primary function is to close the oral orifice (sphincter). When origin and insertions are on
bone there is limitation to the positions and actions of the muscles. When attachment is in an
aponeurosis, a raphe or another muscle a more flexible situation exists.
The muscles of facial expression, the muscles of tongue, the suprahyoid muscles, the muscles of
soft palate and the pharyngeal muscles do not have both origins and insertions in bone. These
are the muscles primarily involved with determining the extent of denture borders, the contour of
denture bases and the positions of the teeth. Impression techniques are influenced by these
attachments. The muscles should not be stretched or left unsupported during an impression. The
teeth not the denture borders support the muscles of facial expression. The available vestibular
spaces should be used to their fullest extent but not overfilled.
A muscle contraction is said to be isometric when the length of muscle does not shorten during
contraction. A muscle contraction is said to be isotonic when muscle shortens, but the tension
remains the same. In isometric contraction the muscle does not work, but tension of muscle
becomes a greater. Muscles contract both isometrically and isotonically in the body with most
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contractions being a combination of the two. The contraction of the retractor and elevator
muscles of mandible during jaw closure is both isotonic and isometric. That is isotonic to move
the mandible and isometric to brace the jaw when teeth contact.
When load is applied to muscle the muscle elongates and within limits, the greater the load, the
greater the stretch. When load is released, the muscle shortens almost to its original length. It
load is excessive; the muscle relaxes reflexly to keep from injuring the muscle.
C- ORAL MUCOUS MEMBRANE
The oral mucous membrane, which covers the bone of the maxilla and mandible, provides
support for the complete dentures. The denture comes in direct contact with the mucous
membrane and thus, their features must be analysed how best the support can be utilized.
The oral mucosa can be divided into three categories depending on its location in the mouth and
its function. They are
1. Masticatory mucosa - which covers the crest of residual ridge, including residual attached
gingiva, firmly adherent to supporting bone. Secondly the hard palate
The masticatory mucosa is characterized by well-keratinized layer on its outer most
surfaces that is subject to changes in thickness depending on whether dentures are worn and on
the clinical acceptability of dentures.
2. Lining mucosa - is generally found to cover the mucous membrane in the oral cavity that is the
firmly attached to periosteum of the bone. It forms the covering of lips and cheeks, the vestibular
spaces, the alveololingual sulcus, the soft plate, the ventral surface of tongue, and the unattached
gingiva found on slopes of residual ridges. It is devoid of keratinized layer and is freely movable
with the tissues to which it is attached because of its elastic nature of lamina propria.
3. The specialized mucosa - covers the dorsal surface of tongue. The mucosal covering is
keratinised and includes specialized papillae on upper surface of tongue. The mucous membrane
is composed of two layers, the mucosa and the submucosa. The mucosa in the oral cavity is
formed by stratified squamous epithelium (often keratinised on its outer surface) and a subjacent
narrow layer of connective tissue known as lamina propria.
The nature of mucous membrane in different parts of mouth varies between patients and within
the some patient. The keratinised layer of epithelium (stratum corneum) maybe totally absent in
some instances and extremely thick in others.
The submucosa is formed by CT that varies in character from dense to loose areolar tissue and
also varies considerably in its width and thickness, depending on its location in the mouth. The
submucosa may contain glandular, fat or muscle cells and transmit the blood and nerve supply to
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mucosa. When mucous membrane is attached to bone, the attachment occurs between the
submucosa and periosteal covering of bone.
The thickness and consistency of submucosa are largely responsible for support that the
soft tissues afford the dentures since in most instances the submucosa makes up the bulk of
mucous membrane.
In a healthy mouth, the submucosa is firmly attached to periosteum of the underlying
bone of RR and will usually successfully withstand the pressures of dentures. When submucosal
layer is thin over the bone, the soft tissue will be non resilient and small movements of denture
will tend to break retentive seal. When submucosal layer is loosely attached to periosteum of RR
or is inflamed or edematous the tissues are easily displaceable and stability and support of
dentures are adversely affected.
D- The physiology of the TMJ
Basic mandibular movements:
The basic mandibular movement classified into four movements of prime importance to
complete denture construction, which are hing-like movement, protrusive and retrusive
movements, as well as, lateral movement.
The backward glide movement is a short backward path movement starting from centric
occlusion (maximum inter-cuspasion) to centric relation (most
retruded contact position).
The most retruded contact position is a position, in which the
mandible can hold back and up by either the patient using the
active conscious construction of the retractors of mandible
(posterior fibers of the temporal muscle), and / or passively by the operator pressing on the
symphasis menti when the patient is completely relaxed. This position is called terminal
hinge position, which denotes the posterior functional range of the mandible. The position of
centric occlusion in complete closure is determined by the
maximum inter-cuspasion of teeth and called centric occlusion.
All mandibular motions are either rotation or translation or more
commonly a combination of these. Rotation occurs as movement
within the inferior cavity of the joint it is thus movement between
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the superior surface of the condyle and the inferior surface of the articular disc. The
mandibular translation occurs within the superior cavity of the joint, between the superior
surface of the articular disc and the inferior surface of the articular fossa. Both rotation and
translation occur simultaneously, that is, while the mandible is rotating around one or more
of the axes, each of the axes is translating.
In centric relation the mandible can be rotated around the horizontal axis to a distance 20-25
mm as measured between the incisal edges of the maxillary and mandibular incisors. At the
point of opening, the TM ligaments tighten after which continued opening results in an
anterior and inferior translation of the condyles resulting in the second stage of the posterior
opening border movement.
The opening movements are divided into posterior opening and anterior opening where the
range between them is limited primarily by the ligaments and morphology of the TMJ.
The mandibular axes :
Rotational movements of the mandible can occur in the three reference planes: horizontal,
frontal and sagittal. In each plane, it occurs around an axis. These axes were defined as
Transverse hang axis: an imaginary line around which the mandible rotate in the sagittal
plane.
Vertical axis: an imaginary line around which the mandible rotate in the horizontal plane.
Sagittal axis: an imaginary antero-posterior line around which the mandible rotate in the
frontal plane
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Histological features
MUCOUS MEMBRANE
The denture bases rest on the mucous membrane, which serves as a cushion between the
bases and the supporting bone.
The mucous membrane is composed of two layers
Mucosa
Submucosa
mucosa
It is formed by the stratified squamous epithelium and a subjacent layer of connective
tissue known as the lamina propria.
submucosa
It is formed by connective tissue. It may contain glandular , fat , or muscle cells and
transmits the blood and nerve supply to mucosa.
The thickness and consistency of submucosa are largely responsible for the support that
the soft tissue affords the denture, since in most instances the submucosa makes up the
bulk of the mucous membrane.
In a healthy mouth the submucosa is firmly attached to the periosteum of the underlying
bone of the residual ridge and will usually successfully withstand the pressure of the
denture.
HISTOLOGY OF THE MUCOUS MEMBRANE
COVERING CREST OF THE RESIDUAL RIDGE
BONE
PERIOSTEUM
SUBMUCOSA
MUCOSA
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CLASSIFICATION OF ORAL MUCOSA:
The oral mucosa is divided in three catogories depending on its location in the mouth
A) Masticatory mucosa :
covers the crest of the ridge ,the residual attached gingiva firmly
adherent to the supporting bone , hard palate.
It is characterized by a well defined keratinized layer on its outermost
surface subject to changes in thickness.
B) Lining mucosa :
is generally devoid of the keratinized layer.
It is found to cover the : mucous membrane of lips, cheek , vestibular
spaces , alveolingual sulcus , soft palate, ventral surface of the tongue
and, the unattached gingiva found on slopes of residual ridge.
C) Specialized mucosa : covers the dorsal surface of the tongue. This mucosal
covering is keratinized.
Upper residual ridge crest
Microscopically the mucous membrane covering the crest of upper residual ridge in healthy
mouth is firmly attached to periosteum of bone of maxillae by connective tissue of sub mucosa.
The stratified squamous epithelium is thickly keratinised.
The sub mucosa is devoid of fat or glandular cells and thus does not become edentulous but
characterised by dense collagenous fibers that are contiguous with lamina propria. The
submucosa though relatively thin in comparison to other parts of mouth is still sufficiently thick
to provide adequate resiliency for primary support of the denture.
The mucous membrane covering the crest is comparable to attached gingiva in edentulous mouth
except submucosal layer in edentulous mouth is usually thicker than is found in attached gingiva
of dentulous mouth.
The outer surface of bone in crest of upper RAR is compact in nature made of haversian
systems. The compact bone in combination with tightly attached mucous membrane makes the
crest of upper RR histologically best able to provide primary support to maxillary denture. One
should take advantage of this nature of tissue when providing additional stress to be placed on
crest of ridge of upper jaw during final impression making.
COMPLETE DENTURE THEORY AND PRACTICE Anatomy and Physiology2
Dr.mostafa.fayad@gmail.com 94
As mucous membrane extends from crest along the slope of the upper RR to reflection, it tends
to lose its firm attachment to underlying bone, marking the end of residual attached mucous
membrane. The loosely attached mucous membrane in this region is non-keratinised or slightly
keratinized.
Submucosa contains loose CT and elastic fibers. This type of tissue will not withstand forces of
mastication or other stress transmitted through denture base and firmly attached over ridge crest.
Less stress is placed on movable tissue of slope of ridge during impression making because the
impression material is closer to escape ways (border of impression tray) than material over crest
of ridge. This follows the principles that in a semi confined container impression material
farthest from the escapeways is under greatest pressure.
Note: the thick submucosal layer compact bone making it the primary stress bearing area
-----------------------------------------------------------------------------------------------
COMPLETE DENTURE THEORY AND PRACTICE Anatomy and Physiology2
Dr.mostafa.fayad@gmail.com 95
Hard palate
Histology of mucous membrane in a) Anterolateral part of palate b) Posterolateral part of
palate
-------------------------------------------------------------------------------------------------------
Histology of midpalatine suture area Note: thin submucosal layer unsuitable for support of
the denture
COMPLETE DENTURE THEORY AND PRACTICE Anatomy and Physiology2
Dr.mostafa.fayad@gmail.com 96
Vestibular space
Histologically the mucous membrane lining the vestibular space depicts a relatively thin
nonkeratinised epithelium. The submucosal layer is thick and contains large amounts of loose
areolar tissue and elastic fibres. The nature of submucosa in vestibular space makes tissue easily
movable. Thus the labial flanges and buccal flanges of upper impression can easily be over
extended or under extended.
Histology of lining areas . Note :loose areolar tissue and elastic fibers permit relatively large
movement of tissues at the reflection.
-----------------------------------------------------------------
Crest of lower residual ridge
The crest of ridge is covered by keratinised layer of FCT firmly attached but its submucosa to
periosteum of mandible. The extent of attachment to bone varies considerably.
In some patients the submucosa is loosely attached to bone over entire crest of RR and soft tissue
covering is quite movable. In relatively few patients the submucosa is relatively firmly attached
to bone on both crest and slopes of lower residual ridge. The mucous membrane of ridge crest is
histologically capable of providing proper soft tissue support for the lower denture. However, the
underlying bone of crest of RR is cancellous made up of spongy trabeculae. Therefore crest of
lower RR may not be favourable as primary stress bearing areafor lower denture. Proper relief to
be provided for crest of lower ridge during making final impression.
-----------------------------------------------
COMPLETE DENTURE THEORY AND PRACTICE Anatomy and Physiology2
Dr.mostafa.fayad@gmail.com 97
The bone of buccal shelf is very dense because the resultant forces of elevator muscles are
directed to this area and trabeculation is arranged perpendicular to occlusal forces.
The mucous membrane covering the buccal shelf area is loosely attached and less keratinised
than mucous membrane covering the crest of lower edentulous ridge. The submucosal layer is
thicker. The fibers of buccinator are located horizontally in submucosa.
Although the mucous membrane may be not be suitable to provide primary support than mucous
membrane overlying crest of ridge, the bone of buccal shelf area is a layer of compact (with
haversion systems)bone.
----------------------------------------------------------
THE BONE
The success of complete denture prosthesis is particularly dependent on the degree of stability
that the underlying bone can maintain. The structure of alveolar ridge has a direct relation on
stability and retention of completed prosthesis.
Bone is a type of connective tissue derived from the multi potential embryonic mesenchymal
cells. It consists of an organic portion composed of collagenous fibrils and an amorphous ground
substance, mainly mucopolysaccharide and an in organic compound of calcium phosphate
complexes.
Bone of maxilla and mandible is formed by outer cortical bone and central meduallary cavity
filled with red or yellow bone marrow.
The marrow cavity is intercepted throughout its length by reticular network of trabecular
(alternatively cancellous or spongy bone). These internal trabeculae act as reinforcement rods to
support outer thicker cortical crust of compact bone.
Surrounding every compact bone is osteogenic (bone forming) CT membrane Periosteum
consists of 2 layers.
Inner layer - next to bone surface consists of bone cells their precursors and a rich micro
vascular supply.
Outer layer - is fibrous layer giving rise to sharpey fibres. Both internal surface of
compact bone and entire cancellous bone is covered by single layer of bone cells the
endosteum, which physically separates bone surface from bone marrow.
1
William C. Scarfe
Maxillary and Mandibular
Anatomic Radiographic
Landmarks
Intraoral Radiography
William C. Scarfe
Principles
Normal is a range, not an ideal or
absolute.
Appearance of landmarks depends upon
projection geometry and contrast.
Radiolucent vs. Radiopaque
Radiopacity is relative
Law of Cube of Atomic Density
Law of Summation
Rule of Tangency
2
William C. Scarfe
Radiographs are
two-dimensional
representations of
objects that occupy
three dimensions.
Facial, central and
lingual features are
superimposed.
All landmarks are
NOT clearly
demonstrated on
radiographs from all
individuals.
Image(s) courtesy Dr. Allan G. Farman
Remember
Radiographs are two-dimensional
representations of objects that occupy
three dimensions.
Facial, central and lingual features are
superimposed.
All landmarks are NOT clearly
demonstrated on radiographs from all
individuals.
3
William C. Scarfe
Tooth and
supporting
structures
Enamel
radiopaque
Dentin and
Cementum
radiopaque
Pulp space
radiolucent
Lamina dura
radiopaque
Periodontal ligament
space
radiolucent
Alveolar bone
radiopaque
William C. Scarfe
Enamel
Dentin
Dentin-enamel
junction
Cemento-
enamel junction
Pulp space
Lamina dura
pdl space
Alveolar bone
Image(s) courtesy Dr. Allan G. Farman
4
William C. Scarfe
Anatomic
Landmarks
MAXILLA
ZYGOMATIC BONE
Central Incisor View (Maxilla)
Premaxillary/median palatal suture
(radiolucent).
Incisive fossa and foramen (radiolucent).
Nasal passages (radiolucent).
Nasal septum (radiopaque).
Anterior nasal spine (radiopaque).
Bracket-shaped line (radiopaque).
Soft tissues of nose and lips (radiopaque).
5
William C. Scarfe
Central incisor region: Features
Anterior Nasal Spine
William C. Scarfe
Central incisor region: Features
Incisive Fossa / Foramen
6
William C. Scarfe
Central incisor region: Features
Nasal Septum
William C. Scarfe
Central incisor region: Features
Pre-maxillary / Median Palatine Suture
7
William C. Scarfe
Central incisor region: Features
Inferior Concha / Turbinates
William C. Scarfe
Central incisor region: Features
Nasal Fossa / Cavity / Meatus
8
William C. Scarfe
Central incisor region: Features
Incisive / Nasopalatine Canal
William C. Scarfe
Central incisor region: Features
Ala Cartilage Nose & Lip Line
9
William C. Scarfe
Central incisor region: Features
Incisive / Nasopalatine Canal
William C. Scarfe
Anterior nasal
spine
Nasal septum
Premaxillary
suture
Nasal passage
Maxillary Anterior
Image(s) courtesy Dr. Allan G. Farman
10
William C. Scarfe
Incisive fossa
Premaxillary
suture
Anterior Maxilla
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Premaxillary suture
Incisive fossa
Anterior nasal spine
Pulp
Lamina dura
Periodontal ligament
space
Anterior Maxilla
Image(s) courtesy Dr. Allan G. Farman
11
William C. Scarfe
Dental caries
Premaxillary
suture
Soft tissue
shadow of nose
Anterior nasal
spine
Nasal passage
Nasal septum
Nasal passage
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Floor of nasal
passage
Soft tissue shadow
of nose
Image(s) courtesy Dr. Allan G. Farman
12
William C. Scarfe
Nasal septum
Inferior conchae
Bracket-shaped
line
(anterior nasal spine and
lower wall of nasal passage)
Inferior meatus
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Incisive fossa
Cartilagenous nasal
septum
Bony nasal septum
Edentulous
anterior maxilla
Inferior conchae
Image(s) courtesy Dr. Allan G. Farman
13
William C. Scarfe
Incisive fossa or periapical lesion?
The periodontal
ligament spaces
intact.
SLOB Rule
Same Lingual
Opposite Buccal
The incisive fossa
being lingually
situated moves on
the resulting image
in the same direction
as the movement of
the tubehead.
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe Image(s) courtesy Dr. Allan G. Farman
14
William C. Scarfe
Central and lateral projections
Image(s) courtesy Dr. Allan G. Farman
Note how shadow of the incisive fossa moves
in the direction of the movement of the tubehead.
The fossa becomes superimposed over the root
apex of the central incisor.The periodontal ligament
space is intact.
15
William C. Scarfe
Lateral/Canine region: Maxilla
Structures found on central incisor view
are displaced
lingual structures appearing more
posteriorly and facial structures more
anteriorly.
Inverted Y
Lateral wall of nasal passage and anterior
medial wall of maxillary sinus.
William C. Scarfe
Lateral/Canine region: Features
Canine Fossa
16
William C. Scarfe
Lateral/Canine region: Features
Canine Fossa
William C. Scarfe
Lateral/Canine region: Features
Antral /
Inverted
Y
17
William C. Scarfe
Lateral/Canine region: Features
Antral /
Inverted
Y
William C. Scarfe
Lateral/Canine region: Features
Anterior Sinus
18
William C. Scarfe
Nasal passage
Anterior nasal spine
Canine fossa
Canine eminence
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Anterior wall of
nasal passage
Soft tissue shadow
of nose
Canine fossa
Image(s) courtesy Dr. Allan G. Farman
19
William C. Scarfe
Maxillary sinus
Anterior wall of
maxillary sinus
Lateral wall of
nasal fossa
Inverted Y
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Lateral wall of
nasal fossa
Anterior wall of
maxillary sinus
(antrum)
Inverted Y
Image(s) courtesy Dr. Allan G. Farman
20
William C. Scarfe
Inverted Y
Locule in maxillary
sinus: note tooth
periodontal ligament
space intact
Septum in maxillary
sinus
Bridge unit in porcelain
fused to metal
Radiolucent anterior
filling material
Image(s) courtesy Dr. Allan G. Farman
Premolars (maxilla)
Maxillary sinus (radiolucent).
Maxillary sinus floor and septums
(radiopaque).
Nutrient canals (radiolucent).
Occasionally: lateral wall of nasal
passage (radiopaque).
Soft tissue shadow of lips/cheeks.
21
William C. Scarfe
Premolar region: Features
Nasolabial Fold
William C. Scarfe
Premolar region: Features
Maxillary Sinus
22
William C. Scarfe
Premolar region: Features
Nutrient Canals
William C. Scarfe
Premolar region: maxilla
Image(s) courtesy Dr. Allan G. Farman
23
William C. Scarfe
Floor of maxillary sinus
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Maxillary molar region showing septum in sinus
Floor of maxillary sinus
Septum in
sinus
Zygomatic
process of
maxilla
Soft tissue
over
tuberosity
Image(s) courtesy Dr. Allan G. Farman
24
First/Second Molar (Maxilla)
Maxillary sinus floor and septums
(radiopaque).
Maxillary sinus (radiolucent).
Nutrient canals (radiolucent).
Zygomatic process of the maxilla (U-
shaped radiopacity).
Zygomatic arch/zygoma (radiopaque).
Less commonly: Lateral wall of nasal
passage (radiopaque).
William C. Scarfe
Zygomatic
bone
Zygomatic
process of
maxilla
Zygomatic process (temporal bone)
Articular eminence
Structures anterior
to green line seen
on intraoral
radiographs
Molar region: maxilla
Zygomatic
Arch
Image(s) courtesy Dr. Allan G. Farman
25
William C. Scarfe
Zygomatic process
of the maxilla
Zygomatic
arch
shadow
Floor of
maxillary
sinus
Maxillary
tuberosity
Endodontically
treated tooth
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Zygomatic process
of the maxilla
Floor of
maxillary
sinus
Shadow of
zygomatic arch
Coronoid
Process
(mandible)
Image(s) courtesy Dr. Allan G. Farman
26
William C. Scarfe
Zygomatic
arch
Zygomatic process
of maxilla
Floor of
maxillary
sinus
Nutrient
canal
Image(s) courtesy Dr. Allan G. Farman
Second/Third molar (maxilla)
Coronoid process of mandible (radiopaque).
Maxillary tuberosity (radiopaque).
Posterior wall of maxillary sinus (radiopaque).
Maxillary sinus (radiolucent).
Pterygoid hamulus (radiopaque).
Pterygoid notch (radiolucent).
Lateral pterygoid plate (radiopaque).
27
William C. Scarfe
Coronoid
process of
mandible
Zygomatic
process
of maxilla
Zygomatic
arch
3
rd
molar region: maxilla
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Maxillary tuberosity Maxillary sinus
Image(s) courtesy Dr. Allan G. Farman
28
William C. Scarfe Zygomatic process of the maxilla
Dental
follicle
space
Tuberosity
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Pterygoid
hamulus
Air space
Posterior wall of maxillary sinus
Image(s) courtesy Dr. Allan G. Farman
29
William C. Scarfe
Coronoid
process of
mandible
Zygomatic process of maxilla
Floor of maxillary sinus
Zygomatic
arch
Pterygoid
hamulus
Pterygoid
plate
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Pterygoid
hamulus
(medial
Pterygoid)
Lateral
pterygoid
plate
Maxillary tuberosity
3
rd
Molar region: maxilla
Image(s) courtesy Dr. Allan G. Farman
30
William C. Scarfe
Pterygoid hamulus
3
rd
Molar region: maxilla
Image(s) courtesy Dr. Allan G. Farman
Coronoid
process of
mandible
Zygomatic process
of maxilla
Zygomatic arch
31
William C. Scarfe
Pterygoid
hamulus
Coronoid process of mandible
Maxillary
tuberosity
Shadow of zygomatic arch
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Anatomic Landmarks
MANDIBLE
32
William C. Scarfe
Incisor region: mandible
Lingual foramen
radiolucent
Genial tubercles
radiopaque
Soft tissue shadow of lower lip
radiopaque
Mental ridges
radiopaque
Nutrient canals
radiolucent
William C. Scarfe
Facial
Mental
depression
Mental
ridge
Lingual
groove
Genial
tubercles
Lingual
Image(s) courtesy Dr. Allan G. Farman
33
William C. Scarfe
Mental ridge
Soft tissue
shadow of lower lip
Cortex of
lower border of
mandible
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Lingual foramen
Mental ridge
Genial tubercles
Cortical plate of
lower border of
mandible
Soft tissue shadow of
lower lip
Image(s) courtesy Dr. Allan G. Farman
34
William C. Scarfe
Mental ridge
Embossed
(locating) dot
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Second shadow of
periodontal ligament
space due to shape
of root
Periodontal ligament
space
Image(s) courtesy Dr. Allan G. Farman
35
William C. Scarfe
Nutrient canals
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Nutrient canals
Image(s) courtesy Dr. Allan G. Farman
36
William C. Scarfe
Nutrient canals in
anterior mandible
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Lingual foramen
Embossed dot
Image(s) courtesy Dr. Allan G. Farman
37
William C. Scarfe
Mandibular tori
Genial tubercles
Mental ridge
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Canine/Premolar region: mandible
Mental foramen
Radiolucent
usually situated between and just beneath
roots of the premolars.
Soft tissue shadow of reflected cheek
radiopaque
Mandibular canal
radiolucent
38
William C. Scarfe
Canine region: mandible
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Mental
foramen
Premolar region: mandible
Image(s) courtesy Dr. Allan G. Farman
39
William C. Scarfe
Mental
foramen
Mandibular
canal
Submandibular fossa
Mylohyoid ridge
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Periapical granuloma, abscess or cyst
(periodontal ligament space not intact)
Mental
foramen
Image(s) courtesy Dr. Allan G. Farman
40
William C. Scarfe
Mental foramen
Mylohyoid
ridge
Submandibular fossa
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Molar region: mandible
Mandibular canal
radiolucent
External oblique
ridge
radiopaque
Mylohyoid ridge
(internal oblique
ridge)
radiopaque
Submandibular
fossa
radiolucent
Cortex of lower
border
radiopaque
41
William C. Scarfe
Mandibular canal
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
External oblique ridge of mandible
Image(s) courtesy Dr. Allan G. Farman
42
William C. Scarfe
External oblique ridge of mandible
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
External oblique ridge
Mandibular canal Image(s) courtesy Dr. Allan G. Farman
43
William C. Scarfe
Internal oblique (mylohyoid) ridge of mandible
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Internal oblique (mylohyoid) ridge of mandible
Image(s) courtesy Dr. Allan G. Farman
44
William C. Scarfe
Submandibular fossa
Lower
cortex of
mandible
External
oblique
ridge
Internal
oblique
ridge
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Lower cortex of mandible
External
oblique
ridge
Internal
oblique
ridge
Image(s) courtesy Dr. Allan G. Farman
45
William C. Scarfe
Lower cortex of mandible
External
oblique
ridge
Internal
oblique
ridge
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Anatomical Variations
Mandibular torus.
Palatal torus.
High vs. low mandibular canal.
Double mandibular canals.*
Stafnes bone cavity (static bone cyst).*
*usually seen only on extra-oral radiographs.
46
William C. Scarfe
Mandibular torus
Syn: lingual exostoses, torus mandibularis
William C. Scarfe
Mandibular torus
Syn: lingual exostoses, torus mandibularis
Image(s) courtesy Dr. Allan G. Farman
47
William C. Scarfe
Mandibular torus
Syn: lingual exostoses, torus mandibularis
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Maxillary torus
Syn: torus palatinus
48
William C. Scarfe
Maxillary torus
Syn: torus palatinus
Image(s) courtesy Dr. Allan G. Farman
William C. Scarfe
Maxillary torus
Syn: torus palatinus
Image(s) courtesy Dr. Allan G. Farman
49
William C. Scarfe
Maxillary torus
Syn: torus palatinus
Image(s) courtesy Dr. Allan G. Farman
28-11-2010
1
Dr Honey Arora
Post Graduate Student
Department of Prosthodontics and Implantology
1
Its Role in Removable Prosthodontic
INTRODUCTION
OSTEOLOGY
MUSCLE ATTACHMENT OF THE MANDIBLE
GROWTH AND DEVELOPMENT
MANDIBLE IN COMPLETE DENTURE
2
28-11-2010
2
The mandible is derived from Latin word
mandibula, "jawbone.
Also referred as inferior maxillary bone
Is the largest and strongest bone of the face, serves
for the reception of the lower teeth. It consists of a
curved, horizontal portion, the body, and two
perpendicular portions, the rami.
3
4
28-11-2010
3
BODY OF MANDIBLE
corpus mandibulae
The body is curved somewhat like a horseshoe
and has two surfaces and two borders.
- 2 surfaces External
Internal
- 2 borders Superior or Alveolar
Inferior
5
MENTAL FORAMEN-
It lies below the interval between the premolar
teeth, on the either side, midway between the upper
and lower borders of the body.
It is the passage of the mental vessels and nerve.
descends slightly in edentulous individuals
Absence of mental foramen and accessory mental
foramina has also been
reported.[1][2]
shape of the MF was oval in
most of the cases.[3] [4]
Central African Journal of Medicine
6
28-11-2010
4
MENTAL PROTUBERANCE-
It is a median triangular projecting area in the
lower part of the midline.
- The inferolateral angles of the protuberance from the
mental tubercules.
7
EXTERNAL OBLIQUE LINE
It is a faint ridge running backward and
upward from each mental foramen and is continuous
with the anterior border of the ramus.
8
28-11-2010
5
INCISIVE FOSSA
It is a depression that lies just below the
incisor teeth on the either side of the symphysis.
(no. 11 is incisive fossa)
9
MENTAL SPINES (GENIAL TUBERCULE / GENIAL
APOPHYSIS)
There are 2 pairs of spines .
1. Superior pair of spine . It gives origin to the Genioglossi and
2. Inferior pair of spines lies immediately below the first pair,
gives origin of the Geniohyoid.
SPECIAL CASES
- May be fused to form a single eminence.
- A median foramen and furrow
are sometimes seen above
the mental spines( spinous
Foramen)[6]
10
28-11-2010
6
ATTACHMENT OF ANTERIOR BELLY OF
DIGASTRIC
It is an oval depression on the either side of the
mid line jus below the mental spines for the
attachment of anterior belly of digastric .
11
MYLOHYOID LINE
It extends upward and backward on either side from
the lower part of the symphysis .(figure b)
- It gives origin to the mylohyoid.
- posterior part of this line - gives attachment to a small
part of the superior constrictor and to the
pterygomandibular raphe.
-Above the anterior part of this line - is a smooth
triangular area against which
the sublingual gland rests.
- below the hinder part, an
oval fossa for the submaxillary
gland.
12
28-11-2010
7
13
SUPERIOR OR ALVEOLAR BORDER
- wider behind than in front
- is hollowed into cavities, for the reception of the teeth;
these cavities are sixteen in number.
- outer lip of the superior border - on either side, the
buccinator is attached as far
forward as the first molar tooth.
14
28-11-2010
8
INFERIOR BORDER
- rounded, longer than the superior, and thicker in front
than behind.
- point where it joins the lower border of the ramus - A
shallow groove; for the FACIAL ARTERY , may be
present.
15
ramus mandibul; perpendicular portion
The ramus is quadrilateral in shape, and has
two surfaces, four borders, and two processes
16
28-11-2010
9
LATERAL SURFACE
- Lateral surface is flat and marked by
oblique ridges at its lower part.
- It gives attachment nearly
the whole of its extent to the
masseter.
17
MEDIAL SURFACE
MANDIBULAR FORAMEN
It provides entrance for the inferior alveolar
nerve and vessels.
18
28-11-2010
10
LINGULA OR LINGULAE MANDIBULAE
it is a sharp spine present in front of
mandibular foramen opening .
- It gives attachment to the spenomandibular ligament
19
MYLOHYOID GROOVE
From the lower and back part of the lingulae
mandibulae is a notch from which the mylohyoid
groove runs obliquely downward and forward.
- It lodges the mylohyoid vessels and nerve.
20
28-11-2010
11
MANDIBULAR CANAL
The mandibular canal is a canal within the
mandible that contains the inferior alveolar nerve
,inferior alveolar artery, and inferior alveolar veins.
runs obliquely downward and forward in the ramus
then horizontally forward in the body
communicates with alveoli
by small openings
21
Types of mandibular canal [5]
1. TYPE III - the canal is located close to the lower
border of the mandible is the most common,
2. TYPE II -the canal is noted between the apices of the
first and second molars and the lower border of the
mandible
3. TYPE I -the canal is in close contact with the apices
of the first and the second molars
22
Hell Period 1990
28-11-2010
12
LOWER BORDER
Is marked by oblique ridges on each side, for the
attachment of the Masseter laterally, and the
pterygoideus internus medially; the
sphenomandibular ligament is attached to the angle
between these muscles.
23
ANTERIOR BORDER
Is thin above, thicker below, and continuous with
the oblique line.
POSTERIOR BORDER
Is thick, smooth, rounded, and covered by the
parotid gland.
24
28-11-2010
13
UPPER BORDER
Is thin, and is surmounted by
2 processes -
the coronoid in front
the condyloid behind,
separated by a deep concavity, the mandibular notch.
25
processus condyloideus
Is thicker than the coronoid, and consists of
two portions: the condyle, and the constricted portion
which supports it, the neck.
It forms the articular surface for articulation with
articular disk of tempromandibular joint.
26
28-11-2010
14
THE CONDYLE
- It presents an articular surface for
articulation with the articular disk
of the temporomandibular joint
- At the lateral extremity of the
condyle is a small tubercle for the
attachment of the
temporomandibular ligament.
27
THE NECK
The neck is flattened from backward, and
strengthened by ridges which descend from the
forepart and sides of the condyle.
- Its posterior surface is convex
- its anterior surface presents a depression for the
attachment of the Pterygoideus externus.
28
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15
processus coronoideus
Is a thin, triangular eminence, which is
flattened from side to side and varies in shape and size.
The Coronoid process (from Greek korone, "like a
crown")
29
BORDERS
anterior border - is convex and is continuous below
with the anterior border of the ramus.
posterior border- is concave and forms the anterior
boundary of the mandibular notch.
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16
SURFACES
Lateral Surface - affords insertion to the Temporalis
and Masseter.
Medial Surface -provides insertion to the Temporalis
and presents a ridge from apex till last molar
Between This Ridge And The Anterior Border - is a
grooved triangular area, the upper part of which gives
attachment to the Temporalis, the lower part to some
fibers of the buccinator.
31
It is the faint ridge on the median line
of the external surface of the
mandible.
This ridge divides below and
encloses a triangular
eminence, the mental protuberance,
the base of which is depressed
in the center but raised on either
side to form the mental tubercule.
It serves as the origin for the
Geniohyoid and the Genioglossus
32
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17
It is the junction of the lower border of the ramus of
the mandible with the posterior border of body of
mandible
Provides attachment
- Masseter laterally
- the Pterygoideus internus medially
- the stylomandibular ligament
is attached to the angle
between these muscles.
33
Sub-mandibular: run along the underside of the jaw
on either side, drains the structures in the floor of the
mouth also drain mandibular teeth except the central
incisors.
Sub-mental: These nodes are just below the chin.
They drain the central incisors and midline of lower lip
and tip of the tongue.
34
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18
mainy by the 3
rd
division of trigeminal nerve ->
mandibular nerve
INFERIOR ALVEOLAR NERVE, branch of the
mandibular division -> enters mandibular foramen
and runs forward in the mandibular canal, supplying
sensation to the teeth->at mental foramen the nerve
divides into two terminal branches: incisive and
mental nerves-> The incisive nerve runs forward in the
mandible and supplies the anterior teeth. The mental
nerve exits the mental foramen and supplies sensation
to the lower lip.
35
INTERNAL SURFACE
36
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19
EXTERNAL SURFACE
37
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE
SUPPLY
ACTION & CLINICAL
SIGNIFICANCE
MASSETER
musculus
masseter
( Greek word
chewing ,
associated
with anger )
ORIGIN
Zygomatic arch
Blood supply
Masseteric
Artery
Nerve supply:
Masseteric
Nerve
Elevationand
retraction of the
mandible
Antagonist muscle
platysma
INSERTION
Coronoid process
and ramus of
mandible
TEMPORALIS
musculus
temporalis
ORIGIN
Temporal line on the
parietal bone of the
skull
Blood supply :
Deep temporal
artery
Nerve supply:
Mandibular
nerve
Elevationand
retraction of the
mandible
Antagonist muscle -
platysma
INSERTION
Coronoid process of
mandible
38
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20
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
MEDIAL
PTERYGOID
musculus
pterygoideus
internus
ORIGIN
Medial surface of lateral
pterygoid plate of
sphenoid, palatine bone ,
pterygoid fossa
Blood supply:
Medial pterygoid
artery
Nerve supply:
Medial pterygoid
Nerve
Elevates
mandible, closes
jaw, helps lateral
pterygoids in
moving the jaw
from side to side
INSERTION
Inner surface of ramus ,
Angle of the mandible
LATERAL
PTERYGOID
m.
pterygoideus
externus
ORIGIN
Superior head: lateral
surface of the greater
wing of the sphenoid
Inferior head: lateral
surface of the lateral
pterygoid plate
Blood supply:
Lateral pterygoid
artery
Nerve supply:
lateral pterygoid
Nerve
Depresses
mandible,
Protrude
mandible, side to
side movement of
mandible
INSERTION
neck of the mandibular
condyle , articular disk of
the TMJ 39
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
DEPRESSOR
ANGULI
ORIS
(musculus
depressor
anguli oris)
ORIGIN
along the oblique line of
mandible
lateral aspect of mental
tubercle of the mandible
Blood supply:
Facial artery
Nerve supply:
Mandibular branch
of facial Nerve
Depresses the
mouth as in
frowning
INSERTION
modiolus
DEPRESSOR
LABII
INFERIORIS
musculus
depressor labii
inferioris
ORIGIN
Oblique line of mandible,
between symphysis and
mental foramen
Blood supply:
Facial artery
Nerve supply:
Mandibular branch
of facial Nerve
Draws the lip
downward and
laterally
INSERTION
Skin of the lower lip
40
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MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
BUCCINATOR
musculus
buccinator
ORIGIN
Posterior alveolar process
of maxilla and mandible
Blood supply
:
Buccal artery
Nerve supply:
buccal branch of
facial nerve
The buccinator
compresses the
cheeks against the
teeth and is used in
acts such as
blowing. It is an
assistant muscle of
mastication
(chewing).
INSERTION
modiolus
ORBICULARIS
ORIS
ORIGIN
Near midline on anterior
surface of maxilla and
mandible and modiolus
at angle of mouth
Blood supply :
Facial artery
Nerve supply:
buccal branch of
facial nerve
Narrows orifice of
mouth, purses lips
and puckers lip
edges
INSERTION
Mucous membrane of
margin of lips and raphe
with buccinator at
modiolus 41
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
MENTALIS
(so named
because it is
associated with
thinking or
concentration
and use to
express doubt)
ORIGIN
Symphysis of mandible
Blood supply
:
Buccal artery
Nerve supply:
mandibular
branch of facial
nerve
elevates and
wrinkles skin of
chin, protrudes
lower lip
INSERTION
Skin of chin
PLATYSMA ORIGIN
subcutaneous tissue of
infraclavicular and
supraclavicular regions
Blood supply :
branches of the
Submental
artery and
Suprascapular
artery
Nerve supply:
cervical branch
of the facial
nerve
Draws the corners
of the mouth
inferiorly and
widens it (as in
expressions of
sadness and fright).
Also draws the skin
of the neck
superiorly when
teeth are clenched
INSERTION
base of mandible; skin of
cheek and lower lip;
angle of mouth;
orbicularis oris
42
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22
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
GENIOGLOSSUS
musculus
genioglossus
ORIGIN
Superior part of mental
spine of mandible
Blood supply:
Lingual artery
Nerve supply:
Hypoglossal
nerve
Inferior fibers
protrude the
tongue, middle
fibers depress the
tongue, and its
superior fibers draw
the tip back and
down
INSERTION
Dorsum of tongue and
body of hyoid
GENIOHYOID
musculus
geniohyoideus
ORIGIN
Inferior mental spine on
the inner surface of the
symphi
Blood supply :
Lingual artery
Nerve supply:
C1 and
Hypoglossal
nerve
Elevates the
tongue, depress
the mandible ,
helps in
deglutition
INSERTION
Body of hyoid bone
43
MUSCLE ORIGIN AND
INSERTION
BLOOD& NERVE
SUPPLY
ACTION
ANTERIOR
BELLY OF
DIGASTRIC
musculus
digastricus
ORIGIN
digastric fossa
(mandible)
Blood supply:
anterior belly -
Submental branch of
facial artery;
Nerve supply:
mandibular division
(V3) of the trigeminal
(CN V) via the
mylohyoid nerve
Opens the jaw
when the masseter
and the temporalis
are relaxed.
INSERTION
Intermediate tendon
(hyoid bone)
MYLOHYOID
musculus
mylohyoideus
ORIGIN
inner surface of
mandible off the
mylohyoid line
Blood supply :
mylohyoid branch of
inferior alveolar
artery
Nerve supply:
mylohyoid nerve
Raises oral cavity
floor, elevates
hyoid, elevates
tongue, depresses
mandible
INSERTION
body of hyoid bone
and median raphe
44
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23
MUSCLE ORIGIN AND
INSERTION
BLOOD& NERVE
SUPPLY
ACTION
SUPERIOR
CONSTRICTOR
ORIGIN
pterygoid hamulus,
pterygomandibular
raphe, posterior end of
the mylohyoid line of the
mandible, and side of
tongue.
Blood supply:
Ascending pharyngeal
artery and tonsillar
branch of facial artery
Nerve supply:
pharyngeal plexus of
nerves(IX , X and
cervical sympathetic
ganglion )
deglutition
INSERTION
median raphe of pharynx
and pharyngeal tubercle.
45
LIGAMENT ORIGIN AND INSERTION DESCRIPTION
STYLOMANDIBULAR
LIGAMENT
ORIGIN
Apex of styloid process of the
temporal bone
Paired , it is the
thickening of parotid
fascia,
from its deep surface
some fibers of the
Styloglossus take origin.
INSERTION
to the angle and posterior
border of the angle of
mandible
SPHENOMANDIBUL
AR
LIGAMENT
ORIGIN
the ligament that attaches to
the spine of the sphenoid
bone superiorly
paired; pterygoid fascia
thickening and is a
remnant of the Meckel's
cartilage
limit distension of the
mandible in an inferior
direction.
its related to lateral
pterygoid (laterally )
and medial pterygoid
(medially)
INSERTION
the lingula of the mandible
inferiorly
46
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PTERYGOMANDIBULAR
RAPHE (LIGAMENT)
Tendinous band of
buccopharyngeal fascia
passes between the tip of
the hamulus of the
pterygoid bone and the
internal surface of the
mandible at a point just
posterosuperior to the
posterior limit of the
mylohyoid ridge
medial surface - covered
by the mucous
membrane.
lateral surface - is
separated from the
ramus of the mandible
by a quantity of adipose
tissue.
posterior border- gives
attachment to the
superior pharyngeal
constrictor muscle.
anterior border attaches
to the posterior edge of the
buccinator
47
48
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25
Prenatal
Week 6 - Intramembranous ossification center develops lateral to
Meckel's cartilage.
Week 7 - Coronoid process begins differentiating.
Week 8 - Coronoid process fuses with main mandibular mass.
Week 10 (approx) - Both condylar and coronoid processes are
recognizable and anterior portion of Meckel's cartilage begins to ossify.
Weeks 12-14 - Secondary cartilages for the condyle, coronoid, and
symphysis appear.
Weeks 14-16 - Deciduous tooth germs start to form.
Birth
At birth mandible still has separate right and left halves.
Postnatal
Year 1 - Fusion of right and left halves of mandible at the symphysis.
Infancy and childhood - Increase in both size and shape of the
mandible; eruption and replacement of teeth.
Year 12-14 - All permanent teeth emerged except third molars.
49
The mandible makes its structure in the sixth week of
foetal life.
It is ossified in the fibrous membrane covering the outer It is ossified in the fibrous membrane covering the outer
surfaces of surfaces of Meckel's Meckel's cartilages, cartilages, derrivative derrivative of first brachial arch of first brachial arch
These These cartilages cartilages form form the the cartilaginous cartilaginous bar bar of of the the mandibular mandibular
arch arch and and are are two two in in number, number, aa right right and and aa left left. .
50
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26
Their proximal or cranial ends are connected with the
ear capsules, and their distal extremities are joined to
one another at the symphysis by mesodermal tissue.
51
INCUS
51
MALLEUS
Meckels cartilage has a close, relationship to the
mandibular nerve, at the junction between posterior
and middle thirds, where the mandibular nerve divides
into the lingual and inferior alveolar nerve.
52
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27
The lingual nerve passes forward, on the medial side
of the cartilage, while the inferior Alveolar lies lateral
to its upper margins & runs forward parallel to it and
terminates by dividing into the mental and incisive
branches.
53
LINGULA is replaced by fibrous tissue, which persists to
form the sphenomandibular ligament & the perichondrium
of the cartilage persist as sphenomallular ligament.
Between the lingula and the canine tooth the cartilage
disappears, while the portion of it below and behind the incisor
teeth becomes ossified and incorporated with this part of the
mandible.
54
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28
Greater part of Meckels cartilage disappears without
contributing to the formation of mandible.
Small part of cartilage near the midline is the site of
endochondral ossification. Here it calcifies and is
destroyed by chondroblasts and are replaced by
connective tissue and then by bone.
Small irregular bones known as mental ossicles
develop in it and by the end of first year fuse with the
mandibular body.
At the same time two halves of mandible unite by
ossification of the symphyseal fibrocartilage.
55
The ramus of the mandible develops by a rapid spread of
ossification backwards into the mesenchyme of the first
branchial arch diverging away from Meckels cartilage.
This point of divergence is marked by the mandibular
foramen.
56
Mandible of human embryo 95 mm. long. Outer aspect. Nuclei of
cartilage stippled.
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Somewhat later, accessory nuclei of cartilage make
their appearance:
a wedge-shaped nucleus in the condyloid process and
extending downward through the ramus.
a small strip along the anterior border of the coronoid
process.
.
57
Mandible of human embryo 95 mm. long. Outer aspect.
Nuclei of cartilage stippled.
The condylar cartilage:
Carrot shaped cartilage appears in the region of the
condyle and occupies most of the developing ramus. It
is rapidly converted to bone by endochondral
ossification (14
th
. WIU) it gives rise to -> Condyle
head and neck of the mandible.
The posterior half of the ramus to the level of inferior
dental foramen
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The coronoid cartilage:
It is relatively transient growth cartilage center ( 4
th
. -
6
th
. MIU). it gives rise to -> Coronoid process.
The anterior half of the ramus to the level of inferior
dental foramen
59
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61
Growth of the mandible
I. Growth by secondary cartilage
II. Development of the alveolar process
III. Subperiosteal bone appositionand bone resorption
62
I. Growth by secondary cartilage
( mainly condylar cartilage )
Increase in height
of the mandibular ramus
Increase in the over all length
of the mandible
Increase of the inter condylar
distance
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II DEVELOPMENT OF ALVEOLAR PROCESS
bone apposition occurs at the crest of the alveolar process and
the fundus of the alveolus contributing to the growth of
mandible in height.
63
Bone deposition Bone deposition Bone resorption Bone resorption Result in Result in
External surface External surface
of the mandible of the mandible
Inner surface of Inner surface of
the mandible the mandible
Increase the Increase the
transeverse transeverse
dimension dimension
Posterior border Posterior border
of the of the ramus ramus
Anterior border Anterior border
of the of the ramus ramus
Adjust the Adjust the
thickness of the thickness of the
ramus ramus
Anterior border Anterior border
of the of the coronoid coronoid
process process
Posterior border Posterior border
of the coronoid of the coronoid
process process
Displacement of Displacement of
the the coronoid coronoid
process process
Chin region Chin region Modeling Modeling of the of the
lower face lower face
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65
The available area of support from an edentulous mandible is 14 14
cm2 cm2 while the same for the edentulous maxilla is 24cm2 24cm2 .
The landmarks can be broadly grouped into:
Limiting structures:
Labial frenum
Labial vestibule
Buccal frenum
Buccal vestibule
Lingual frenum
Alveololingual sulcus
Retromolar pads
Pterygomandibular raphe.
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Supporting structures:
Buccal shelf area
Residual alveolar ridge
Relief areas:
Crest of the residual alveolar ridge
Mental foramen
Genial tubercles
Torus mandibularis.
67
These are the sites that will guide us in having an optimum
extension of the denture so as to engage maximum surface
area without encroaching upon the muscle actions
Encroaching upon these structures will lead to dislodgement
of thedenture and/or soreness
of thearea while failure to
cover the areas upto the
limiting structurewill imply
decreased retention stability
and support.
68
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Masticatory forces produce quite a pressure on the
underlying structures and not everyplace beneath
the denture can take such stress hence we need to
know the areas which can bear the stresses well.
These can be divided into-
1.Primary stress bearing area
2.Secondary stress bearing area
69
PRIMARY STRESS BEARING AREA
These are the areas that are most capable to take
the masticatory load providing a proper support
to the denture.
- Are at right angle and usually do not resorb
easily ( buccal shelf area )
Properties :-
1.Tightly adherent sufficient fibrous connective
tissue with an overlying keratinized mucosa
2.Presence of cortical bone cover
3.Should be at right angles to the vertical occlusal
forces.
4.No underlying structures should be present that will
get harmed due to stress.
70
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SECONDARY STRESS BEARING AREA
Area of edentulous ridge that are greater than or at
right angle to occlusal forces but tend to resorb under load.
Mandibular:- ridge slopes
71
Secondary stress bearing area
Secondary stress bearing area
These are the areas which either resorb under constant
load or have fragile structures within or are covered by
thin mucosa which can be easily traumatized
& hence should be relieved.
72
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Fibrous band extending from
the labial aspect of the residual
alveolar ridge to the lip.
Give attachment to orbicularis oris and incisivus.
Active and sensitive frenum
The activity of this area tends to be vertical so the
labial notch on the denture should be narrow.
73
Extends from the labial frenumto the buccal frenumon
each side.
Potiential space bounded by
- mucolabial fold
- orbicularis oris
- labial aspect of residual alveolar ridge
Mentalis quite active in this region.
74
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CLINICAL SIGNIFICANCE
Extent of denture is limited because of
muscle inserted close to the ridge .
Muscles of lip actively pull across the
denture.(on opening mouth wide
orbicularis muscle is stretched->
narrowing the sulcus -> displacing
denture )
Impression are narrower in this region.
Tone of the skin of lip and orbicularis
depends on the thickness & position of
the flange.
HISTOLOGY
-Epithelium is thin and non-keratinized
- Submucosa formed by loosely
arranged connective tissue fibre mixed
with elastic and muscle fibre.
75
It overlies the depressor anguli oris muscle
Clinical significance
- Clearance must be achieved in the denture to avoid
dislodgement of the denture
76
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77
Accomodated within
sublingual cresent area .
Vary in width and height.
Overlies the genioglossus
muscle which takes
origin from mental spine
Fold of mucous
membrane from tongue
to the residual ridge is
sublingual fold.
It extends posteriorly form buccal frenumto the retromolar
pad .
Houses the buccal flange
Clinical significance
- Impression is wide in this region
- It is nearly 90 degree to the biting forces , providing
denture with greates surface for the resistance to the
vertical occlusal forces.
78
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Buccinator muscle in buccal vestibule
The extent of the buccal flange is highly
influenced by the buccinator muscle, which extends
from
- Modiolus (anteriorly)
- Pterygomandibular raphe ( posteriorly )
Clinical significance:-
- Denture should completely
cover the vestibule and
buccal shelf
- Action of buccinator muscle
moulds the buccal flange.
79
External oblique ridge
It is a ridge of dense bone extending from jus
above the mental foramen and distally , becoming
continous with anterior border of the ramus
- Gives attachment to buccinator muscled fibres.
Clinical significance:-
- Can be used as guide for extent of denture laterally
80
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It accomodates the masseter muscle in the
distobuccal area of the denture
Magnitude of its force is exerting the molar region.
Clinical significance :-
- Overextension soreness of the tissue &
dislodgement of the denture
81
It is recorded by masseter muscle contraction, its
fibres runs ouside and behind the buccinator ->
contraction of masseter ->pushes inward against the
buccinator muscle -> producing bulge.
Movements
- downward pressure in 2
nd
premolar region by dentist
and forces exerted by the closing of the mouth.
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Relief area
Microscopically
- Mucous membrane ->
keratinized layer
- submucosa is attached to the
periosteum.
- Covered by fibrous connective
tissue.
- Bone -> cancellous and
without good cortical plate
covering.
Clinical significance :-
- Should be relieved during
impression making.
83
Primary stress bearing area
Consist of horizontal shelves 0f bone so
called buccal shelf (by sheldon winkler
2
nd
edition )
Bounded by :-
- medially -> crest of residual
alveolar ridge
- anteriorly -> buccal frenum
- laterally -> external oblique
ridge
- distally -> retromolar pad
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Wide and perpendicular to the vertical occlusal forces ,
so offers excellent resistance to such forces -> serving
as primary stress bearing area.
Buccinator muscle fibres runs anteroposteriorly,
paralleling the bone and denture doesnot resist the
contracting forces of the muscle.
85
Microscopically
- Mucous membrane -> loosely attached and less
keratinized than crest of residual ridge
- Thicker submucosal layer
- Fibres of buccinator are found running horizontally in
submucosa
- Bone -> compact thus making it suitable as primary
stress bearing area
- Buccinator fibres -> runs horizontally allows denture
to rest without damage to the muscle or dislodgement
of denture
86
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44
Irregular rough, bony crest extending from the 3
rd
molar region
to the lower border of the mandible
Prominent -> 3
rd
molar the 2
nd
bicuspid.
Levels of attachments of mylohyoid muscle :-
- anteriorly-> close to the
inferior border of mandible
- posteriorly ->close to the
alveolar crest
87
88
Clinical significance :-
- Mucous membrance can be easily traumatized by
denture.
- Area under ridge is undercut
- Lingual flange of the mandible should extend
inferior but not lateral to the mylohoid line
Buccal Buccal
Attachments Attachments
To Hyoid To Hyoid
Mylohyoid Mylohyoid
Ridge Ridge
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Irregular area of bony prominence at the distal
termination of the mylohyoid line
Prominent -> acts as undercut
89
It is located on the lateral surface of the mandible,
between the 1
st
and 2
nd
bicuspid , halfway between the
lower border and the alveolar crest.
Clinical significance :-
- Extensive loss of alveolar
ridge -> foramen occupies
more superior position.
- Should be relieved over
the foramen
- If not relieved -> can
occlude the mental nerve and
blood vessels -> causing numbness of the lip
90
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Situated on the lingual aspect of the symphysis area
slightly above the border.
Divided into :-
- superior -> genioglossi attachment
- inferior -> genohoid attachment
Clinical significance:-
- Extensive loss -> superior
positioning of spine ->
soreness -> surgical
procedure indicated.
91
Pear shaped pad
Triangular soft pad of the tissue at the distal end of the
lower ridge.
Microscopically
- Composed of a thin nonkeratinized epithelium and loose
areolar tissue
- Submucosa contains :
> glandular tissue
> fibres of buccinator and superior constrictor
>pterygomandibular raphe
> tendons of temporalis
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93
Clinical significance :-
- Usable guide on the cast for the
distal extension of denture
- Action of the muscles in
retromolar pad , limits the extent
of the denture -> So denture base
should extend approximately to
2/3
rd
over the retromolar pad.
(zarb-bolender 12
th
edition )
- Should be covered by denture
(sheldon winkler 2
nd
)
- Aids in the stability of the denture
by adding another plane to resist
movement of the denture.
Is a small pear shaped area of gingival tissue that
remains fused to the scar after loss of the last molar.
This small , hard pale pear shaped tissue is situated at
the base of the retromolar pad, approximately at the
centre of the ridge.
94
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It can be divided into three areas
anterior vestibule/sublingual crescent area/ anterior
sublingual fold
the middle vestibule/ mylohyoid area
the distolingual vestibule/ lateral throat form/
retromylohyoid fossa
95
Anterior lingual vestibule Anterior lingual vestibule
This extends from the lingual frenumto where the
mylohyoid ridge curves down below the level of sulcus.
Here a depression the premylohyoid fossa can be palpated.
This is mainly influenced by the genioglossus muscle,
lingual frenumand some part by anterior portion of
sublingual glands .
96
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Middle vestibule Middle vestibule:
This is the largest area and is mainly influenced by
mylohyoid muscles and somewhat by sublingual glands.
The mylohyoid muscle is the largest muscle in the floor of
the mouth whose principal function occurs during
swallowing. Its intra oral appearance is misleading because
the membranous attachment makes the muscle appear to
be horizontal when contracting.
97
Nagel and sears have shown that at maximum contraction
the fibers are still in a downward and forward direction so
that a denture can be extended below the muscle
attachment along the mylohyioid ridge.
The lingual borders in the mylohyoid areas are formed by
contact with the mylohyoid muscle in functional, but not
extreme, contracted or elevated positions.
The average mylohyoid border is 4-6 mm beyond the
mylohyoid ridge in fair to good ridge it is about 2-3 mm . If
the ridge is flat it is often advantageous to make mylohyoid
border thicker (4-5mm or more).
98
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50
Distolingual Distolingual vestibule vestibule:
The lateral throat form is bounded anteriorly by mylohyoid
muscle, laterally by pear shaped pad, posterolaterally by
superior constrictor, posteromedially by palatoglossus and
medially by tongue.
The so called s curve of the lingual flange of the
mandibular denture results from stronger intrinsic and
extrinsic tongue muscles, which usually place the
retromylohyoid borders more laterally and towards the
retromylohyoid fossa, as the oppose weaker superior
constrictor muscle.
99
The posterior limit of the mandibular denture is
determined mainly by the palatoglossus muscle and
somewhat by weaker superior constrictor muscle this is
area is called posterior/ retromylohyoid curtain.
Neil described this area and noted that the denture could
have three possible lengths, depending on the tonicity,
activity, and anatomic attachments of the adjacent
structures-
Class III lateral throat form has minimum length and
thickness. The border usually ends 2-3 mm below the
mylohyoid ridge or sometimes just at the ridge.
100
28-11-2010
51
Class I throat form: The horizontal border is usually 2-3
mm thick, but a thicker border of 4-5 mm should be used
for better seal if the ridge is flat. The retromylohyoid
curtain area should be thinner, about 2-3 mm, and very
rounded and smooth.
Class II throat form is about half as long and narrow as
class I and about twice as long as class III.
101
102
Maxilla-
1.Has more supporting
areas
2.Limiting structures are
less in number and
have a less stronger
influence over the
denture border
Mandible-
1.Has less supporting
area.
2.Limiting structures
are more in number
and have a stronger
influence over the
denture border
28-11-2010
52
1. de Freitas V, Madeira MC, Toledo Filho JL, Chagas
CF. Absence of the mental foramen in dry human
mandibles. Acta Anat (Basel). 1979; 104(3): 353-355.
2. Dharmar S. Locating the mandibular canal in
panoramic radiographs. Int J Oral Maxillofac
Implants. 1997; 12: 113-117.
103
3. Mbajiorgu EF, Mawera G, Asala SA, Zivanovic S.
Position of the mental foramen in adult black
Zimbabwean mandibles: a clinical anatomical study.
Central African Journal of Medicine 1998; 44: 24-30.
4. Gershenson A, Nathan H, Luchansky E. Mental
foramen and mental nerve: changes with age. Acta
Anatomica 1986; 126: 21-8.
5. Zografos J, Kolokoudias M, Papadakis E Dental
School, University of Athens, Greece. Hell Period
Stomat Gnathopathoprosopike Cheir. 1990
Mar;5(1):17-20.
104
28-11-2010
53
6. Sheller WR and wisewell OB. Lingual foramen on the
mandible. Anat rac 1954; 119 387-390
7. Sheldon winkler 2
nd
edition OF ESSENTIALSOF
COMPLETE DENTURE PROSTHESIS
8. Charles m. heartwell, Jr, urthur O. Rahn . Syllabus of
complete denture 4
th
edition
9. Grays anatomy 39
th
edition
10. Zarb and Bolender 12
th
edition . Prosthodontic
treatment of edentulous patient
105
11/28/2010
1
BY :- DR.MOHIT DHAWAN
M.D.S 1
ST
YEAR
PG. DEPT. OF PROSTHODONTICS
B.R.S DENTAL COLLEGE
SULTANPUR(PANCHKULA)
Its Role in Removable Prosthodontic
introduction
Functions
External features
Mucous membrane
Muscles
Arterial supply
Venous supply
Nerve supply
Lymphatic drainage
11/28/2010
2
Prosthodontic
considerations
Influence and action of
floor of the mouth
Applied anatomy
Tongue is always the most
integral part of oral anatomy.
every prosthodontist should
have a proper knowledge of its
anatomy to implement it for
delivering a retentive denture.
11/28/2010
3
FUNCTIONS OF
THE TONGUE
Taste, mastication and deglutition.
The tongue takes part in the functions of
sucking, swallowing, receiving food into
the mouth, mastication,vocalizationand
speech.
In speech, this is the most accurate and
fastest mechanisms of the body.
It plays an intrinsic part in the formation
of sounds of vowels and consonants.
11/28/2010
4
Control guide to direct the
flow of the food and liquids to
the pharynx.
Its a contributing factor in
aiding normal positioning of
erupting teeth in the dental
arches as a counter pressure
to facial muscles on the labial
and buccal side of the teeth.
Acts as an additional thermal
guide
EPITHELIUM
Anterior 2/3:- I
st
brachial arch.
Posterior 1/3:- III
rd
brachial arch .
Posterior most :- 4
th
brachial arch.
MUSCLES from Occipital myotomes
CONNECTIVE TISSUES from the local
mesenchyme
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5
EXTERNAL
FEATURES
11/28/2010
6
Body has 2 surfaces:
The dorsum, convex, curved upper
surface.
The ventral surface, inferior surface.
The dorsum of the tongue is divided into:
1. an oral part( anterior two third)
2. A pharyngeal part ( posterior one
third)
The parts are separated by a faint v
shaped groove, the sulcus terminalis.
11/28/2010
7
It is placed on the floor of the mouth.
It is covered by mucous membrane
which consists of a layer of
connective tissues & lined by
stratified squamous epithelium.
its margins are free &are in contact
with the gums &teeth.
in front of the palatoglossal
arch each margin show 4-5
vertical folds foliate
papillae.
SUPERIOR SURFACE of the
oral part shows a median
furrow which is rough and
covered with papillae.
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8
INFERIOR
SURFACE
11/28/2010
9
It is covered with a smooth mucous
membrane, which shows a median fold
called frenulumlingulae.
On either side prominence by deep lingual
veins
Laterally fold called plica fimbriata
directed towards the tip of the tongue.
The folds converge anteriorly & terminate
on either side of the lingual frenumin a small
elevation called the sublingual caruncula or
papilla. (wartons duct opens here).
11/28/2010
10
Lies beneath the palatoglossal
arches and the sulcus
terminalis.
The mucous membrane has no
papillae, but has many lymphoid
follicles collectively
constitute the lingual tonsil.
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11
The posterior part of the tongue is
connected to the epiglottis by three
folds of mucous membrane.
These are the median, right and left
glossoepigloticfolds.
On either side of the median fold
there is a pouch called the Vallecula.
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12
PAPILLAE OF
THE TONGUE
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13
11/28/2010
14
Large 1-2mm diameter.
8-12 in no.
Situated in front of sulcus terminalis.
Cylindrical projection.
Walls raised above the surface.
FUNGIFORM PAPILLAE: FUNGIFORM PAPILLAE:
Numerous
Near tip and margins
Smaller than vallate but larger than filliform.
Narrow peduncle and rounded head
Bright red colour.
VALLATE PAPILLAE: VALLATE PAPILLAE:
FILLIFORM PAPILLAE: FILLIFORM PAPILLAE:
Cover the presulculararea of the dorsum.
Velvety appearance.
Smallest and numerous.
Pointed and covered with keratin.
11/28/2010
15
The mucous membrane of the
tongue contains the receptors
for the special sensory modality
of taste.
Other sensory nerve endings
permit the tongue to detect
particle size of food, pain,
temperature, pressure & even
defects on natural teeth or a
denture.
Mucous membrane forms papillae,& is
adherent to the muscles.
Numerous glands, both serous &
mucous lie deep to the mucous
membrane.
Numerous taste buds are distributed
throughout the mucous membrane.
Taste buds are not present in the
middle of the tongue.
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16
MUSCLES OF
THE TONGUE
It contains 4 intrinsic and 4
extrinsic muscles.
Intrinsic
(I) superior longitudinal
(II) inferior longitudinal
(III) transverse
(IV) vertical
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17
Extrinsic muscles:
(I) genioglossus
(II) hyoglossus
(III) styloglossus
(IV) palatoglossus.
11/28/2010
18
Superior
longitudinal
Shortens & makes the dorsum concave. lies
beneath mucous membrane.
Inferior
longitudinal
Shortens &makes the dorsum convex. Close
to inferior surface between genioglossus
and hyoglossus.
Transverse Makes the tongue narrow & elongated.
Extends from median septum to margins.
Vertical Makes the tongue broad & flattened. Found
in the borders of anterior part of tongue.
Origin
Upper genial tubercle
Insertion
Upper fibers: tip
middle: dorsum
Lower: hyoid bone
Action
Retract the tip,
Depress tongue,
Protrude the tongue
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19
It is a lingual fixing muscle of the lower
denture.
The movements of the tongue esp the contraction is in
conjunction with the lingual vertical and the
genioglossus muscle that helps in the drawing of the
tongue anteriorly towards the floor of the muscle.
Hence, it increases the pressure which the tip of the
tongue can exert on the floor of the oral cavity and
the alveolar process.

11/28/2010
20

Origin
Greater cornu & lateral part of body of hyoid bone
Insertion
Side of the tongue between
styloglossus & inferior
longitudinalmuscle of
the tongue
Action
Depress the tongue,
Retrudes the tongue
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21
Origin
Tip and anterior surface of the
styloid process
Insertion
Side of the tongue
action
Pull the tongue upward and
forward
When the muscle contract

Terminating part of Alveolingual


sulcus is lifted alongwith
the mucousa.

Dislocating the denture


Generally, its a LINGUAL DISLOCACTING MUSCLE.
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22
Origin
Oral surface of palatine aponurosis.
Insertion
Side of the tongue at the junction of oral and
pharyngeal part of palatoglossal arch.
Action
Touches the palate. thus preventing the
bolus from coming out.
It is also a lingual dislocating
muscle.
It is having the same action as that of
the styloglossus muscle.

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23
MOTOR NERVES:
Intrinsic & extrinsic muscles except
palatoglossus- Hypoglossal nerve.
Palatoglossus Cranial part of Accessory
n. through Pharyngeal plexus.
SENSORY NERVES
Anterior 2/3 Chorda Tympani (Facial
Nerve).
General sensation -Lingual nerve.
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Posterior 1/3 general taste &sensation-
Glossopharyngeal nerve.
Posterior most- Vagus nerve.
Lingual artery which is
a branch of external
carotid artery .
The root is supplied by
tonsillar & ascending
pharyngeal arteries.
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25
Deep lingual vein is
the principal vein.
Runs backwards
&unite to form
lingual vein.
Ends in either
common facial vein
or internal jugular
vein.
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26
Tip bilaterally to Submental nodes.
The remaining right & left halves of anterior 2/3s
drain unilaterally to submandibular nodes.
Posterior 1/3 drains bilaterally into jugulo-omohyoid
nodes. (lymph nodes of the tongue).
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27
A common nodular varicose
enlargement of superficial veins on the
undersurface of the tongue is seen.
Becomes smooth &glossy or red
&inflamed in appearance.
Lingual mucosa soreness, burning or
abnormal taste sensations. (in elderly
&postmenopausal women)
The presence of a retracted tongue affects
the complete denture construction;
however, its effect on denture function
remains questionable. (J.Oral Rehab:2005 jun397-
402)
Focal collections of chronic inflammatory
cells are common, because of the infiltration
of microorganisms or toxins through the thin
epithelium of this region.
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As the age increases the motor skills
of the tongue decreases.
For complete denture wearers, the
tongue plays an important role in the
retention and stability of dentures.
Here, BRODIE spoke about the
Antagonistic muscle groups.
It can be used to stabilize the dentures.

11/28/2010
29
The resting muscles can be made to fix
a denture by 2 condtions:-
By the inclination of the polished
surfaces of the dentures.
By the polished surfaces of the
denture between the cheeks and the
lower lip on the one side and the
tongue on the other side.
The buccal flanges of the lower denture must
slope inferiorly and laterally.
The lingual flanges also must extend
inferiorly and medially below the anterior and
lateral parts of the tongue, and as far as
posteriorly by the range of the action of
tongue and internal pterygoid muscle.
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30
The position of the polished surfaces should
be such that it can be wedged between the
supporting structures.
It should be in equilibrium with the forces
acting on both side.
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31
Prosthodontic
considerations
Tongue thrusting habit tend to displace
mandibular denture and sometimes
maxillary denture also.
Measurement of the tongue force and
fatigue indicate that long span
edentulous state effects the
musculature of the tongue. The tongue
becomes stronger and this increase in
strength must be considered.
(JPD 1963,,VOL 13,857-865, by Philip Rinaladi)
11/28/2010
32
IMPRESSIONS:
Small narrow tongue easy to make
impressions. Poor border seal.
Broad thick tongue makes impression
making tough but provides good lingual
seal.
HOUSES CLASSIFICATION OF TONGUE
SIZES.
Class I: normal in size ,development &
function.
Class II: teeth have been absent long
enough to permit a change in form &
function of the tongue.
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33
Class III: the tongue is retracted &
depressed into the floor of the mouth ,with
the tip curled upward, downward or
assimilated into the body of tongue.
Class I is ideal for prostheses .
Class II & III Unfavorable
WRIGHT S CLASSIFICATION OF TONGUE
POSITION.
Class I: Tongue lies in the floor of the
mouth with the tip forward & slightly
below the incisal edges of the
mandibular anterior teeth.
Class II : The tongue is flattened &
broadened but the tip is in a normal
position.
11/28/2010
34
Class III: the tongue is retracted &
depressed into the floor of the mouth ,with
the tip curled upward, downward or
assimilated into the body of tongue.
Class I is ideal for prostheses .
Class II & III Unfavorable.
This is an area posterior to mylohyoid muscles.
Bounded by retromylohyoid curtain.
Posterolateral- overlies the superior constrictor
muscle.
Posteromedial- covers the palatoglossal muscle.
Inferior- overlies submandibular gland.
11/28/2010
35
The denture border should extend
posteriorly to contact retromylohyoid
curtain when the tip of the tongue is placed
against the front part of upper residual
ridge.
Protrusion of the
tongue
causes the
retromylohyoid
curtain to move
forward.
11/28/2010
36
The space between the residual ridge and the
tongue which extends from lingual frenum to
the retromylohyoid curtain.
Can be considered in 3 regions.
1. Anterior region : This extends from
lingual frenum to where the mylohyoid curves
down below the level of the sulcus. This
depression is called premylohyoid fossa.
This results from the concavity of the
mandible joining the convexity of the
mylohyiod ridge.
The lingual border of the impression in this
anterior region should extend down to
make definite contact with the mucous
membrane floor of the mouth when the tip
of the tongue touches the upper incisors
11/28/2010
37
Extends from the premylohyoid fossa to the distal
end of mylohyoid ridge curving medially from body of
the mandible. The curvature is caused by prominence
of mylohyoid ridge.
When the mylohyoid muscle and the tongue are
relaxed, the muscle drapes back under the mylohyoid
ridge. If the impression is made under these
conditions,the muscle will be trapped under the
ridge when the tongue is placed against upper
incisors
A slope of the lingual flange towards the
tongue in the molar region allows the
mylohyoid muscle to contract and raise the
floor of the mouth without displacing the
denture.
11/28/2010
38
This part is the retromylohyoid space or
fossa.
It extends from the end of the mylohyoid
ridge to the retromylohyoid curtain (
glossopalatine and superior constrictor
muscles).
The denture border should extend
posteriorly to contact the retromylohyoid
curtain( the posterior limit of
alveololingual sulcus) when the tip of the
tongue is placed against the front part of
upper residual ridge.
The distal end of the
lingual flange turns
buccally to fill the
retromylohyoid
fossa.
When the lingual
flange is developed
in this manner the
border has a typical
s shaped curve
11/28/2010
39
If the floor is too low ,so the dentist tends
to over extend the denture flange, which
leads to loss of retention because the
denture flange impinges on the tissue & gets
dislodged during the activation of the floor
of the mouth.
The mandibular denture should be stable
enough to resist a gentle push on the
mandibular incisors by the tongue.
Tongue position has an important bearing on
impression making and subsequent ability of
the patient to manage with the mandibular
denture.
All procedures leading to completing a
lower impression should be done with
tongue in its normal position.
11/28/2010
40
According to the degree of activity and
functional type:
1.occupational tongue.
2. Still tongue.
3.normal tongue.
4.habitual tongue.
JPD 1955,vol.5,629-635,by Barnett kessler.
Apply to those whose activities require
increased tongue action: jurist, teachers.
Lecturers.
This implies that the organ has developed a
greater range of power movements which may
results in trauma where flexibility in range is
interfered with or restricted by prosthetic
appliance.
11/28/2010
41
2. Still:Limited activity due to injury or deformity.
Can not project the tongue forward much.
Passive tongue: tongue- tie.
3. Normal :Welcomed by prosthodontists as they give a
range within limit2. s in effecting desirable
rehabilitation.
4. Habitual: describes those disturbing power movements
developed by habit.
The base of the tongue is thick and
powerful and dislodging force is most
offending to prosthetic denture.
It is suggested that the lower 2 molar in the
prosthesis may be reduced buccolingually
and may be set buccal to the ridge crest for
stability
11/28/2010
42
The actions of the tongue & cheek along
with the esthetics ,primarily determine the
lateral limits of the mandibular posterior
teeth.
The teeth shouldnt be placed more lingual
than the extent of the ridge, since elevation
of the tongue may dislodge the prosthesis.
At rest after swallowing the tip gently
touches the lingual surface of the lower
anterior teeth.
The anterior teeth must not be set too far
labially as the tongue normally rests on
the anterior teeth.
The tongue assumes a position in which its
lateral border is at the level of lingual
contour of the lower natural posterior
teeth.
11/28/2010
43
The dorsal surface is nearly at the level of
the occlusal plane of posterior teeth.
It can be used as a good guide for the height
of occlusal plane of artificial posteriors.
In prolonged edentulous patients the tongue
is hypertrophied.
Applied anatomy
11/28/2010
44
Injury to the hypoglossal nerve produces
paralysis of the muscles of the tongue on
the side of the lesion.
The lesion may be either infranuclear or
supranuclear.
Infranuclear:- gradual atrophy of the
affected half of the tongue.
Muscular twitching are also observed.
Seen typically in motor neuron
disease & in syringobulbia.
Supranuclear lesions:- produce
paralysis without wasting.
Seen in pseudobulbar palsy where the
tongue is stiff & small
11/28/2010
45
Glossitis is usually a part of generalized
ulceration of the mouth cavity.
The presence of a rich network of lymphatic &
of loose areolar tissue,in the substance of
the tongue is responsible for enormous
swelling of the tongue in acute glossitis.
The tongue fills up the mouth cavity &
protrudes out.
The under surface of the tongue is a good site
(along with the bulbar conjunctiva) for
observation of jaundice.
In unconscious patients the tongue may fall
back & obstruct air passages.
This can be prevented by lying the patient on
one side with head down (the tonsil position)
or by mechanically pulling the tongue out.
11/28/2010
46
In patients with grand mal epilepsy the tongue is
commonly bitten between the teeth during the attack.
This can be prevented by hurriedly putting a mouth gag
at the onset of the seizure.
Carcinoma of the tongue is quite common.
It is treated by radiotheraphy than by surgery.
Carcinoma of the posterior 1/3
rd
of tongue is more
dangerous due to bilateral lymphatic spread.
Lingual cusps of upper premolars protrude
lingually and restrict lateral border of
anterior 3
rd
of the tongue- needs reduction
and trimming of premolars.
Positioning of lower posteriors lingually off
the ridge causes restriction of tongue
movement- lack of space for the tongue to
stretch and relax- tongue extend towards the
throat- difficulty in breathing.
11/28/2010
47
Insufficient vertical dimension causes
excessive friction of the dorsum against the
palatal vault and occlusal surfaces of
upper teeth- Affects phonetics an
deglutition.
When dentures are worn for many years
with insufficient vertical dimension,
papillae in the anterior 3
rd
and middle 3
rd
are obliterated leading to smooth and shiny
tongue.
A total glossectomy or laryngectomy results
in loss of basic vital functions and loss of
speech.
In these patients fabrication of a mandibular
tongue prosthesis can be done.
Procedure:
Diagnostic casts are made and articulated.
Mandibular RPD is constructed with a chrome
cobalt alloy mesh work which extends to the
floor of the mouth.
11/28/2010
48
Superior portion of the tongue is concave in
form to permit food and liquid to pass
posteriorly towards the pharynx.
This tongue prosthesis is effective in
improving esthetics and function of the
patient.

11/28/2010
49
Superior portion of the tongue is concave in
form to permit food and liquid to pass
posteriorly towards the pharynx.
This tongue prosthesis is effective in
improving esthetics and function of the
patient.
B.D.Chaurasias-Human anatomy
Bouchers-Prosthodontic treatment for edentulous
patients.
Clinically oriented anatomy- Moore and Dalley.
Winklers-Essentials of complete denture
prosthodontics.
Wikipedia
Gray,s anatomy
11/28/2010
50
JPD-1955,VOL 5,629-635.
JPD-1963,VOL 13,857-865.
JPD-1978,VOL 39,652-655.
(J.Oral Rehab:2005 jun397-402)
Hps online .com
COMPLETE DENTURE THEORY AND PRACTICE Diagnosis and treatment planning
Dr.mostafa.fayad@gmail.com 1
Diagnosis and Treatment Planning
Diagnosis in complete dentures is a very important process and is not accomplished in a
short time. The dentist should be the first to recognize the problem and be ready to change the
treatment plan to meet the new findings. Treatment does not terminate with the construction
and delivery of complete dentures, and the patient should be so advised.
Diagnosis and treatment planning are the most important parameters in the successful
management of a patient. Inadequate diagnosis and treatment planning are the major reasons
behind the failure of a complete denture.
S.O.A.P.
Subjective (What the patient tells us)
Objective (What we see)
Assessment (What we deduce)
Plan (What we offer to do) (Tx Plan)
The following items will be disscussed:
Diagnosis
-Patient Evaluation
-Clinical History Taking
-Clinical Examination of the Patient
-Radiographic Examination
Assessment
Treatment Plan
Prognosis
Prosthodontic Care
COMPLETE DENTURE THEORY AND PRACTICE Diagnosis and treatment planning
Dr.mostafa.fayad@gmail.com 2
Definitions
Diagnosis
(1) The act or process of deciding the nature of a diseased condition by examination.
(2) A careful investigation of the facts to determine the nature of a thing,
(3) The determination of the nature, location, and causes of disease.
Treatment planning is a consideration of all of the diagnostic findings, systemic and local,
which influence the surgical preparations of the mouth, impression making, maxillomandibular
relation records, occlusion to be developed, form and material in the teeth, the denture base ma-
terial, and instructions in the use and care of dentures.
The factors in these findings will be governed by
(1) The patient's mental attitude,
(2) The patient's systemic status,
(3) Past dental history, and
(4) Local oral conditions.
COMPLETE DENTURE THEORY AND PRACTICE Diagnosis and treatment planning
Dr.mostafa.fayad@gmail.com 3
Factors evaluated to arrive at a proper diagnosis and treatment planning.
1-diagnosis:
a-Patient Evaluation
- Gait
- Complexion
- Cosmetic Index
- Mental Attitude
b-History taking:
Personal history
- Name
- Age
- Sex
- Occupation
- Race
- Location
- Religion
Medical History
Debilitating Diseases
Diseases of the Joints
Cardiovascular Diseases
Diseases of the Skin
Neurological Disorders
Oral Malignancies
Climacteric Conditions
Dental History
Chief Complaint
Expectations
Period of Edentulousness
Pre-treatment Records:
Previous Denture
Current Denture
Pre-extraction Records
Diagnostic Casts
Denture Success
c- Clinical Examination of the patient
Extraoral
Facial examination:
- Facial Form
- Facial Features
Muscle Tone
Muscle Development
Complexion
COMPLETE DENTURE THEORY AND PRACTICE Diagnosis and treatment planning
Dr.mostafa.fayad@gmail.com 2
Lip Examination
TMJ Examination
Neuromuscular Examination
- Speech
-Co-ordination
Intraoral:
Existing teeth (If any)
Mucosa:
- Colour of the mucosa
- Condition of the Mucosa
-Thickness
Saliva
Residual Alveolar Ridge:
- Arch Size
- Arch Form
- Ridge Contour
- Ridge Relation
- Ridge parallellism
- Inter-arch Space
Ridge Defects
Redundant Tissue
Hyperplastic Tissue
Hard palate
Soft palate and palatal Throat Form
Lateral Throat Form
Gag Reflex
Bony Undercuts
Tori
Muscle and Frenum Attachments
- Border Attachments of the Mucosa
- Frenal Attachments
Tongue
Floor of the Mouth G
d- Radiographic Examination
Bone Quality
e- Examination of the Existing Prosthesis
COMPLETE DENTURE THEORY AND PRACTICE Diagnosis and treatment planning
Dr.mostafa.fayad@gmail.com 2
2-TREATMENT PLANNING:
Adjunctive care:
Elimination of Infection
Elimination of Pathosis
Pre-prosthetic Surgery
Tissue Conditioning
Nutritional Counselling
Prosthodontics care
Patients destined to be edentulous:
Immediate or Conventional Denture
Definitive or Interim Denture
Implant or Soft Tissue Supported Denture
Patients already edentulous:
Soft Tissue Supported
Implant Supported(fixed or removable)
Material of Choice
Selection of Teeth
Anatomic Palate
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1-DIAGNOSIS
Essential diagnostic data obtained from patient interview, definitive oral examination,
consultation with medical and dental specialists, radiographs, mounted and surveyed diagnostic
casts should be carefully evaluated during treatment planning.
A - PATIENT EVALUATION
The dentist should begin evaluating the patient as soon as he/she enters the clinic. This
is to obtain a clear idea of what type of treatment is necessary for the patient.
Gait
People with neuromuscular disorders show a different gait. Such patients will have
difficulty in adapting to the denture.
Complexion and Personality
Evaluating the complexion helps to determine the shade of the teeth. Executives require
smaller teeth.
Cosmetic Index
It basically speaks about the aesthetic expectations of the patient. Based on the cosmetic
index, patients can be classified as:
- Class I: High cosmetic index. They are more concerned about the treatment and wonder
if their expectations can be fulfilled.
- Class II: Moderate cosmetic patients. They are patients with nominal expectations.
- Class III: Low cosmetic index. These patients are not bothered about treatment and the
aesthetics. It is very difficult for the dentist to know if the patient is satisfied with the
treatment or not.
Mental Attitude of Patients
A doctor should evaluate the patient's hair colour, height, weight, gait, behaviour, socio-
economic status, etc right from the moment he/ she enters the clinic. A brief
conversation will reveal his/her mental attitude.
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De Van stated, "meet the mind of the patient before meeting the mouth of the patient". Hence,
we understand that the patient's attitudes and opinions can influence the outcome of the
treatment.
Based on their mental attitude, patients can be grouped under two classifications.
1-Dr. MM House proposed the first one in 1950, which is widely followed.
House's Classification
Dr.MM House in 1950 classified patient's psychology into four types:
Class I: Philosophical
a. Those who have presented themselves prior to the extraction of their teeth, have had no
experience in wearing dentures, and do not anticipate any special difficulties in that regard.
b. Those who have worn satisfactory dentures, are in good health, are a well-balanced type,
and are in need of further denture service.Generally they can be described as mentally well
adjusted, cooperative and confident of the dentist. These patients have excellent prognosis.
Class II: Exacting
a. Those who, while suffering from ill health, are seriously concerned about appearance
and efficiency of artificial dentures. They are reluctant to accept the advice of the
physician and the dentist and are unwilling to submit to the removal of their artificial teeth.
b. Those wearing dentures unsatisfactory in appearance and usefulness, and who doubt the
ability of the dentist to render a satisfactory treatment, and those who insist on a written
guarantee or expect the dentist to make repeated attempts to please them.
These patients are precise, above average in intelligence, concerned in their dress and
appearance, usually dissatisfied by their previous treatment, do not have confidence in the
dentist. It is very difficult to satisfy them. But once satisfied they become the dentist's
greatest supporter.
Class III: Hysterical
a. Those in bad health with long neglected pathological mouth conditions and who are
positive in their minds that they can never wear dentures. They are emotionally unstable
and tend to complain without justification.
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b. Those who have attempted to wear dentures but failed. They are thoroughly
discouraged. They are of a hysterical, nervous, very exacting temperament and will
demand efficiency and appearance from the dentures equal to that of the most perfect
natural teeth. Unless their mental attitude is changed it is difficult to give a successful
treatment.
They have unrealistic expectations and want the dentures to be better than their natural
teeth. They are the most difficult patients to manage. They show poor prognosis.
Class IV: Indifferent
Those who are unconcerned about their appearance and feel very little or no necessity for
teeth for mastication. They are, therefore uncooperative and will hardly try to become
accustomed to dentures. They will not maintain the dentures properly and do not
appreciate the efforts and skills of the dentist.
2-other Classification
Patients may also be classified under the following categories:
a-Cooperative
These patients represent the optimum group. They may or may not recognize the need for
dentures but they are open-minded and are amenable to suggestion. Procedures can be
explained with very little effort and they become fully cooperative.
b- Apprehensive
Even though these patients realize the need for dentures they have some problem, which
cannot be overcome by ordinary explanation. The approach to all of these patients is to
talk with them and to make them speak out their thoughts about dentures.
Apprehensive patients are of different types namely:
Anxious: These patients are anxious and upset about the uncertainities of wearing
dentures. They often put themselves into a neurotic state. In extreme and rare
cases they may be psychotic.
Frightened: Some fear the development of cancer; others fear that they will not be
able to wear the teeth; still others fear that the teeth will not look well. Extreme
cases should be referred to a psychiatrist.
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Obsessive or exacting: These persons are naturally of an exacting nature and are
accustomed to giving directions to others. They state their wants and are inclined
to tell the dentist how to proceed. Patients of this type must be handled firmly.
They should be told tactfully at the outset that they would not be allowed to direct
the denture construction.
Chronic complainers: They are a group of people who are habitually faultfinding
and dissatisfied. Appreciating their cooperation and incorporating as many of
their ideas as possible with good denture construction is the best way to handle
them. It is best to have an understanding with such patients before work
commences. In this way they are made to share responsibility for the outcome.
Self-conscious: The apprehension here centres chiefly on appearance. It is wise to
give overt reassurance to the self-conscious patient and permit participation in the
reconstruction as far as feasible in order to establish some responsibility in the
result.
c- Uncooperative
These patients present themselves usually upon being urged by relatives or friends. They
do not feel a need for dentures, though the need exists. Their general attitude is negative.
They constitute an extremely difficult group of potential denture wearers and tax the
dentist's patience to the limit. In many cases, an attempt to make dentures for these
individuals is a waste of time.
Along with analyzing the mental attitudes of the patient, the dentist must collect information
about the patient's habits, diet, past dental history and the physical characteristics, etc. The
expectations of the patient should be taken into consideration to achieve patient satisfaction.
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B- HISTORY TAKING
History taking is a systematic procedure for collecting the details of the patient to do a proper
treatment planning. Personal and medical particulars are gathered to rule out general diseases
and to determine the best form of treatment for that patient.
Personal history
Name
The name should be asked to enter it in the record. When the patient is addressed by his
name, it brings him some confidence and psychological security. The name also gives
an idea about the patient's family and community.
Age
Some diseases are limited to certain age groups. Hence, age can be used to rule out
certain systemic conditions apart from determining the prognosis.
Patients belonging to the fourth decade of life will have good healing abilities and
patients above the sixth decade will have compromised healing.
Increasing age decreases the readiness to form new habits and also muscular efficiency is often
impaired. Young people adapt themselves more readily than do the aged. They are usually more
demanding in esthetics. Age has a definite relation to the selection of teeth, not only in their
size, shape and color, but also in various degrees of abrasion, attrition and erosion.
Sex
Generally the mentality of the patient is affected by the gender. Certain diseases are
confined to a particular sex. so, sex can be used to rule out certain systemic conditions.
Male patients are generally busy people who appear indifferent treatment. They are
only bothered about comfort and nothing else. On the other hand, female patients are
more critical about aesthetics.
Factors such as menopause are an influencing factor in the overall success of dentures.
Menopause is often reflected in symptoms of a burning mouth, which most patients will
attribute to the prosthetic appliance rather than to systemic disturbances.
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Occupation
Executives and sales representatives require more idealistic teeth. While other people
who work in places with high physical exertion require rugged teeth. And people with
higher income have greater expectations. People who are very busy will be more critical
about comfort.
This will frequently have a relation to the design of the dentures and the technique used
in impression making, for example:
a- With most professional men whose occupation entails intimate contact with their
fellows, appearance and retention are more important than efficiency. They are
more demanding of artificial replacements as they constantly deal with people.
b- Public speakers and singers require perfect retention and particular attention to
palatal shape and thickness because of the importance of these in phonation.
Race
It helps to select the shade of the teeth.
Location
Some endemic disorders like fluorosis are confined to certain localities. People from
that locality may want characterization (pattern staining) in their teeth for a natural
appearance.
Religion and Community
Gives an idea about the dietary habits and helps to design the denture accordingly.
Medical History :The following medical conditions should be ruled out.
Debilitating Diseases
Complete denture patients, most of whom are geriatric, may suffering from debilitating
diseases like diabetes, blood dyscrasias and tuberculosis.
These patients require specific instructions on denture/tissue care. They also require
special follow-up appointments to observe the response of the soft tissues to the denture.
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Diabetic patients show excessive rate of bone resorption, hence, frequent relining may
be necessary. And Epithelium is thinner, less keratinized and more sensitive to trauma.
Result in Compromised, support and impaired tolerance of complete dentures.. In
planning a denture for a diabetic, we should consider a reduced occlusal table, an
increased amount of free way space together with frequent scheduled adjustments and
recalls. The diabetic shows a tendency toward edema during periods of imbalance. This
must be considered in scheduling impression procedures.
Diseases of the Joints
Complete denture patients with osteoarthritis affecting the finger joints may find it
difficult to insert and clean dentures.
Osteoarthritis plays an important role in complete denture construction when it affects
the TMJ. With limited mouth opening and painful movements of the jaw, it becomes
necessary to use special impression trays. It may also become necessary to repeat jaw
relations and make post-insertion occlusal adjustments due to changes in the joint.
Osteoporosis
Although this condition has already been mentioned with respect to the denture-bearing
tissues, it is appropriate to mention that it can lead to a hunched posture, or kyphosis,
which requires the dentist to ensure that work is undertaken with the patient in the
sitting position with the head and neck adequately supported.
Cardiovascular Diseases
It is always advisable to consult the patient's cardiologist before commencing treatment.
Cardiac patients will require shorter appointments.
Angina
Angina can cause pain that is experienced around the left body of the mandible or even
the left side of the palate. This usually occurs in association with chest pain and the
onset is usually related to physical exertion.
Congestive heart failure, chronic bronchitis and emphysema
Elderly patients with these conditions are likely to become breathless if the dental chair
is tipped back into the supine position.
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Cerebro-vascular accident
The occurrence of a stroke may result in unilateral paralysis of the facial muscles,
making it more difficult for the patient to control dentures, especially the lower denture.
The patient may also have difficulty clearing food which has lodged in the buccal
sulcus.
Speech may be affected, making it difficult for the patient to communicate with the
dentist.
Diseases of the Skin
Skin diseases like Pemphigus have oral manifestations, which vary, from ulcers to
bullae. Such painful conditions, make the denture use impossible without medical
treatment.
Neurological Disorders
Diseases such as Bell's palsy and Parkinson's disease can influence denture retention
and jaw relation records. Patients should understand the difficulty in denture fabrication
and usage.
Anemia
The anemia results in poor nervous disorders reflecting lack of coordination and
extreme irritability. Parkinson's disease affects the ability of the patient to wear
dentures, and increase the hazards of denture procedures.
Transmitted diseases:
Hepatitis, T.B., influenza, H.I.V.
Hazards From communicated blood, saliva, aerosol& instruments.
Impression should be immediately disinfected.(Chemical sterilization)
Pemphigus Vulgaris:
Before 1959 the disease is fatal.
Bulla with gradual extension. Chronic ulceration withsubsequent scarring of the oral
mucosa.
Acute phase: Oral discomfort& dryness of the mouth are common pain& loose
denture.
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Limited denture extensions compromising support, stability, retention and tolerance of
complete dentures. Borders should be smooth& polished to prevent irritation.
Post-insertion care.
Oral Lichen Planus
Erosive lesions and subsequent scarring in the buccal shelf area limit denture extension
in this region and make it difficult for some patients to tolerate their dentures.
Result - Compromised support and tolerance of the mandibular denture.
Chronic Candidiasis
Low saliva flow rates lead to increased numbers off fungal organisms leading tto a high
incidence of chronic candidiasis..
Burning and irritation of the denture bearing mucosa, making tolerance of complete
dentures difficult. In addition the fungus is keratolytic, further compromising support
and tolerance.
Treatment: Antifungal therapy*
Nystatin powder (100,000 units per gram). Apply to undersurface of denture
three times per day for 3-4 weeks
Nystatin cream Best used for lesions associated with the corners of the mouth
Reline or remake denture
*Nystatin rinse is generally ineffective. Nystatin oral lozenges are reserved for fungal
infestations that extend beyond the denture bearing surfaces.
Parkinson disease:
Rhythmic contractions of the musculature (muscles of mastication).
Severe cases (Impossible for a pt. to insert& remove the denture).
Impression procedures may be compromised by the presence of excessive saliva in this
case.
Acromegaly:
Pt. may have a large Mandible.
Frequent examination to evaluate fit& function.
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Paget's disease:
Pt. with disease may have enlarged maxillary tuberosity (affects fit& occlusion).
Surgical re-contouring or relief.
Frequent recall appointments.
Oral Malignancies
Some complete denture patients with oral malignancies may require radiation therapy
before prosthetic treatment.
A waiting period should elapse between the end of radiation therapy and the beginning
of complete denture construction. Only the radiotherapist determines this waiting
period.
Tissues having bronze colour and loss of tonicity are not suitable for denture support.
Once the dentures are constructed, the tissues should be examined frequently for
radionecrosis.
Climacteric Conditions
Climacteric conditions like menopause can cause glandular changes, osteoporosis and
psychiatric changes in the patient. These can influence treatment planning and the
efficiency of the complete denture.
Other common manifestations in and around the oral cavity must be considered. These include
tempromandibular joint disturbances, facial neuralgias, various types of neurosis, multiple
sclerosis, coordination, intelligence, and even the desire to wear dentures.
Nutritional deficiencies
Deficiencies of the vitamin B complex, folic acid and iron can lead to pathology of the
mucosa and to widespread discomfort or burning.
Psychiatric disorders
Depression is the most common mental disorder in later life. The prevalence of
depression requiring clinical intervention in the over 65s is between 13% and 16%).
This condition can result in poor appetite and weight loss, and can adversely affect
motivation and self-care.
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Evaluating the effect of drugs on Dental& Prosthetic ttt:
1- Anticoagulants:
Medical consultation is required when surgical preparation for the prosthodontic
restoration is required.
2- Antihypertensive Agents:
Syncope may occur when pt. change it's position suddenly into upright position
(It occurs when the pt. rises from dental chair).
Saliva& dry mouth may be found.
3- Endocrine therapy:
Endocrine therapy may lead to Xerostomia& oral discomfort.
4- Saliva Inhibiting drugs:
Atropine& their derivatives (used to control excessive salivation).
These drugs should be avoided in Prostatic hypertrophy& Glaucoma and the
salivary secretion controlled mechanically.
Xerostomia is produced by certain antidepressants, diuretics, antihypertensives and
antipsychotics. Lack of saliva adversely affects the retention of dentures, increases the
possibility of oral infection and, through the absence of lubrication, can result in generalised
soreness or even a burning sensation.
Certain drugs, such as steroid inhalers used in the treatment of asthma, immunosuppressive
drugs and broad-spectrum antibiotics used over a long period, can alter the oral flora thus
predisposing to candida infection.
Tardive dyskinesia is a condition characterized by spasmodic movements of the oral, lingual
and facial muscles. These uncontrollable movements can make it extremely difficult, or even
impossible, to provide stable dentures. The condition is brought on by extensive use of drugs
such as antipsychotics and tricyclic antidepressants.
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Dental History
Chief Complaint
It should be recorded in the patient's own words. It gives ideas about the patient's
psychology.
Expectations
The patient should be asked about his/her expectations. The dentist should evaluate the
patient's expectations and classify them as realistic or attainable and unrealistic.
If prior to being rendered edentulous, a partial denture was worn with comfort and
efficiency, the same will be expected of complete dentures. It should be explained to
such patients that, although partial denture experience is helpful in relation to complete
dentures, the latter require a considerably greater degree of control because they are not,
as were the partial dentures, retained or supported by the natural teeth.
If complete dentures are already being worn and they have been comfortable and
efficient, the same will be expected of the new dentures. If the old complete dentures
were troublesome, the attitude may be expectant of better results with the new dentures
or pessimism that nothing better can be hoped for.
If no previous denture experience exists, friends or relations may have colored the
patient's mind with their own attitudes. In such cases the efficient control and use of
complete dentures depends to a very large extent on the formation of new habits and a
new pattern of muscular movement. This demands time and some patience on the part
of the wearer. Many complete denture troubles can be traced to the fact that no
preparation of the patient's mind preceded the fitting of the dentures.
Information regarding the loss of the natural teeth:
A history of difficult extractions should be followed by a radiographic examination of
the jaws to verify the absence of retained roots.
Questioning should be directed to eliciting the general order in which the teeth were
lost. For example if all the posterior teeth were extracted some years before the anterior
ones and no partial dentures were worn in the meantime, then a habit of eating with the
front teeth will have been formed which, if persistent, will have a pronounced
unstabilizing effect on complete dentures.
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A similar condition will exist in individuals who have been edentulous for a
considerable length of time and have not worn dentures, as a result they are only able to
approximate their jaws in the anterior region and consequently forward travel of the
mandible is necessary all the time during eating.
When there is a history of abnormal mandibular function or movement, then difficulty
can be anticipated when registering the anteroposterior occlusal relationship.
Period of Edentulousness
This data gives information about the amount and pattern of bone resorption. The cause
for the tooth loss should be enquired (caries, periodontitis, etc.)
Pre-treatment Records
The pre-treatment record is a very valuable information. Pre-treatment records include
information about the previous denture, current denture, pre-extraction records and
diagnostic casts. It includes pre-extraction radiographs, photographs, diagnostic casts,
etc. They can be used to reproduce the anterior aesthetics.
Previous denture
It denotes the dentures, which were worn before the current denture. The reason for the
failure of the prosthesis should be enquired with the patient. The patients who keep
changing dentures in a short period of time are difficult to satisfy and are risky to deal
with.
Current denture
The existing denture, which is worn by the patient at present, should be examined
thoroughly. The reason for wanting a replacement should be evaluated. This denture
gives us information about the denture experience, denture care, dental knowledge and
para-functional habits of the patient.
Denture success
The patients should be asked about the aesthetics and functioning of the existing
denture. Based on the patient's comment, the denture success should be classified as
favourable or unfavourable.
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The following factors should be noted on the existing prosthesis:
The period for which the patient has been wearing the denture should be determined. The
amount of ridge resorption should be assessed to determine the amount of expected ridge
resorption after placement of the new prosthesis.
Anterior and posterior teeth shade, mould and material.
Centric occlusion and also the patient profile in centric relation. (Centric occlusion is "the
centered contact position of the occlusal surfaces of the mandibular teeth against the occlusal
surfaces of the maxillary teeth"'-GPT). It should be marked as acceptable or unacceptable.
Vertical dimension at occlusion. It should be marked as acceptable or unacceptable.
Plane of orientation of the occlusal plane. Improperly-oriented plane will have teeth
arranged in a reverse smile line.
The tissue surface and the polished or cameo surface of the palate should be examined.
Reproduction of rugae should be noted.
The patient's speech pattern should be noted for any valving nasal twang.
The posterior extension of the maxillarydenture should be noted.
The posterior palatal seal should beexamined. It should be marked as acceptableor
unacceptable.
Proper basal seat coverage and adaptationshould be noted. It should be marked as acceptable
or unacceptable
The midline of the denture should be checked. At-least the maxillary denture should coincide
with the facial midline.
Characterization or purposeful staining of the denture for esthetics should be recorded.
Wear or breakage. This may be an indication of bruxism. Denture wear can be classified as:
1. Minimal
2. Moderate
3. Severe.
Diagnostic cast
Sometimes, intraoral examination may be inaccurate because the patient moving his jaws and
altering ridge relationship. In such cases it may be necessary to prepare diagnostic casts and
mount them in an articulator in a tentative jaw relation. This set-up serves to assess the inter-
ridge space, ridge form and ridge shape.
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C- CLINICAL EXAMINATION OF THE PATIENT
A- Extraoral Examination
The patient's head and neck region should be examined for any pathological condition.
Facial colour, tone, hair color and texture, symmetry and neuromuscular activity are noted. It
includes facial examination, examination of muscle tone and development, lip examination,
TMJ examination and neuromuscular examination.
Facial Examination: An edentulous patient should be examined facially in front and
profile views.
1. The fullness and normal contour of the upper lip is lost due to the lack of support by
the loss of teeth.
2. The normal lip line and natural vermilion border of the upper lip is changed due to
this falling in and the philtrum looks unsupported.
3. The nasal folds are deepened, the mental tip is exaggerated and facial wrinkles may
result as the person has been without teeth for sometime
It includes the evaluation of facial features, facial form, facial profile and lower facial height.
a-Facial Features The following features should be noted during diagnosis of the patient:
Length of the lips.
Lip fullness.
Apparent support of the lips.
Philtrum.
Nasolabial fold.
Mentolabial sulcus or labiomental groove.
Labial commissures and modiolus.
Width of the vermillion border. It influences the degree of tooth display.
Size of the oral opening. It also influences the degree of tooth display.
Texture of the skin: (rough or smooth)
All the above-mentioned factors aid to determine the shade, shape and arrangement of teeth
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b-Facial form
House and Loop, Frush and Fisher, and Williams classified facial form based on the outline of
the face as square, tapering, square tapering and ovoid.
Examining the facial form helps in teeth selection
c-Facial profile
Angle classified facial profile as:
Class I: Normal or straight profile
Class II: Retrognathic profile.
Class III: Prognathic profile
Examination of the facial profile is very important because it determines the jaw relation and
occlusion.
d- Lower facial height
If the face appears collapsed, it indicates the loss of vertical dimension (VD). Decreased VD
produces wrinkles around the mouth. Excessive VD will cause the facial tissues to appear
stretched
Determining the lower facial height is important to determine the vertical jaw relation . For
those patients who are already wearing a complete denture, the lower facial height is examined
under occlusion.
Muscle Tone
House classified muscle tone as:
Class I: Normal tension, tone and placement of the muscle of mastication and facial
expression. No degeneration. It is common in immediate denture patients because all
other patients generally show degeneration.
Class II: Normal muscle function but slightly decreased muscle tone.
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Class III: Decreased muscle tone and function. It is usually accompanied with ill-
fitting dentures, decreased vertical dimension, decreased biting force, wrinkles in the
cheeks and drooping of commissures.
House classified muscle development as:
Class I; Heavy
Class II: Medium
Class III: Light.
Muscle tone can affect the stability of the denture. People with excessive muscle development
have more biting force.
Complexion
The colour of the eye, hair and the skin guide the selection of artificial teeth.
Pale skin colour is indicative of anaemia and should be treated.
Lip Examination
Lip support: Based on the amount of lip support, lips can be classified as
adequately supported or unsupported.
Lip mobility: Based on the mobility, lips are classified as
normal (class 1),
reduced mobility (class 2) and
paralysed (class 3).
Thickness of the lips: Thick lips need lesser support from the artificial teeth and
the labial flange. Thus, the operator is free to place the teeth to his wishes. On the other
hand, thin lips rely on the appropriate labiolingual position of the teeth, for their fullness
and support.
Length of the lips: It is an important determinant in anterior teeth selection.
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Health of the lips: The lips are examined for fissures, cracks or ulcers at the
corners of the mouth. If present these indicate vitamin B deficiency, candidiasis, or
prolonged overclosure of the mouth due to decreased VD.
TMJ Examination
The joint should be examined for range of movements, pain, muscles of mastication, joint
sounds upon opening and closing.
TMJ plays a major role in the fabrication of a CD. Severe pain in the TMJ indicates increased
or decreased VD.
Neuromuscular Examination
It includes the examination of speech and neuro-muscular coordination.
Speech
Speech is classified based on the ability of the patients to articulate and coordinate it.
Type 1: Normal. Patients who are capable of producing an articulated speech with their
existing dentures can easily accommodate to the new dentures.
Type 2: Affected. Patients who have impaired articulation or coordination of speech
with their existing dentures require special attention during anterior teeth arrangement
(setting).
Patients whose speech was altered due to a poorly-designed denture require more time to adapt
to a proper articulated speech in the new denture.
Neuromuscular coordination
The patient is to be observed from the time he/she enters the clinic. The patient's gait,
coordination of movements, the ease with which he moves and his steadiness are
important points to be considered.
Any deviation from the normal will indicate that the patient is suffering from
neuromuscular diseases like Parkinson's disease, hemiplegia, cerebellar disease or even
the use of psychotropic drugs. These conditions also produce their manifestations on the
face.
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Neuromuscular coordination of a patient can be classified as:
Class I: Excellent.
Class II: Fair.
Class III: Poor.
Patients with good neuromuscular coordination can easily learn to manipulate dentures.
B- Intraoral visual Examination
a- Existing Teeth :
The condition of the existing teeth is of importance for single complete dentures. The
state of the remaining teeth influence the success of tooth-supported overdentures.
b- Mucosa
Colour of the mucosa The mucosa should have a healthy pink colour. colour changes
such as white patches or redness should be noted .
White patches may indicate an area of frictional keratosis.
Redness may indicates an inflammatory change. This may be due to ill-fitting denture,
smoking, infection or a systemic disease. Inflamed tissues provide a wrong recording while
making an impression. it may be due to inflammation caused by irritation, which may be due to
mechanical, chemical or bacteriological causes.
Common prosthetic causes:
1- Overextension of the periphery of the denture: this is frequently seen as a bright red line,
which may break down to ulceration if the irritation is continued. It may be due to
overextension of the periphery of new dentures or the altered position of existing dentures due
to alveolar absorption. In some cases this irritation if continued over a long period of time, will
cause a proliferation of the mucous membrane, which is visible as a ridge, flap or series of flaps
(Denture fissuratum).
2- Dirty, ill fitting dentures: the inflammation usually appears as an ill-defined red area, which
varies with the extent of the mucous membrane most constantly in contact with the denture.
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3- Continuous wearing of the denture: it may cause a chronic inflammation of the underlying
mucosa.
4- Faulty articulation of teeth (traumatic occlusion): Inflammation may be found on the crest of
the alveolar ridge if the occlusion is too heavy in one particular spot, or on the sides of the ridge
if there is a lateral drag caused by cuspal interference.
5- Traumatic injury: the edentulous mouth frequently sustains injuries to the mucosa from sharp
pieces of food such as crusts or small bones.
6- Small spicules of alveolar bone: sharp edges of both sockets not yet rounded by absorption
frequently cause inflammation of Ire mucosa covering them. Also, small pieces of bone
fractured during the extraction of the teeth ad in the process of being exfoliated may cause
inflammation.
7- Allergy: it is very rare. Most of the cases are due to dirty, ill-fitting dentures.
8- Other causes of color variation:
These are most frequently signs of some general systemic disturbances for which reference
should be made to textbooks on oral pathology, and the only safe rule to follow is never to
proceed with prosthetic work until the cause of color variation has been investigated.
Condition of the mucosa House classified the condition of the mucosa as:
Class I: Healthy mucosa.
Class II: Irritated mucosa.
Class III: Pathologic mucosa.
Thickness of the mucosa The quality of the mucoperiosteum may vary in different parts of the
arch. House classified thickness of the mucosa as:
Class I: Normal uniform density of mucosal tissue (approximately 1 mm thick).
Investing membrane is firm but not tense and forms ideal cushion for denture basal seat.
Class II: It can be of two types:
a. Soft tissues have a thin investing membrane and are highly susceptible to irri-
tation under pressure.
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b. Soft tissues have mucous membranes that are twice the normal thickness.
Class III: Soft tissues have excessively thick investing membranes filled with redundant
tissues. This requires tissue treatment
Variations in the thickness of mucosa make it very difficult to equalize the pressure under the
denture and to avoid soreness
Inflammatory Fibrous Hyperplasia (Epulis Fissuratum)
Continued denture wear and irritation leads to inflammatory fibrous hyperpllasiia
(epulliis ffiissurattum).. Therapy - surgical excision
Inflammatory Papillary Hyperplasia
Papillary hyperplasia is secondary to ill-fitting maxillary dentures and is sometimes
complicated by chronic candidiasis. Therapy: Antifungal medications applied topically.
In extreme cases, surgical excision.
c- Saliva
All major salivary gland orifices should be examined for patency. The viscosity of the
saliva should be determined. Saliva can be classified as:
Class I: Normal quality and quantity of saliva. ideal cohesive and adhesive properties
Class II: Excessive saliva. Contains much mucus.
Class III: Xerostomia. Remaining saliva is mucinous.
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Thick ropy saliva alters the seat of the denture because of its tendency to accumulate between
the tissue and the denture. Thin serous saliva does not produce such effects.
Xerostomic patients show poor retention and excessive tissue irritation wheras excessive sali-
vation complicates the clinical procedures.
d- Residual Alveolar Ridge
While examining the residual alveolar ridge the arch size, shape, inter-arch space, ridge
contour, ridge relation and ridge parallelism should be noted.
Arch size : Arch size can be classified as follows:
Class I: Large (ideal retention and stability)
Class II: Medium (good retention and stability)
Class III: Small (difficult to achieve good retention and stability)
Arch should be observed for two main reasons:
Denture bearing area increases with arch size and in turn increases the retention.
Discrepancy between the mandibular and maxillary arch sizes can lead to difficulties in
artificial teeth-arrangement and decrease the stability of the denture resting in the smaller one of
the two arches.
Arch form : House classified arch form as:
Class I: Square
Class 11: Tapering
Class III: Ovoid
This plays a role in support of a denture and in tooth selection. Discrepancies between the
maxillary and mandibular arch forms can create problems during teeth setting.
Ridge contour :Ridges should be both inspected and palpated. The ridge should be
palpated for bony spicules which produce pain on palpation.
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Ridges can be classified as based on their contour as:
High ridge with flat crest and parallel sides (most ideal)
Flat ridge
Knife-edged ridge
There is another classification for ridge contour. According to that classification, the
maxillary and mandibular ridges are classified separately.
Classification of maxillary ridge contour:
Class I: Square to gently rounded.
Class II: Tapering or 'V shaped.
Class III: flat.
Classification of mandibular ridge contour:
Class I: Inverted 'U' shaped (parallel walls, medium to tall ridge with broad ridge
crest)
Class II: Inverted 'U' shaped (short with flat crest)
Class III: Unfavourable
Inverted W
Short inverted V
Tall, thin inverted V
Undercut (results due to labioversion or linguoversion of the teeth
Ridge relation
Ridge relation is the positional relation of the mandibular ridge to the maxillary ridge" - GPT.
Ridge relation refers to the anterior posterior relationship between the ridges.
Angle classified ridge relationship.
Class I: Normal Class II: Retrognathic Class III: Prognathic
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While examining ridge relation, the pattern of resorption of the maxillary and mandibular
arches should be remembered (maxilla resorbs upward and inward while the mandible resorbs
downward and outward).
Ridge parallelism
Ridge parallelism refers to the relative parallelism between the planes of the ridges. The ridges
can be relatively parallel or non-parallel.
Teeth setting is easy in relatively parallel-ridge
Inter-arch space
Inter-arch space The amount of inter-arch space should be measured and recorded.
Inter-arch space can be classified as follows:
Class I: Ideal inter-arch space to accommodate the artificial teeth (Fig. 2.38).
Class II: Excessive inter-arch space (Fig. 2.39).
Class III: Insufficient inter-arch space to accommodate the artificial teeth
Increase in inter-arch space will be due to excessive residual ridge resorption. These patients
will have decreased retention and stability of their dentures.
Decrease in inter-arch space will make teeth-arrangement a difficulty. However, stability of the
denture is increased in these patients due to decrease in leverage forces acting on the denture
e- Ridge Defects
Ridge defects include exostoses and pivots that may pose a problem while fabricating a
complete denture.
f- RedundantTissue
It is common to find flabby tissue covering the crest of the residual ridges. These
movable tissues tend to cause movement of the denture when forces are applied. This
leads to loss of retention.
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g- HyperplasticTissues
The most common hyperplastic lesions are epulis fissuratum, papillary hyperplasia of
the mucosa and hyperplastic folds. Treatment for these lesions includes rest, tissue
conditioning and denture adjustments. Surgery is considered if the above mentioned
treatments fail.
h- Hard Palate
The shape of the vault of the palate should be examined.
Hard palates can be classified as:
U-shaped: Ideal for both retention and stability
V-shaped: Retention is less, as the peripheral seal is easily broken
Flat: Reduced resistance to lateral and rotatory
i- Soft Palate and Palatal Throat Form
While examining soft palates, it is important to observe the relationship of the soft palate to
the hard palate. The relationship between the soft palate and the hard palate is called palatal
throat form.
Classification of soft palates
Class I: It is horizontal and demonstrates little muscular movement. In this case
more tissue coverage is possible for posterior palatal seal
Class II: Soft palate makes a 45 angle to the hard palate. Tissue coverage for
posterior palatal seal is less than that of a class I condition (Fig. 2.45).
Class III: Soft palate makes a 70 angle to the hard palate. Tissue coverage for
posterior palatal seal is minimum
It should be observed here that a classIII soft palate is commonly associated with a V-shaped
palatal vault and classI or classII soft palates are associated with a flat palatal vault.
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j- Gag Reflex and Palatal Sensitivity
Some patients may have an exaggerated gag reflex, the cause of which can be due to a
systemic disorder, psychological, extraoral, intraoral or iatrogenic factors.
House classified palatal sensitivity as:
Class I: Normal
Class II: Subnormal (Hyposensitive)
Class III: Supernormal (Hypersensitive)
The management of such patients is through clinical, psychological and pharmacological
means. If the patient lacks progress he/she should be referred to a specialized consultant.
k- Bony Undercuts
Bony undercuts do not help in retention, rather they interfere with peripheral seal.
Bony undercuts are seen both in the maxilla and the mandible.
In the maxillary arch, they are found in the anterior region and laterally in the
region of the tuberosities. In the mandibular arch, the area under the mylohyoid
ridge acts as an undercut.
In case of maxillary arch, surgical removal of the undercut is not necessary, providing relief is
enough. In case of the mylohyoid ridge, surgical reduction or repositioning of the mylohyoid
attachment can be done. Bilateral undercuts should be eleminated.
l- Tori
Tori are abnormal bony prominences found in the middle of the palatal vault and on the
lingual side of the mandible in the premolar region.
It is not necessary to remove maxillary tori surgically unless they are very big. On the
other hand, lingual tori are a constant hindrance to complete denture construction and
have to be removed surgically.
In order to prevent injury to the thin mucosa covering the tori, adequate relief should be pro-
vided in that region during complete denture fabrication. Rocking of the denture around the tori
will occur in cases with excessive residual ridge resorption.
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m- Muscle and Frenal Attachments
Muscular and frenal attachment should be examined for their position in relation to the
crest of the ridge. In cases with residual ridge resorption, it is common to see the
maxillary labial and lingual frenal attachments close to the crest of the ridge.
These abnormal attachments can produce displacement of the denture during muscular action.
These muscular and frenal attachments should be surgically relocated.
n- Tongue
The tongue should be examined for the following:
o Size: Presence of a large tongue decreases the stability of the denture and it is
hindrance to impression making. Tongue-biting is common after insertion of the
denture. A small tongue does not provide adequate lingual peripheral seal.
o Movement and coordination: Tongue movements and coordination are
important to register a good peripheral tracing. They are also necessary in
maintaining the denture in the mouth during functional activities like speech,
deglutition and mastication, etc.
o- Floor of the Mouth
o The relationship of the floor of the mouth to the crest of the ridge is crucial in
determining the prognosis of the lower complete denture.In some cases, the floor
of the mouth is found near the crest of the ridge, especially in the sublingual and
mylohyoid regions. This decreases the stability and retention of the denture.
o The floor of the mouth can be measured with a William's probe. The patient
should touch his upper lip with the tongue to activate the muscles of the floor of
the mouth.
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C- Intraoral Digital Examination
Before starting to explore the mouth with the fingertips the patient should be asked to indicate
immediately if any pain is felt and the cause of such pain must be found. Any area, which is
painful to the pressure of a soft finger, is unlikely to tolerate the pressure of a hard denture.
1- Firmness of the ridge:
Placing a finger on each side of the ridge and applying alternate lateral pressure most
conveniently tests this. Flabby fibrous ridge may be encountered in all parts both of
upper and lower jaws.
2- Regularities of the alveolar ridge:
Alveolar absorption is never uniform and hard nodules, sharp edges, spikes and
irregularities are frequently felt and pain on pressure over these areas is common. The
prosthodontist must at this stage decide whether surgical correction is needed, whether
they will remedy themselves in time in course of normal absorption or whether relief of
the denture alone will be satisfactory.
3- Variations of mucous membrane:
The ideal mucosa on which to seat complete dentures should be:
a- Firmly bound down to the sub-adjacent bone by union with the periosteum, thus
prevent the denture and mucosa moving together in relation to the supporting bone.
b- Slightly compressible: to allow the denture to bed comfortably into place because
the mucosa will adjust itself slightly to the fitting surface of the denture. This will very
materially increase the retention by adhesion and cohesion because the film of saliva
between the denture and the mucous membrane will be very thin. It will also allow
maximum retention from atmospheric pressure because the denture bedding slightly into
the tissue will prevent air leaks. In addition such mucosa will act as a cushion to the
normal stresses of mastication and prevent the development of sore spots
c- Even thickness: Thin mucosa covering a well-defined torus palatinus and flanked by
thick compressible membrane will result in a denture, which rocks during function
causing pain to the patient and frequently fracture of the denture due to the repeated
flexure the base is required to undergo during mastication.
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4- Maxillary tuberosities:
There may be found on visual examination to be bulbous and to have a definite undercut
area above them, but only by palpation can it be determined whether the bulbous portion
is composed of hard or soft tissues.
5- Mylohyoid ridges:
Some of these ridges are felt to be pronounced and sharp and others are felt ill-defined
and rounded.
6- Lingual pouch:
The extent of the pouch with the tongue at rest and with the tongue protruded
sufficiently to lick the lips and also during the act of swallowing should be noted. This
is done by gently inserting the index finger into the pouch and asking the patient to
perform the above actions.
Determination of functional depth of alveolingual sulcus
Carefully examine the retromylohyoid space to determine
the floor of mouth posture.
After placing the mirror in the retromylohyoid space,
instruct the patient to move the tongue to opposite side.
The less your mirror is displaced the more favorable the
floor of mouth posture and the longer the distal lingual
flange can/should be.
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D- RADIOGRAPHIC EXAMINATION
The radiograph of choice for the examination of a completely edentulous patient is panoramic
radiograph because they image the entire mandible and maxilla.
Considerations During Radiographic examination
The jaws should be screened for retained root fragments, unerupted teeth, rarefaction,
sclerosis, cysts, tumours and TMJ disorders
The amount of ridge resorption should be assessed.
Wical and Swoope devised a method for measuring ridge resorption. According to
them, the distance between the lower border of the mandible and the lower border of
the mental foramen multiplied by three will give the original alveolar ridge crest
height. The lower edge of the mental foramen divides the mandible into upper two-
thirds and lower one-third.
The amount of resorption can be classified as follows:
Class I: (mild resorption) loss of upto one-third of the vertical height.
Class II: (moderate resorption) loss of upto two-thirds of the vertical height
Class III: (severe resorption) loss of more than two-thirds of the vertical height.
The quantity and quality of the bone should be assessed.
Branemark et al classified bone quantity radiographically as Classes A,B,C,D and E .
He classified bone quality radiographically as Classes 1,2,3 and 4 .
X-ray photographs should l be taken to confirm or assist in diagnosis in the following cases:
1- Buried roots.
2- Sinuses.
3- Unilateral swellings.
4- Rough alveolar ridges.
5- Areas painful to pressure.
6- Impacted teeth. Cysts.
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E- Examination of the Existing Prosthesis
Extra-oral examination of the dentures
The dentures are removed from the mouth and a detailed and systematic extra-oral
examination is made of their impression, polished and occlusal surfaces. Any relevant
findings are recorded.
Impression surface
The presence or absence of a post-dam and palatal relief.
Width of borders.
The amount and distribution of plaque, an important cause of denture stomatitis . Painting
disclosing solution on the impression surface will help to visualize the plaque.
Evidence of adjustments, relines or repairs.
Surface roughness.
Polished surface
Shape and inclination. In essence, is the shape such that it will allow the muscles to help
rather than hinder the control of the denture?
Condition and general cleanliness of the denture material.
Occlusal surface
Amount of wear; presence of shiny facets.
Teeth acrylic or porcelain; size, shape and colour.
Intra-oral examination of the dentures
Each denture is then placed in the mouth separately and examined for:
Stability
Retention
Border extension.
The dentures are then examined together to assess the:
Occlusion
Occlusal vertical dimension
Appearance.
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Additionai Diagnostic Inormaton
Diagnostic casts
They are very helpful to further evaluate the anatomy and condition of the residual ridges.
Generally diagnostic casts are made from preliminary impressions made wii irreversible
hydrocolloid (alginate) in stock trays. Good diagnostic casts should include the retromolar
pads and border tissues as well as the pterygomaxillary notch and the posterior palatal seal
area
Prosthodontic Diagnostic Index (PDI).
Another tool to help the dentist identify' the complexity of their denture patient is called the
Prosthodontic Diagnostic Index (PDI). The American College of Prosthodontists has
recommended that practioners use the PDI to classify edentulous patients. This system is said
to help better identify difficult denture patients.
[For details see: introduction]
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2-Prosthodontic assessment
-Clinical factors influencing stability, retention, and support of complete dentures
- Previous denture assessment
3- TREATMENT PLAN
Elimination of Infection
Sources of infection like infected necrotic ulcers, periodontally weak teeth, and
nonvital teeth should be removed. Infective conditions like candidiasis, herpetic
stomatitis, and denture stomatitis should be treated and cured before commencement
of treatment.
Elimination of Pathology
Pathologies like cysts and tumours of the jaws should be removed or treated before
complete denture treatment begins. The patient should be educated about the harmful
effects of these conditions and the need for the removal of these lesions. Some
pathologies may involve the entire bone. In such cases, after surgery, an obturator may
have to be placed along with the complete denture.
Preprosthetic Surgery
Preprosthetic surgical procedures enhance the success of the denture. Some of the common
preprosthetic procedures are:
Labial frenectomy.
Lingual frenectomy.
Excision of denture granulomas.
Excision of flabby tissue.
Reduction of enlarged tuberosity.
Excision of hyperplastic retromolar
pad.
Alveoloplasty.
Alveolectomy
Reduction of genial tubercle.
Reduction of mylohyoid ridge.
Excision of tori.
Vestibuloplasty.
Lowering the mental foramen.
Ridge augmentation procedures.
Implants
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Tissue Conditioning
The patient should be requested to stop wearing the previous denture for at least 72
hours before commencing treatment. He/she should be taught to massage the oral
mucosa regularly.
Special procedures should be done in patients who have adverse tissue reactions to the
denture. Denture relining material should be applied on the tissue side of the denture
to avoid denture irritation. Treatment dentures or acrylic templates can be prepared to
carry tissue-conditioning material during the treatment of abused tissues.
Nutritional Counseling
Nutritional counseling is a very important step in the treatment plan of a complete
denture. Patients showing deficiency of particular minerals and vitamins should be
advised a proper balanced diet. Patients with vitamin B2 deficiency will show angular
cheilitis. Prophylactic vitamin A therapy is given for xerostomic patients. Nutritional
counseling is also done for patients showing age-related changes such as osteoporosis.
Following the diagnosis, a treatment plan is formulated. Possible treatment options include:
No treatment.
Preparatory treatment such as denture adjustment or a short-term reline
Definitive denture modifi cations such as reline, rebase, repair or cleaning.
Replacement dentures.
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There are several approaches to designing and constructing complete dentures.
Thedentist should make a positive decision at the treatment plan stage as to which is
appropriate for the patient.
(1) Copy dentures. Where dentures have provided satisfactory service for the patient in the
past, it may be advisable to base the design of replacement dentures on the well-accepted
features of the old ones. Although such an approach is particularly appropriate for the
treatment of elderly patients who have a reduced ability to adapt, it can also be of value in a
number of other clinical situations. A potentially accurate method of maintaining the well-
accepted features of existing dentures is to use a copy technique.
(2) Carving record rims. The shape, or design, of the dentures may be determined by the
dentist carving the record rims as described in Chapter 11, so that the upper rim provides
adequate lip support and the lower rim lies in the neutral zone.
(3) Biometric guides. Another approach to design involves the use of biometric guides
measurements from certain anatomical landmarks which allow the denture teeth and base to
be placed in positions similar to those formerly occupied by the natural teeth and alveolar
bone. The desirability of so doing has been a source of controversy for many years but has
received a considerable measure of support. Anatomical guidelines have now been researched
which assist the dentist in trying to achieve this aim.
(4) Functional neutral zone impression. When there are particular problems in achieving
stability of a lower denture for example, if there is abnormal muscular activity or intra-oral
anatomy the dentist can record the neutral zone by getting the patient to mould a soft record
rim into a position of stability between the tongue and cheeks and lips by means of
swallowing and speaking. A lower denture is then produced whose shape is derived from the
neutral zone impression. This clinical technique has been shown to enhance the tongues
retentive ability over a conventional design.
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4- PROGNOSIS
It based upon:
Bearing surface anatomy, tongue position and floor of mouth posture
Neuromuscular control
Denture history
Psychological classification
After reviewing the Complete Denture Evaluation, Diagnosis, and Treatment Planning
Form as well as the Prosthodontic Diagnostic Index (PDI) the practitioner should be able
to make some judgment about the prognosis of their patient.
A patient who has a Class 1 antero-posterior ridge relationship, has proper size and
function of the tongue, has normal quality and quantity of saliva, has U-shaped (cross-
section) ridges that approximate the opposing arch, has successfully worn complete
dentures in the past, and is a philosophical patient (PDI I) will have a good prognosis.
A patient who is in very poor health, has a Class II antero-posterior ridge relationship, a
retracted tongue, maxillary posterior bilateral undercuts in need of pre-prosthetic surgery;
ropy saliva, and an indifferent attitude (PDI 1V) will have a poor prognosis.
5- PROSTHODONTIC CARE
The type of prosthesis, denture base material, anatomic palate, tooth material and teeth shade
should be decided as a part of treatment planning. Depending upon the diagnosis made, the
patient can be treated with an appropriate prosthesis. For example:
For a patient with few teeth, which are likely to be extracted an immediate or conventional,
definitive or interim, implant or soft tissue supported dentures can be given.
For a patient who is already edentulous a soft tissue supported or implant supported denture
can be given.
For patients with acquired or congenital deformities, a denture with an obturator can be
given.
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Impression Trays
Impression: a negative likeness or copy in reverse of the surface of an object; an imprint of the
teeth and adjacent structures for use in dentistry
Impression material: any substance or combination of substances used for making an
impression or negative reproduction
Impression tray: a receptacle into which suitable impression material is placed to make a
negative likeness 2: a device that is used to carry, confine, and control impression material while
making an impression 3 a device used to carry the impression material into the mouth,
maintaining it in position during setting, and supporting it during removal from the mouth and
when casting the impression.
A cast or model is a positive reproduction of the form of the tissue of the upper or lower arch,
which is made in an impression.
Preliminary cast: a cast formed from a preliminary impression for use in diagnosis or the
fabrication of an impression tray [Diagnosticcast study cast ]
Preliminary impression: a negative likeness made for the purpose of diagnosis, treatment
planning, or the fabrication of a tray
Final impression: the impression that represents the completion of the registration of the surface
or object 2 An impression made for the purpose of fabricating a prosthesis
Master cast: A replica of the tooth surfaces, residual ridge areas, and/or other parts of the dental
arch and/or facial structures used to fabricate a dental restoration or prosthesis.[working cast
final cast ]
Stock tray: a prefabricated impression tray typically available in various sizes and used
principally for preliminary impressions
Custom tray: an individualized impression tray made from a cast recovered from a preliminary
impression. It is used in making a final impression
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Component parts
The tray consists of a body and a handle. The body consists of a floor and flanges. the upper has
a palatal portion while the lower has lingual flanges.
Requirements of impression trays
1- They should be strong and rigid to avoid distortion of the impression on removal.
2- They should be smooth, clean and can be sterilized if they are not disposable .
3- They should confine the impression material and hold it in correct position in the mouth and
cover the whole area of the jaw which is required for the impression.
4- They should allow for equal thickness of impression material over the entire fitting surface.
5- The flanges of the tray must reach the functional position of the sulci and frena but not
displace them.
6- They should provide for mechanical locking of the impression material to the tray through
rim-lock undercut or perforation. Otherwise, adhesives should be used for the elastic impression
materials.
7- The stock trays should be available in different size and shapes.
8- They must be inexpensive.
Types of impression trays
1- Stock trays.
2- Special, individual or custom trays.
3- Bite registration trays: They record the occlusal surfaces of both arches and used to
relate the upper and lower casts in the lab in the same manner as in the patients mouth.
4-Triple tray(double bite tray): It takes an impression of the prepared teeth, opposing
teeth and a bite registration at the same time.
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I- Stock Trays
These are ready-made trays available in different shapes and sizes.
Types:
1- Size: Most commonly, they are supplied in small, medium, large and extra large
sizes.
2- The shape of the tray differs according to the case whether it is dentulous, edentulous
or partially edentulous.
For dentulous patients:
The tray has flat floors, high flanges and the handle is in-line with
the floor of the tray. The trays for dentulous patients may be
perforated, rim-lock trays or water-cooled trays. The rim-lock tray is
the tray of choice because it is rigid and it confines the impression
material, helping to force it into all the areas to be included in the impression. Although,
perforated trays are rigid, they dont confine the material as the rim-
lock tray.
For edentulous patients :
The trays having round floor and short flanges to conform the shape
of the ridge. The handleis bent in the form of L-shaped and joined at
right angle to the floor of the tray to clear the lip and allows proper
border moulding in the labial portion of the impression.
For partially-edentulous patients:
In this type, part of the tray has flat floor and high flanges in the
dentulous area and the other part has rounded floor and short flanges
in the edentulous area.
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3- Material : The stock trays can be made fromdifferent materials
Metallic as nickel silver, stainless steel, aluminum tin
plastics. The plastic stock trays are usually disposable.
4- Stock trays may be perforated or rim lock for hydrocolloid
impression materials. Non perforated trays are used for
compound. water-cooled trays used for reversible hydrocolloid
impression materials
5- The Border-Lock tray has been developed especially to develop
dynamic pressure when highly fluid materials are used.The
Border-Lock tray has excellent mechanical retention.
Uses:
The stock trays are used for making the preliminary impression. The tray must be selected to
conform nearly the shape and size of the arch. Incorrect selection of the tray results in a distorted
impression.
If a short tray is used the impression material leaves the tissue and will be unsupported. These
impressions give an inaccurate cast and cause discomfort to the patient.
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Modification
Some dentists prefer to modify stock trays to improve their fitness.
These modifications include bending the flanges to provide adequate
space for impression material, or cut the flanges to accommodate for
labial or buccal frena or to reduce over extended flanges. Also
modeling plastic may be used to improve adaptation or to prolong the
short flanges.
Problems in using stock trays
The problem in using stock trays is that the impression
material is of various thickness which can lead to distortion
The flow of the impression material cannot be guaranteed to
cover all the areas of the teeth or tissues required
Pressure points can occur when using a stock tray. the patient can experience discomfort
during impression taking due to the large amount of impression material used in the tray.
in order to overcome these problems, special tray should be constructed.
N.B. Many edentulous patients who need a new complete denture are already having old denture.
The old denture may be relined with tissue conditioning material and used to produce primary
cast .
If undercut is present in the fitting surface the cast may produce preferably in silicon putty which
have elasticity to removed from undercut and is rigid enough to allow for fabrication of custom
tray
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Construction of primary, study or diagnostic casts:
The study cast is made from the preliminary impression and the working
cast is made from the final impression, and over which denture bases or
other dental restoration may be fabricated.
The impression should not subjected to pressure or tension. Before the
impression is poured the surface of impression is sprinkled with dry plaster then rinsed to
remove any free alginic acid that may be detrimental to surface of stone cast [Geering , Kelsey]
1. The study cast is made by measure powder liquid ratios provided by the manufacturer's
instructions appropriate to the models to be poured (approximately one part water to two
parts plaster). Add powder to water rather than water to
powder.
2. Mix the material thoroughly assuring that all dry stone is
wet, and a smooth mixture with minimal bubbles is
achieved. For best results, vacuum mixing is
recommended. A vibrator set to a medium to low speed should be used when pouring the
impression. High speed vibration will often trap air bubbles in the cast in critical areas.
3. For alginate impressions rinse the impression. All excess water is carefully removed from
the impression by gently blowing with an air pressure hose. However, the impression
material must not be allowed to become dried.
4. Gently vibrate the plaster into the impression and allow it
to set. The stone is carefully and slowly vibrated into the
anatomical areas of the impression in small increments
until the impression is completely filled and borders
covered
5. Do not invert the impression, as this will cause the plaster to flow away from the
impression surface and lose detail.
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6. When the plaster has set, prepare a thick mix of plaster to form a base and invert the
impression onto the plaster patty. A base of approximately 15-17 mm (3/4 inch) in height
and slightly wider than the initial pour of the impression is formed. Allow to set for at
least one half hour.
7. Remove the impression tray and alginate and recover the diagnostic cast. In case of
compound impression, the impression with the set plaster is immersed in warm water for
few minutes to soften compound and facilitates removal of cast.
8. Adjust the peripheries of the diagnostic cast using the
model trimmer in preparation for the construction of the
custom tray.
9. Once the base of the cast is properly formed, the sides of
the cast can be trimmed to create land areas approximately
3 mm (1/8 inch) in width in the labial and buccal areas and 6 mm (1/4 inch) posterior to
the retromolar pads and hamular notches. The land areas will be trimmed vertically to
create vestibules no deeper than 3 mm (1/8 inch).
10. The bottom should be trimmed so that the ridge crests are
parallel to the bottom, or bench top, and the thinnest portion
of the base of the cast is approximately 12 mm (1/2 inch)
thick.
Plaster mix is always added to the same area to avoid trapping
of air until the impression is filled. Excess plaster is poured over a glass slab and filled
impression is inverted over it. The border is then smoothed and shaped by the use of spatula.
After setting of the plaster the impression is removed from the plaster cast then the periphery of
the cast is trimmed
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Spacer or shim
The Special trays are either made directly on the study cast or made over a shim (spacer)
to provide a room of even thickness in the special tray for the impression material.
The thickness of the shim depends on the impression techniques to be used for taking the
final impression.
Advantages of spacer:
It provides a space of even thickness in the tray for the impression material. Thus;
1- Any dimensional change in the material will be equal throughout the impression.
2- The shape of the tissues may be recorded with minimal displacement.
3- In case of plaster impression, the suitable thickness will help in reassembling the
fractured pieces.
Methods of shim constructions
a- Modeling wax
1-The outline of the denture bearing is penciled on the cast. On the
primary cast the periphery is outlined with an indelible marker. The
outline for wax spacer is drawn on the cast; the edges are usually 2 to 3
mm short of the tray borders
2- The cast is then dusted by talcum powder or immersed in a water for 10
minutes to prevent sticking of the softened wax to it.
3- One or two layers of the modeling wax are adapted evenly on the cast
and are cut down to the denture outline.
The posterior palatal seal area on the maxillary cast is not covered with the wax spacer. Thus the
tray will contact the posterior palatal seal to prevent the final impression material from sliding
down into the pharynx.
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b- Molten wax
The outlined cast is immersed in water for few minutes, then the cast is dipped in molten wax
(54.5 C) repeatedly until the desired thickness is built up on the cast. Three dips are usually
sufficient to produce the spacer. The excess wax beyond the outline is trimmed away.
For the maxillary cast, the posterior palatal seal area is left uncovered with the wax spacer.
Thus the tray will contact the posterior palatal seal to prevent the final impression material
from sliding down into the pharynx.
For the mandibular cast, The buccal shelves are left uncovered with the wax spacer. Thus the
tray will contact the mucosa in these regions to place additional pressure when the final
impression is made. Extra wax can be placed over the lingual slopes of the mandibular cast to
provide additional space for the action of the mylohyoid muscles when the final impression is
made.
An asbestos substitute or shellac-base plate may be adapted on the primary cast to the
desired outline and act as shim. With thermoset plastic vinyl sheets special tray a shim is
prepared by placing appropriate thickness of wet paper towels.
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The use of stops:
Placing stops in the tray before checking and correcting the borders ensuring a uniform thickness
of about 23 mm of impression material, and stabilizingthe tray during impression taking.
(a) Tray in contact with the mucosa the border appears to be correctly extended. (b) Tray separated from the
mucosa by the impression material tray border under-extended.. Placing stops in the tray before checking and
correcting the borders will overcome this problem,
Basker stated that In the lower tray these stops are placed in incisal region and over the pear-
shaped pads. In the upper tray theyare placed in incisal region and along the line of the post-dam
There are several ways that stops can be produced:
(1) During construction of an acrylic tray in the laboratory.
Windows are cut in the wax spacer at appropriate locations. The
stops are produced by the acrylic dough flowing into these windows
and contacting the model. This is the preferred method of producing
stops as it is accurate and saves chairside time.
For mucostatic impression technique, stops are made by perforating the shim. Four stops (4 mm
squares), two in the anterior and two in the molar regions are usually made. The stops should
touch oral mucosa during impression making and should be lightly scraped later before casting.
(2) At the chairside in mouth. Compound is applied to the tray and tempered in
water to avoid burning the mucosa. tray is then seated in mouth to mould the
compound to the ridge tissues creating required space between tray and mucosa.
(3) At the chairside on the cast. compound is applied to the tray as in (2) above and the tray is
then seated on the dampened cast. it has the advantage over method (2) in that it is easier to
check visually that the tray is centred correctly on the ridge while the stops are being formed.
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II- Special trays
The need for special trays
The edentulous ridges show variation of shape, size and contours. In the same patient the
ridge shows different amounts of resorption and irregularities which affect the shape and contour
of the ridge. A stock tray can only fit the ridge in a very arbitrary manner, while a specially
constructed tray permits even thickness of impression material. For this reason the special trays
are used for making the final impression.
Advantages of special tray
It fits the arch more accurately.
It provides even thickness of impression material.
It minimizes tissue displacement and sore spots in the finished denture.
It allows for proper extension of the flanges and facilitates border moulding whichhelps
in better retention of dentures.
The bulk of the impression material is reduced; this is more economic, more comfortable
for patients and gives less distortion of impression by dimensional changes.
Controlled distortion of tissues.
- Muco-static: pertaining to the normal, relaxed condition of mucosal tissues
covering alveolar ridges and denture related surfaces.
- Muco-compressive: pertaining to pressure on mucosal tissues covering
alveolar ridges and denture related surfaces.
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Materials used for special trays
A - Metallic special trays
B- Non metallic special trays
1- Acrylic resin
2- Shellac-base plates
3- Thermoset plastic vinyl sheets.
4- Compound impression
5- Old denture
Special trays are either made directly on the primary cast or made over a shim (spacer) prepared
over the cast.
A- Metallic special trays
This type can be used for any impression materials, but it is required only when
compound is to be used.
Types :
1- Swaged : can be made by swaging nickel silver between dies and counter
dies
2- Casted metal may be used in construction of special trays. An alloy of tin and
lead or tin alone may be used for casting special trays.
Swaged or casted metal special trays are not commonly used because the production of these
trays is difficult, time-consuming and expensive.
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B- Non metallic special trays
1- Shellac base special trays
Disadvantages of shellac special trays:
1- Low strength.
2-Easily distorted by load and temperature.
3- Improper adaptation to the cast.
2- Acrylic resin special trays
This type of trays is mainly made from self-curing acrylic
resin. It can also be made from heat-curing acrylic resin
and Light-cure resins , but the use of heat-curing resin is
more difficult and time consuming.
Advantages of self-cure acrylic resin special trays:
1- Easier to make.
2- Rigid.
3- Can be easily trimmed.
4- Light in weight.
5- Can accept tracing material without warpage.
Visible light cure (VLC) dimethacrylate resins
Although the material is relatively expensive, require special light-curing unit for processing and
difficult to trim when cured, trays made from this material has sufficient rigidity to be used in
fairly thin section and excellent dimensional stability. VLC resins can be disinfected by
immersing into commonly used disinfectant solution such as 1000 ppm sodium hypochlorite .
This can also be used in patients who are allergic to PMMA resins, because of no residual
polymers in set material.
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3- Thermoset plastic vinyl sheets
It is a ready-made sheet used for construction of special trays by
vacuum.
On the stone cast the undercuts are blocked and a shim is
prepared by placing appropriate thickness of wet paper towels.
The cast is placed in its position on the vacuum machine. Vinyl
sheet is inserted in the frame located below the heat source.
Heating should be continued until the sheet is softened and
begins to sag.
The supporting frame carrying the softened sheet is lowered onto
the cast and the vacuum is turned on to adapt the sheet.
The heater is turned off and the base is allowed to cool then
removed and trimmed.
A cold cure acrylic handle can be fabricated.
4- Compound impression
Sometimes compound impressions are used as special trays after
scraping the fitting surfaces and the flanges of the primary
impression to provide space for the impression material.
A scraping of 2mm is sufficient for plaster, 0.5mm for zinc oxide
eugenol ZOE and 3-4 mm plus perforation is required for
alginate.
5- Old denture
The existing denture may be used as a special tray as in case of taking
zinc oxide eugenol ZOE impression for relining or rebasing the denture.
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Construction of Shellac base special trays
A shim of 2-3 mm thickness is made to give space for plaster
impression material and a shim of 4-5 mm should be made for
alginates.
Outline the depth of vestibule
Block-Out Undercuts
The upper tray is made by softening an upper base plate over a flame
and adapting it on the shim of the upper cast.
The palatal portion is adapted first and allowed to harden then the
outer portion, one side at a time.
The excess shellac is trimmed by scissors to the drawn outline and
the edge is smoothed with file.
A handle is made by rolling softened piece of shellac and attaching it
to the base of the tray on the anterior area in such a way that avoids distortion of the lip.
The mandibular tray is made by softening a lower base plate and adapting it on the shim of the
lower cast, section by section.
Excess materials are cut and the edges are rolled out to strengthen the tray. The handle is made in
the same manner as the upper tray. The upper and lower trays should be perforated if alginate
impression material is to be used.
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Construction of self-curing acrylic special trays
A self-curing special tray may be adapted directly on the cast after
blocking out the undercuts by plaster or wax. It may also be
constructed over a shim depending upon the impression technique
used.
A self-curing resin dough is formed by mixing the polymer and the
monomer. The dough is flattened to a sheet of 2-3 mm thickness.
This sheet is then adapted over the dusted cast or shim and trimmed
to the previously drawn outline.
A resin handle is attached to the anterior region of the tray .
A finger rest is attached to the lower tray. This finger rests are used
to seat the lower impression tray and hold the fingers away from the
periphery to avoid distortion of sulci.
When the resin is cured it is separated from the cast and spacer and the
periphery is rounded and smoothed with stone.
Extension: 2 mm short of the peripheral role
These acrylic resin trays should not be used before 24 hours after fabrication because the resin
may not be dimensionally stable before that time. Visible light-cured resins exhibit dimensional
stability immediately after curing, thus allowing immediate clinical use after fabrication.
[INTERNATIONAL DENTISTRY SA 2009 VOL. 12, NO. 3]
Construction of acrylic special trays with stops for mucostatic impression technique
The construction of this tray is exactly the same as the usual acrylic trays except that For
mucostatic impression technique, stops are made by perforating the shim. Four stops (4 mm
squares), two in the anterior and two in the molar regions are usually made. The stops should
touch the oral mucosa during impression making and should be lightly scraped later before
casting.
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Construction of acrylic special trays with occlusion rims for functional impression techniques
- Constructing special trays with occlusion rims facilitates
functional impression made under biting forces.
- The occlusion rims should be designed to facilitate
swallowing and other functional movement used to mold the
impression and must meet evenly to distribute the forces all-
over the denture-supporting area at a suitable vertical
dimension.
- To construct these occlusion rims, the patient is asked to close on a softened (T-shaped)
wax block at the time of obtaining the primary impression. This wax block is used to
mount the primary casts on a simple articulator. The trays are made and the occlusal rims
are attached to them.
Construction of acrylic special trays with relief wax for selective pressure impression
techniques
- the impression tray must be fabricated so that only those areas of the tray that overlie
primary and secondary stress-bearing areas are in physical contact with those tissues
during theimpression procedure. The primary and secondary- stress-bearing areas should
be outlined on the diagnostic castsas an aid to the laboratory technician
- There should be no tray/ tissue contact in those areas that overlie non stress-bearing
tissues.
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- Mushroom-shaped non stress-bearing area of the maxillary arch has been outlined.
The relief chamber is created by applying one thickness of baseplate wax over all non
stress-bearing areas of the diagnostic cast prior to fabricating the impression tray, This
wax is commonly called "relief wax."
-
- to allow tray removal from the diagnostic cast, all excessive undercuts
and tissue irregularities present on the diagnostic cast are minimally
relieved or blocked out using a baseplate wax. This is often referred to as
"block out" wax.
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Design of custom impression trays IJ MDS www.ijmds.org- 2009;1(1) 29-39
1. Material of choice for making custom trays
2. Optimum extension of customtrays
3. Spacer design and thickness used
4. Tissue Stops
5. Relief holes
6. Tray handles
7. Maturation time
8. Tin Foil
1. Material of choice for making custom trays see previous
2. Optimum extension of custom trays
The periphery of the tray should incorporate all dentures bearing area without
distorting the tissue of the vestibules through over extension.
Marking primary cast with pencil 2 mm short of the vestibule, guides the lab technician
to make optimum extensions of custom impression trays which saves clinicians time.
In partially edentulous situations, the custom impression trays should be kept 3 to 5 mm
away from the gingival margin and about 3 mm beyond the most distal tooth.
In correcting the distal extension of the maxillary custom tray, one important feature to
locate is the vibrating line. Extension of the denture beyond the vibrating line will result
in the denture terminating on excessively movable tissue and often cause lack of retention
or irritation to the tissue. [See anatomical landmark for detail]
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A properly shaped mandibular impression tray will most often exhibit the following
three features:
First the labial and lingual flanges in the anterior area
will be approximately the same length unless the
patient has had some type vestibular extension surgical
procedure or severe loss of the residual ridge.
Second, the distal-buccal flange will gradually taper
from the vestibule to the crest of the residual ridge, often
at approximately a 45 to 60 angle, and continuously flow
into the retromylohyoid area, The longest part of the tray
should be just lingual to the crest of the ridge with a
smooth curvature mimicking the shape of the
retromylohyoid curtain.
Lastly, the lingual flange will begin at the level of the
labial fiange in the anterior area and gradually become
longer than the buccal flange as it approaches the
retromylohyoid area. It generally exhibits a smooth
continuous form, not an irregular shape, as it progresses
from the anterior to the posterior.
3. Relief design and thickness used:
Thickness of wax spacer for complete and partially edentulous situations is 1 mm and
2-3 mm respectively. Wax spacer thickness may vary according to load bearing
capacity of the tissue and attachment of soft tissue with periosteum. Presence of
flabby and mobile tissue over the ridges demands for extra thickness of spacer to
allow their undistorted recording in the impressions.
The design of custom trays for complete dentures depends upon choice of impression
material and technique to be used.
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Mucocompressive technique is used for making primary impression of edentulous
arches and thus does not require any spacer.
Mucostatic technique require full spacer with 2 to 4 tissue stops with in custom
trays, thus allowing wash impression material (ZOE paste) to record tissue details
under minimum pressure as recording of tissues under no-pressure is not practically
possible. This technique does not demand for border extension into vestibules, thus
border molding was not suggested. Thus custom trays with borders app. 2 mm short
of vestibules are recommended here.
A variant of mucostatic technique can be used in cases with very prominent mid palatine
raphae, excessively flabby and knife edge ridges by making recess within custom trays in
appropriate areas and recording them with very light viscosity impression materials such as
impression plaster, ZOE and light body addition silicone.
The spacer design for the selective pressure is directly governed by the knowledge of
the stress bearing and relief areas.
o The stress bearing areas in the maxillary arch are the horizontal plates of the
palatine bone and the relieving areas are mid-palatine raphae and the incisive
papilla.
o For mandible, the primary stress bearing area is buccal-shelf area and
relieving area is sharp mylohyoid ridge and crest of alveolar ridge.
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Theviews of different authors on how to achieve selective pressure impression
Author Spacer Tissue stops
RoyMac Gregor Metal foil spacer in incisive papilla and mid palatine raphe
Neill 0.9mm casting wax full spacer/relief except PPS.
Sharry Base plate wax spacer all area
including PPS
4 tissue stops,
2 mm wide in molar and cuspid region,
extended from
Palatal aspect to mucobuccal fold.
Bouchers 1 mm base plate wax spacer except PPS in maxilla,
In mandible buccal shelf area and retro molar pad.
Morrow, Rudd, rhoads Full wax spacer 2mm short of borders 3 tissue stops,
4x4mm equidistance from each other
Barnard Levin 1 layer of pink base plate wax about 2mm thick all over theridges except PPS and
buccal shelf area.
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4) Tissue Stops:
Placement of four tissue stops of 2mm width in cuspid and molar regions which
extends from palatal aspect of ridge to the muco buccal fold are usually
recommended in completely edentulous cases.
In situations requiring fixed partial dentures, tissue stops are placed on widely
separated three or four non-functional cusps of teeth which do not require
preparation (buccal of maxillary and lingual of mandibular).
If all teeth are involved a large soft tissue stop can be placed on the crest of the
alveolar ridge or in the centre of the hard palate.
Tissue stops are made by removing wax at an angle of 45
0
to the occlusal surface of three
or four teeth that have a tripod or quadrangular arrangement in the arch. This provide stability to
the tray and the 45
0
angulated stops will help centre the tray during insertion
5) Relief holes:
After removing wax spacer from inside of the tray, a series of holes are prepared,
about 12.5 mm apart in the center of alveolar groove and the retro molar fossa with
a no. 6 round bur.
The relief holes provide escape way for the final wash impression material and
relieve pressure over crest of the residual ridge and the retro molar pads when the
final impression is made.
Relief holes are of no importance in partially edentulous situations as neither relief
nor adhesion between impression material and custom tray is provided. For good
adhesion between impression material and custom trays, use of tray adhesives
should be encouraged.
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6) Tray handles:
Tray handles are useful in loading, orienting and placing custom impression trays in
the patient mouth. Tray handles if not properly made or placed can cause potential
inaccuracy in complete denture as they distort the lip form and hence the functional
sulcus resulting into overextended borders.
The handle should be 25 mm long from the edge of the labial border of tray. The
handle is positioned in the approximate position of the upper anterior teeth so that it
doesnt distort the upper lip when the tray is in position.
For mandibular custom trays, the anterior handle should be 25 mm long from the
edge of the labial border to the top and 12 mm wide. A handle made this way
enables the clinician to securely grasp the tray without any interference with the
tongue and lips.
Two additional handles, one on each side are placed in the first molar region. These
handles are centered over the crest of the residual ridge at its lowest point and are
approximately 19 mm in height. The posterior handles are used as finger rests to
complete the placement of the tray on the residual ridges and to stabilize the tray on
the correct position with minimal distortion of soft tissue while the final impression
material sets.
One anterior handle and one or two posterior handles are required for partially
edentulous situation with unilateral and bilateral distal extension bases respectively
7) Maturation time:
Maturation time is the time interval between fabrication of custom trays and using it
for making final impression. This is characterized by polymerization of residual
monomer resulting into polymerization shrinkage which exerts significant effect
upon the linear dimensional accuracy of master cast.
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All custom tray materials show linear dimensional changes up to 9 hours, but
maximum shrinkage occurred up to 30 minutes after tray fabrication. Thus custom
trays should be used after 9 hr of fabrication.
If clinical situation demand early use, than custom tray seated over the casts should be
placed in boiling water for 5 minutes and then cooled to room temperature. In complete dentures
there is no significance of maturation time, thus clinicians can use the custom impression tray
immediately after fabrication.
8) Tin Foil:
Tin foil should be placed over wax to prevent conduction of heat from resin to wax
spacer preventing wax spacer from melting. It also allows easy and clean removal of
wax spacer from tray
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Boxing-in the impression and making the casts:
Impression : An impression is a negative reproduction of the tissue of the upper and lower
jaw, made in a tray using impression material. An impression is made to reproduce a positive
form of the shape of the same oral tissue (cast or model).
Cast: It is used as to describe an accurate, positive reproduction of the maxillary or
mandibular dental arch, which is made in an impression, and over which denture bases or
other dental restorations may be made. in which case a descriptive to gives a more specific
meaning, such as: Diagnostic cast, Master cast, Duplicating cast, Refractory cast and altered
cast.
Model: It is a reproduction for demonstration or display purposes; accuracy is in no way
implied.
Boxing of impression
Boxing-in an impression is the process of building up vertical walls around the final
impression to produce the desired size and form of the base of model, preserve certain
details of the impression and to keep the stone mix during vibration.
Beading: the purpose of beading impressions is to define the impression surfaces and also
to aid in supporting the impressions during pouring. The impression surface is defined by
creating shoulders outside the impressed tissue surfaces of the impression. beading is
often done with a rope-type wax, Play-doh or a mixture of stone and pumice
Advantages of boxing
1-The borders of impression are preserved.
2-The thickness of the model can be controlled.
3-Since all the mixed stone can be vibrated, the model will contain fewer air bubbles and
a stronger model will be produced.
4-It is time saving, because trimming may not be required.
5-Material is economized.
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Methods of Boxing:
I- Wax Boxing Method:
1- On the maxillary impression:
A strip of square beading wax 5mm wide is placed around the
periphery buccal and labial and luted at the non-critical edge (about
2 mm from the impression border) and parallel to it. The beading wax
should not be extended across the posterior border of the
impression.
2- On the mandibular impression
A strip of square beading wax is placed around the entire periphery
buccal, labial and lingual and luted at the non critical edges of the
impression.
The tongue space in the lower impression is blocked with wax before
boxing. This wax is attached to the impression at the level of the lingual
beading wax to provide aflat lingual shelf in the master cast just below
the lingual border on both sides.
3- A sidewall is then wrapped around each impression to contact the
beading wax to form a cylinder. The vertical walls of the boxing are
made of sheets of bees-wax. This wall should extend inch (10 to 15
mm ) above the impression and mainly made of boxing wax or base plate
wax. The end of the wax walls is joined together with hot spatula.
A lead sheet or cardboard may be used to make the wall and attached to the carding wax by
means of rubber band.
Wax boxing procedures cannot be used on impression made in hydrocolloid material because the
material will not adhere to the impression or because the impression will be distorted.
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2- Boxing-in the impression with Plaster of Paris and Pumice:
The beading wax does not adhere to alginate and rubber base impression
materials, so the plaster & pumice boxing mix is used:
A mix of half plaster and half pumice is made, poured on glass slab and
smoothed by spatula.
The tray is placed with the under surface over the mix. The material is
raised by the spatula to a height of 3-4mm below the border of the
impression and of 5mm thick.
The mix around the impression is allowed to set and then it is removed
from the slab and trimmed to the desired height and width.
Boxing wax is adapted to the impression to be 1cm above the borders
and sealed to the outer surface of the mix. The exposed surface of the
plaster and pumice is painted with separating medium.
Thin a mix of stone is vibrated into the impression.
3- Boxing-in the impression with Play-doh:
The Play-doh should be built up approximately 75 cm in height and
extended at least 3 mm beyond ail border of the impression. This will
support the impression and provide for a proper land area on the master
cast.
The material will be boxed with two pieces of red boxing wax. They
should be joined together with the tape. Approximately 7.5 cm of tape is
left extended beyond the wax on one end.
To allow for sufficient thickness of stone, the boxing wax chimney
should extend 16 to 18 mm above the highest surface of the
impression (usually a flange).
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Pouring the cast
The stone is mixed carefully according to the manufacturers instruction and placed in
small quantities into the boxed impression. The stone should be carefully vibrated
after each pouring to avoid trapping air bubbles.
The stone is allowed to set for 30-45 minutes, then the wax strap is removed and the
model is carefully separated from the impression.
Plaster of Paris is usually used for casting the preliminary impression, and the final impression
should be cast into dental stone.
Treatment of final casts
Each cast must be carefully examined and the necessary correction should be done. These
corrections include:
1- Removal of any nodules on the surface of the cast that
resulted from trapping of air bubbles in the impression surface.
2- Filling of any voids that found on the surface as a result of
trapping air bubbles in the dental stone.
3- Trimming the cast to provide adequate access to the border
reflections. In the posterior areas, the final cast is trimmed so
that the integrity of the essential contours and dimensions of the border reflections are
maintained. Incorrect trimming of this area will ultimately have an adverse effect on the
retention of the denture.
4- In the anterior portion only a slight amount of the area beyond the greatest depth of the
reflection must be maintained. The thickness of the denture base in this area can be more
accurately determined clinically.
5- Block out of undercuts with a suitable plastic material as wax,
modeling clay or white asbestos. This procedure permits removal
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and replacement of the bases and prevents scoring, abrading or breaking the surface of the cast.
6- Positive defects (bubbles), if any, must be in non-vital areas and small enough to be easily
removed (1-mm diameter or less as a guide).
7-Negative defects (voids), if any, should be small and in non-critical areas. These should be
filled with stone to blend with the surrounding anatomy.
Master cast criteria
Acceptable master casts should be of the proper thickness, bubble and void free, and include an
accurate representation of all impressed tissue surfaces and surrounding finished borders, often
called land areas.
1- The master cast must include all anatomical surfaces in the final impression
2- Base thickness must be 1/2-inch (13 mm) minimum for strength. This is measured from the
deepest part of the palate on the upper or the "floor of the mouth" on the lower.
3-After trimming, the base of the model must be parallel to the residual ridge.
4-The base must be indexed for mounting and remounting. Place rounded notches
(indexes) onthe bottom of the master cast. Thesenotches index the casts and will later
be used to remount the processed dentures back onto the articulator mountings. The
notches should be placed on the back and on the sides of the casts.
5-The depth of the buccal sulcus is approximately 2-mm below the land area.
6-Land Area = 4mm Wide. At least 3mm in thickness to prevent fracture and loss of
vestibular contours during denture fabrication
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Diagramatic view of desired dimensions of a trimmed diagnostic or master cast.
X: thickness of cast (12-18 mm in thinnest area).
Y: width of land area (2-3 mm).
Z: depth of vestibules (2-3 mm).
Indexing and Mounting Master Casts
Prepare four small remount indices into the bottom of the base of the cast. A
medium-sized acrylic resin bur can be use.
Broad buccal frenum
Land area too high - makes
trimming of acrylic and
removal fromcast dif ficult
Lateral view, Mandibular Tray Anterior view, Maxillary Tray
Base of Cast
Narrow notch
for labial frenum
Land area too high - makes
trimmingof acrylicandremoval
fromcast difficult
Auxillary handle
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IMPRESSION MAKING IN COMPLETE DENTURE
Developing an analogue\ substitute for denture bearing area
Ideal impression must be in the mind of the dentist before it is in his hand. He must literally
make the impression rather than take it - M.M. Devan
The impression procedure is a means of recording the detail of the basal seat area so that a
stone replica can be poured .The impression should cover the maximum possible area without
interfering with normal muscle movements.
The Objectives of an Impression Are to Provide:-
1- Preservation of the remaining residual alveolar ridge: - The impression technique and
impression material have an effect on the accuracy of denture base, which has an effect
on the continued health of both the soft and hard tissues of the jaws. Patients with
special cases need some precautions during impression making to prevent tissue
damage.
2- Support: - maximum coverage distributes applied forces over as wide an area as
possible.
3- Stability close adaptation to the undistorted mucosa is most important for stability of the
denture to resist horizontal movement. Stability decreases with the loss of the vertical
height of the ridges or with the increase in flabby, movable tissue.
4- Esthetic: - border thickness should be varied with the needs of each patient in
accordance with the extent of the residual ridge loss. Impression should perfectly
reproduce the width and height of the entire sulcus for the proper fabrication of the
flanges.
5- Retention: - it should be readily seen that if the other objectives are achieved, retention
will be adequate. [see retention]

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Requirements for an impression:
1- The tissues of the mouth must be healthy.
2- Proper space for selected impression material should be provided within the tray.
3- A physiological type of border-molding procedure should be performed.
4- The border must be in harmony with the anatomical limitations of the oral structures.
5- The impression should extend to include all of the supporting and limiting tissues.
6- The impression must be removed from the mouth without damage to the mucousa.
7- The tray and the impression material should be made of dimensionally stable materials.
8- The external shape of the impression must be similar to the external form of denture.
BIOLOGIC CONSIDERATIONS FOR MAXILLARY IMPRESSIONS
The anatomy of the supporting and limiting structures must be understood for:
1. The selective placement of forces by denture bases on supporting tissues
2. The form of the denture borders that will be harmonious with normal function of limiting
structures around them.
3. The fibrous band running along the residual ridge is the vestige of the palatal gingivae
and, like the incisive papilla, remains relatively constant in position during the remodeling of
the ridge which follows extraction of the natural teeth. These two structures can therefore be
used as landmarks allowing teeth on complete dentures to be placed in positions similar to
those of their natural predecessors. This biometric approach requires specific design features
to be incorporated into the impression trays
The anatomical landmarks in the maxilla are:
Supporting Structures:
Limiting structures:
Relief areas
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Diagram of the upper arch showing average distances from the palatal gingival vestige of the furthest
horizontal extent of the denture flange in the incisal (A), canine (B), premolar (C) and molar (D) regions (the
biometric approach). The line (XX) passing through the posterior border of the incisive papilla can be used as a
guide to positioning the tips of the canines.
Buccal anatomical relations of the upper denture
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BIOLOGIC CONSIDERATIONS FOR MANDIBULAR IMPRESSIONS
The considerations for the mandibular impressions are generally similar to that for those of
maxillary impressions and yet there are many differences owing to the following facts:
The basal seat of mandible is different in size and form from the maxillary
counterpart.
The submucosa in some parts of mandibular basal seat contains anatomic
structures different from those in the upper jaw.
The nature of the supporting bone on the crest of residual ridge usually differs
between the two jaws.
The presence of the tongue complicates the impression procedures.
The available area of support from an edentulous mandible is 14 cm
2
while the
same for the edentulous maxilla is 24cm
2
.
The supporting and the peripheral sealing areas will be in contact with the
dentures fitting or impression areas. The support for the mandibular denture is
derived from the body of
mandible.
The anatomical landmarks in the mandible are:
Supporting Structures:
Limiting structures:
Relief areas:
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Anatomy of the sulcus tissues
Anatomical relations of the lower denture.
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Impression can be classified as :
1. depending on the theories of impression making:
a. mucostatic/passive impression.
b. Mucocompressive/functional impression
c. Selective pressure impression.
2. depending on the technique:
a. open mouth technique
b. closed- mouth technique
3.Based on the method of manipulation for border molding.
1. Hand manipulation 2. Functional movements
4. Depending of the type of tray:
a. stock tray impression
b. custom tray impression
5. depending on the purpose of the impression :
a. diagnostic impression
b. primary impression
c. secondary impression
6. depending on the material used:
a. reversible hydrocolloid impression
b. irreversible hydrocolloid impression
c. modeling plastic impression
d. plaster impression
e. wax impression
f. silicone impression
g. Thiokol rubber impression.
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Preparation of the Mouth
The oral tissues should be healthy before impressions are made. Any distortion or inflammation
of the denture foundation tissues must be eliminated before the impressions are made as the
following:-
1- patients should leave their dentures out of the mouth for 48 hours prior to impressioning. If
the patient inserts a denture for even five minutes the tissues may be quickly distorted, and
proper tissue recovery may require two or more additional hours of not wearing the
denture. Therefore patient should not "just wear their dentures into the dentist's office."
2- For patients who are wearing complete dentures requiring refabrication, ensure soft tissue
health by serially relining with a 10- to 14-day period of conditioning with soft acrylic
resin every 3 to 4 days.
3- Oral Physiotherapy
4- Anti-microbial agents
5- Surgical removal of abused tissues
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Preliminary (primary) Impressions
A preliminary impression is an impression made for the purpose of diagnosis or for the
construction of a tray
1- The Position of the Patient:-
For most prosthetic operations the dental chair is set in the upright
position. When the patient is seated the chair should be adjusted so that the
head and neck, are in line with the trunk.
If the head is allowed to bend backwards from the neck the supra and
infrahyoid muscles will be tense and difficulty in swallowing will result, also should a fragment
of impression material break away from the main impression, it can more easily fall into the
throat and possibly cause obstruction in the airway.
A suitable covering in the form of apron or large towel should be provided to protect the
patient's clothing and also, a warm, flavored mouth wash with which remaining fragments of
impression can be rinsed away on instruction from the operator.
Position of the operator for maxillary impression
o When making a mandibular impression, the operator
should be standing between the 9 oclock and 12 oclock
position - The patients upper jaw should be
approximately between the level of the operators elbow
and shoulder
Position of the operator for mandibular impression
o When making a mandibular impression, the operator
should be standing between the 6 oclock and 9 oclock
position. - The operators elbow should be approximately
level with the patients lower jaw
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2- Selection of the Stock Tray:-
The alveolar ridges and palate are examined for shape and size, and
from a selection of previously sterilized stock trays a suitable upper
and lower ones are chosen and tested in the mouth for their
approximation to the oral structures.
Stock Tray Selection:
1. According to impression materials:
1. Compound : solid tray
2. Alginate : perforated tray
3. Agar agar : water coolant tray
2. According to patient mouth:
Based on size of the arch select the tray size which must be large enough to cover
all supporting areas and seal areas with about 2 mm space and shorter about 5 mm
from the full depth of the sulcus.
3. According to presence of teeth
For dentulous patients: The tray has flat floors, high flanges and the handle is in-
line with the floor of the tray.
For edentulous patients : The trays having round floor and short flanges to
conform the shape of the ridge. The handle is bent in the form of L-shaped and
joined at right angle to the floor of the tray to clear the lip.
For partially-edentulous patients: part of the tray has flat floor and high flanges
in the dentulous area and the other part has rounded floor and short flanges.
It may be necessary to bend the tray slightly with pliers to provide adequate
space and in others to cut and trim the flange to accommodate frena and prevent
pressure on bony structures such as the zygomatic process of the maxilla.
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Shortness in the flanges can be corrected by the addition of a little
warmed composition, or wax attached to the flanges of the dried tray. The
corrected tray is reinserted in the mouth and the periphery is moulded.
If the tray is too large, this will:-
1- Distort the tissues around the borders of the impression.
2- Pull the soft tissues under the impression away from the bone.
3- Distort the dimensions of the sulcus.
If it is too small:- The border tissue will collapse inward onto the residual
ridge.
3- The Preliminary Impression:-
Impression materials generally used for preliminary impression:
1- Impression compound.
2- Irreversible hydrocolloid (alginate).
I- Impression compound
The composition is heated in a water bath at 55 to 70
o
C. Since the
material has a low thermal conductivity, it must be immersed in the water
bath for sufficient time to ensure complete softening. The composition is,
then, removed from the water bath and kneaded, the composition is placed
in the tray and placed into the mouth and the patient is asked to do
functional movements.
The tray is held in place for one minute or two, removed and
chilled thoroughly in cold water. In general, composition is not considered as an accurate
impression material and it should never be reused because of fear of cross infection.
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The surface of the compound can be lightly flamed to improve its fl ow, tempered in
warm water and coated with petroleum jelly
In case of the maxillary impression; the material is formed into a ball, dried and loaded
in the center of the palate of the tray after warming it over a flame.
Then spread the compound over the tray and shaping it roughly like
arch.
In case of mandibular impression; the material is formed into a
roll, dried and loaded in the tray after warming it over a flame. Then
spread the compound over the tray and shaping it roughly like arch
Advantages of compound impression::
1- Addition and correction can be done.
2- Ease of manipulation.
3- Well tolerated by the patients.
4- Accuracy is not essential for primary impressions
II - The alginate wash impression (Prosth ttt of Edentulous Patient& HAYAKAWA)
When the dentist might require a more accurate picture of the mucosa so
that the potential denture-bearing area can be visualised more easily. This
can be achieved by refining the initial compound impression with a wash
impression in alginate as follows:
Obtain the best possible impression in compound and dry it thoroughly.
Trim back the borders and the fitting surface of the impression by 12 mm
with a sharp knife.
Apply a thin layer of alginate adhesive to the impression surface.
Load the compound impression with a small amount of low viscosity
alginate, seat it fully on the tissues and complete border trimming as before.
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III- the alginate impression
The alginate impression material can be used as a preliminary and final impression material.
Indications for its use in completely edentulous cases:
1- Some authors recommend the use of alginate for all
completely edentulous cases.
2- Severe undercuts.
Contra-indications:
1- Nausea to the patient.
2- Flat ridges.
Advantages:
1-Alginate produces excellent surface detail.
2-It is elastic and can be withdrawn over undercuts.
Disadvantages:
1- It cannot be added to if faulty.
2-Dimensional instability:
a-Even in the humidor, imbibition may take place.
b-The stresses induced in the material are released slowly, and the sooner it is
cast, the less the stresses will have been released and so the less it will have
warped.
3- The alginates will not adhere to the tray of their own accord. Attachment of the
alginate to the tray is essential because if it pulls away a distorted impression will result
which may easily pass unnoticed since the detail of the surface will remain unchanged.
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Some properties of alginate impression material
1- Compatibility with gypsum:
A- Saliva and blood interfere with the setting of gypsum during impression pouring, and
if free water accumulates, it tends to collect in the deeper parts of the impression and
dilute the model material, yielding a soft, chalky surface.
B- lf the alginate impression is stored for a half hour or more before preparing the model,
it should be rinsed with cool water to remove any exudate on the surface caused by
syneresis of the alginate gel because it will retard the setting of gypsum.
C- The set gypsum model should not remain in contact with the alginate impression for
periods of several hours because contact of the slightly soluble calcium sulfate dihydrate
with the alginate gel containing a great deal of water is detrimental to the surface quality
of the model.
2- Disinfection
The effect of disinfection in 1% sodium hypochlorite or 2% potentiated glutaraldehyde
solutions on accuracy and surface quality has measured after 10- to 30-minute
immersion.
the changes were 0.1%, and the quality of the surface was not impaired. Such changes
would be insignificant for clinical applications.
3- Adherence to the tray
Fixation may be effected by one of the following methods:
1- Small holes may be bored in the tray through which some of the
alginate will flow securing the impression firmly to the tray.
2- Ready made adhesive solutions or spray can be applied to the inside
of the tray.
3- Rim lock tray.
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Time should be allowed after application of the adhesive for it to become tacky, a
process which can be speeded up considerably by dispersing the adhesive over the surface
of the tray with a stream of air from a triple syringe.
A thin layer of adhesive is applied to the internal surface of the tray and should extend
several millimeters beyond the borders of the tray. The adhesive is allowed to dry for at
least 15 minutes prior to the impression procedure.
Also, it is important to remember that each adhesive is specific to the impression
material (ie, a polysulfide adhesive can not be used with an addition silicone impression
material)
Impression procedure
The lower impression is usually taken first as it is easier for the patient to tolerate
than the upper. When the impression is seated in the mouth the patient is asked to
raise the tongue to contact the upper lip and to sweep the tongue to touch each
cheek in turn before returning to maintain contact with the upper lip until the
alginate has set.
Buccal and labial border moulding is achieved by firm stretching of the relaxed
lips and cheeks with the fingers.
Precautions for alginate impression:
When alginate is used as an impression material the following points
should be observed in order to obtain the best results:
1-The clearance between the tray and the model should be approximately 4-
5 mm. The extension of the border of the tray is corrected by compound, if
underextended. Also, the palatal portion of the try is build by compound in
case of high palatal vault.
2-The container of powder should be shaken before use to get an even
distribution of constituents.
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3-The powder and water should be measured, as directed by the manufacturer.
4-Room temperature water is usually used, slower or faster setting time can be achieved, if
required, by using cooler or warmer water, respectively.
5-There should be vigorous mixing-by spreading the material against the side of the bowl-for the
spatulated time, usually one minute.
6- Prior to inserting the impression tray, the patient should be asked to
swallow to eliminate excess saliva. Impression material should be
placed, by finger, into any areas that the clinician feels may not be
adequately reached by the impression tray. These areas often include
the palatal vault, retromylohyoid spaces, and/or buccal vestibules.
If the sulci buccal to the maxillary tuberosities are deep, air may be trapped as the loaded
impression tray is inserted. To overcome this problem, these areas can be prepacked with
alginate before seating the tray.
The labial and buccal vestibules can be molded by asking the patient to suck down onto
the tray. in addition , the patient should be asked to move the mandible from side to side then
open widely
During setting of the material it is important that the impression should not be moved. The
reaction is faster at higher temperature, and so the material in contact with the tissues sets first.
Any pressure on the gel due to movement of the tray will set up stresses within the material,
which will distort the alginate after its removal from the mouth.
7-An alginate impression, when sets, develops a very effective peripheral seal so before trying to
remove it from the mouth this seal should be freed by running the finger round the periphery.
8-An alginate impression should be displaced sharply from the tissues this sudden displacement
ensures the best elastic behavior. A gentle, long continued, pull will frequently causes the
alginate to tear or pull away from the tray.
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9-On removal from the mouth, the impression should be washed with cold water to remove
saliva, covered with a damp napkin to prevent syneresis, and cast up as soon as possible,
preferably not more than 10 minutes after making the impression
10-An alginate impression is particularly susceptible to dimensional change developing as a
result of an increase or decrease in its water content. These two processes are:
imbibition the absorption of water
syneresis the loss of water..
Determination of the borders of the custom tray:-
Two choices are available. Either the periphery of
impresion is outlined with a disposable indelible marker at
the chairside (the preferred option), or arbitrarily marked on
the poured cast in the laboratory.
The completed impression should be observed next to the patient's mouth and the junction of the
attached and unattached mucosal tissue visually identified on the border of the impression.
Construction of primary, study or diagnostic casts:
See IMPRESSION TRAYS
N.B. Many edentulous patients who need a new complete denture are already having old denture.
The old denture may be relined with tissue conditioning material and used to produce primary
cast .
If undercut is present in the fitting surface the cast may produce preferably in silicon putty which
have elasticity to removed from undercut and is rigid enough to allow for fabrication of custom
tray
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The laboratory prescription
After the preliminary impressions have been obtained the following information should normally
be entered on the laboratory prescription by the dentist:
(1) Confirmation that all items sent from the clinic to the laboratory have been disinfected.
(2) Materials to be used for the special trays.
(3) Details of the design of the special trays including:
Spaced or close fitting
Size and location of any stops to be pre-formed in spaced special trays
Perforated or not
Type of handle and any finger rests
Any special requirements, e.g. a special tray for a flabby ridge.
(4) The written prescription can be supplemented by the dentist marking the required extension
of the special trays on the preliminary impressions with an indelible pencil if the impression is in
alginate, or with the tip of a wax knife if the impression is in impression compound.
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The Final Impression
(The Secondary or Working Impression)
The preliminary impressions are cast into plaster of Paris. Special trays are then constructed on
the plaster of Paris models to make the final impressions.
Theories of Final Impressions:- Journal of Prosthodontics 18 (2009) 97105
A- Minimal pressure impression technique (mucostatic impressions or open mouth
impression, PASSIVE IMPRESSION)
In 1938 Harry.L.Page introduced the mucostatic concept. Other consider it was proposed
by Richardson and later popularised by Harry Page.
. Mucostatic impression technique is one in which the soft tissues are in no way compressed or
distorted and therefore the impression material must flow readily; and impose no pressure on the
mucosa.
Plaster of Paris is the only true mucostatic impression material though the hydrocolloids
often give equally good clinical results.
Mucostatic impressions were based on the use of recording materials that duplicated the
tissues in a passive state. The borders of the dentures were also confined to only the stress-
bearing mucosal areas, and were not refined to make a border seal.
The mucostatic technique results in a denture, which is closely adapted to the mucosa of
the denture-bearing area but has poor peripheral seal.
The choices of impression material in these cases were thin zinc oxide eugenol pastes
that accurately recorded the denture-bearing areas.
Trays constructed for this technique require a spacer with stops and one or two holes to
allow escape of the material. These combined features can reduce the pressures by almost half
what is encountered without these features
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Requirements:
1. Fluid impression materials are used to record the supporting area without distortion and
pressure.
2. Rigid special tray with perforation and/or spaced with definite stoppers.
3. The ideal impression material is plaster of paries but zinc-oxide can be used also in
addition to alginate impression material.
4. Used open mouth technique.
Advantages:
1- The operator can see and insure proper border molding and muscle movements are more
easily accomplished.
2- There is less distortion to the mucosa.
3- It is the technique of choice for flabby and thin wiry ridges.
Disadvantages
1- The mucosal topography is not static over a 24-hour period.
2- It neglects the principle of distributing masticatory forces over the largest possible basal
seat area.
3- REALEF concept of Hanau is exaggerated when using this technique which affect
denture retention and occlusion.
Material
I- Plaster of Paris
II- The alginate impression
III- The zinc oxide-eugenol paste
IV- Rubber base impressions (elastomers)
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B- Definitive pressure (mucofunctional or compression impressions,Closed mouth
impression technique)
Given by Carole Jones Functional impression technique is one in which the soft tissues are
under biting force while the impression material sets. The impression material most commonly
used for this technique is zinc oxide and eugenol paste. Trays require occlusion blocks set at the
required vertical dimension.
It uses patients musculature in stabilizing a record base or occlusion
rim. This philosophy was introduced in the early 1900s and often used
wax, modeling plastic compound, or more recently, tissue conditioning
material.
To properly use the closed-mouth technique, well-fitting record bases, accurately occluding
rims, and an acceptable vertical dimension is needed.
Construct custom trays with compound occlusion rims.The blocks are tried in and the
periphery adjusted so that there is no overextension.
The bases are dried and zinc oxide-eugenol impression paste is used to coat the fitting
surface.
The lower is inserted first and muscle trimmed lingually.
The upper is inserted and the patient instructed to closer into centric occlusion. Fairly firm
pressure is maintained for 3 to 4 minutes whilst the material is setting. During this time the
patient is encouraged to swallow several times; to muscle trim the postero-lingual area.
The impressions are removed.
This technique may also be used for reline impressions of existing complete dentures and
may be used with a linear or a branched denture construction technique.
A linear technique is well understood and commences with recording of the tissues with
impressions, recording centric position and eccentric pathways, trial tooth arrangements, and
insertion procedures.
A branched technique includes the use of a diagnostic prosthesis to accommodate for
tongue thrusting habits, maxillomandibular discrepancies and other scenarios that create
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difficulties in obtaining comfort and function with complete dentures. This diagnostic prosthesis
aids in making the functional impression and gives indication if the patient can comfortably
function. The functional impression is inclusive within the branched technique and is effective in
achieving an accurate recording in relation to stable occlusal relationships.
The use of functional impression material, such as a tissue conditioner, in its flowable state,
accurately records the tissues in a functional state. These soft acrylic resins do not set hard. They
have properties that allow them to flow when forces are placed upon them, optimizing the shape
and distribution of the material dependent upon the functional displacement of the tissue beneath
the denture base. Some tissue conditioners have extended periods of flow, conforming to tissues
during several hours of eating, speaking, and swallowing. After a suitable evaluation period of
several days, the patient returns, the denture base is inspected for retention and stability, and, if
satisfactory, it is invested and cast in newly polymerized acrylic resin
In some patients, a moderate variation in mucosal compressibility may be present.
A mucostatic impression, particularly in the case of the lower jaw, results in a denture that
distributes the occlusal loads unevenly with consequent mucosal injury and associated
discomfort.
In this situation, it may be advisable to record the shape of the mucosa in a displaced state by
using an impression material of high viscosity. The load applied during the impression-taking
procedure should be the same as that occurring during function. A method which fulfi ls these
requirements is known as a functional impression technique
Requirements:
1. Impression materials used should have a relatively longer setting time and not be easy
flow, to allow functional movements of border tissues.
2. Rigid, non-perforated special tray with closed fit and occlusion rim are used.
3. The ideal impression material is zinc-oxide impression material.
4. Used closed mouth technique.
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Advantages: -
1- The patient can exert his own masticatory force on the impression material.
2- It permits adequate trimming of the lingual borders of the lower impression.
3- Its the technique of choice in cases need to increase the capability of support .
Disadvantages: -
1- Dentures constructed from such an impression do not fit well at rest, as the compressed
tissues tend to rebound .This results in premature contacts..
2- An overextended denture may result due to improper border molding.
3- It interferes with blood supply and this may accelerate ridge resorption.
C- Selective pressure impressions
Given by Boucher in 1950. This technique combines pressures over areas and little pressure on
others. Some of these concepts were advocated by the Green Brothers in 1907 and were
considered a significant advance in impression making
This is useful if the tissues in any area are exceptionally flabby and distortion to be avoided.
Primary stress bearing areas are recorded under pressure
The secondary stress bearing areas are recorded with minimal pressure
Peripheral areas are recorded under compression to develop seal
The pressure can be selectively applied to the tissue by the custom trays for making final
impression
1- The Splint Method:
A loosely fitting tray is selected or a special tray made with heavy relief over the flabby areas.
Plaster is mixed and applied over the flabby area to a thickness of about 1/8 in. This is allowed
to set. The tray is then filled with second mix of plaster and the impression is made; the initial
coating of the flabby areas thus acting as a "splint" whilst the impression is made and being
removed with the impression.
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2- The Composite Method:
This technique is used if the flabby tissue is in the anterior part of the mouth. A metal or acrylic
tray is made covering the normal area only. The impression of this area is then made using zinc
oxide paste. Whilst the impression is still in the mouth, plaster is painted around the flabby
tissues, and built up in thickness sufficient to allow its withdrawal with the rest of the composite
impression
3-Zinc oxide paste or plaster wash for compound impression:
A correctly muscle trimmed composition impression is made in a metal tray. The area of the
mobile tissue is then cut away and the removed -composition is replaced with zinc oxide paste
or plaster and the impression reinserted into the mouth of the patient.
4- Spacer and Holes Technique:
Spacers are placed over the relieved areas only. Acrylic resin tray is adapted to the jaws.
Holes are drilled over the relieved areas to allow escaping for the material through it. Zinc oxide
eugenol & elastomeric impression material can be used.
The holes are done in the tray over the following areas:
1- The median palatal raphe.
2- The anterolateral and posterolateral regions of the hard palate.
3- Residual ridge sites where the soft tissues are mobile and displaceable.
4- Over the retromolar pads.
making holes to avoid recording denture-bearing tissues in displaced or distorted position.
5-Heavy and light silicon method:
Impression is made by heavy body silicon, which removed over the flabby area. Holes are drilled
over the relieved areas to allow escaping for the material through it Wash impression by light
body silicon is carried out
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PROCEDURES FOR RECORDING THE FINAL IMPRESSION:
1. Checking and adjusting the special tray.
2. Border molding the special tray.
3. Final impression making.
4. Checking the impression.
5. Beading, boxing and pouring the impression.
I . Chec k i ng and adj ust i ng t he spec i al t r ay: see tray extension in impression trays
The tray should be well adapted to the cast, following the outline but 2
mm shorter than the vestibule.
The border should be smoothened with V-shaped notches around frena.
The tray is then checked visually and digitally for extension and
adaptation in the patient's mouth. Any adjustments should be made.
The diagnostic impression
A rapid and effective way of checking tray extension is to take a diagnostic impression with
alginate. For this it is not necessary to apply adhesive to the tray, which simplifies subsequent
removal of the impression material from the tray once it has served its purpose.
The tray well adapted to the cast & 2mm shorter than the vestibule.
Do not cover the post palatal seal area with wax spacer. Completed custom tray will contact the
post palatal seal area so Additional stress can be placed at this area during impression making
Provide tissue stops at the molar and incisal regions.
If the custom tray is constructed on a cast taken from the optimized previous denture, it can
be presumed that the tray already reflects the border molding developed with the tissue condi-
tioner that has been used to reline the denture. Hence, further border molding is very likely un-
necessary.
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Correction of over-extension
Over-extension must be corrected by trimming away the offending acrylic resin with a
bur or stone until the height of the flange has been reduced by the appropriate amount.
the over-extended flange will injure the tissues; in addition, elastic recoil of the displaced
sulcus tissues will cause instability of the denture.
Correction of under-extension
Under-extension is corrected by extending the tray in the region of the deficiency with a
border-trimming material.. It should be remembered that the common areas of under-
extension of the upper denture are the posterior border and around the tuberosities, while
the lower denture is often under-extended in the regions of the pear-shaped pads and
lingual pouches
If an under-extended tray is not corrected, there are two possible sequelae:
(1) The impression material is not carried to the full depth of the sulcus, so that
the fi nished denture is under-extended.
(2) The impression material reaches the full functional depth of the sulcus, but is
not supported by the under-extended tray. When the cast is poured, the weight of
the artificial stone will distort the unsupported part of the elastic impression
material, resulting in a denture which is an inaccurate fit
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I I . Bor der mol di ng (Func t i onal l y t r i mmed bor der s of t he spec i al t r ay,
Ref i ni ng c ust om t r ay, per i pher al mol di ng, per i pher al t r ac i ng ) :
It is the shaping of the border areas of an impression tray by functional or manual manipulation
of the tissue adjacent to the borders to duplicate the contour and size of the vestibule.
The correction is completed using a soft but slightly viscous impression material that becomes at
least semi-rigid as it cools, or polymerizes.
a- Objective of border molding:
The objective of border molding is to determine the contours and width of the
borders of the completed denture and to register this width and contour on the final
impression. This procedure fulfills impression-making objectives of maximum area
coverage and border seal.
The requirements of a material to be used for molding of all borders are:
(1) Have sufficient body to remain in position on the borders during loading of the tray.
(2) Allow some reshaping of the form of the borders without adhering to the fingers.
(3) Have a adequate setting time of 3 to 5 minutes.
(4) Retain adequate flow while the tray is seated in the mouth.
(5) Allow finger placement of the material into deficient parts after the tray is seated.
(6) Not cause excessive displacement of the tissues of the vestibules.
b-Materials of border molding:
1- Green stick compound and red impression compound:
One end of the stick is heated over a flame without burning.
The heated compound is added to the tray in the area to be molded and
built to a height of 3 or 4mm. The compound on the tray is then
tempered in a water bath at 140F. The tray is then quickly inserted in
the patient's mouth to proceed with molding.
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Advantages:
If the final impression must be remade, often the impression material can be
removed from the impression tray and the modeling compouiid border molding can
be reused.
Because of its rigidity, it can be used to extend custom impression trays whose
borders have become excessively short, more than 3-4 mm, of the desired final
extension. Once chilled in ice water, this rigidity also allows the trimming of the
material without fear of distortion.
Even when acceptably soft for border molding purposes, it is generally sufficiently
viscous to retain its form. This often provides an ideal width (2-.S mm) to the tray
flange.
Disadvantages
the need for planned preparation and the use of several pieces of equipment and
materials, including a water bath, a Bunsen burner, petrolatum jelly, sharp trimming
knife, and an alcohol torch.
Modeling compound is acceptably soft and yet not uncomfortably hot, between
approximately 49C (120 F) and 60 C (140F). Setting the hot water bath to the
upper limit of this range provides an acceptable but minimal working time.
Therefore only reasonably small areas of the borders can be corrected before the
material cools and becomes too rigid to be useful.
The material must be very soft to be used effectively and therefore must remain in
the mouth for approximately 15 seconds to be sufficient!)' rigid not to distort when
being removed from the mouth.
It must immediately be immersed in ice water and become rigid before attempting
to trim any excess material. A sharp knife blade must be used to allow for trimming
of the material rather than breakage.
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, once cooled, because of its rigidity it is often difFicult to place and remove from
bilateral undercut areas, particularly the retromylohyoid areas, without causing
trauma to the tissues and discomfort to the patient.
2- Autopolymerizing acrylic resins have been used for recording the entire border
simultaneously however, they have a long setting time; do not attain proper consistency
immediately after mixing, which means that there is a waiting time before insertion; and
they are difficult to trim.
3-Polyether impression materials is prefer because they are
well suited for this purpose and meet all of the requirements listed
previously.
4- Heavy body vinylpolysiloxane
Advantages
1. Simple material to work with that requires minimal
equipment. The working times of varieties of VPS vary,
from approximately two to eight minutes, the clinician can
select the one that best fits his/her impression technique.
Generally a material with a working time of about two or
three minutes in the mouth provides plenty of time to border mold and is ideal.
2. Even when polymerized, it can be removed from undercut areas with minimal
discomfort to the patient.
3. the extended working time compared to modeling compound, permit to border
mold an extended border of an impression tray at one time as opposed to having
to complete it one smaller section at a time, as is necessary with modeling
compound.
4. If an area of the border molding must be redone, it is quite simple to add
additional material and repeat the procedure.
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Disadvantages
1. To border molding and making the final impression with VPS is that the border
molding and impression materials bond during polymerization and cannot be
separated when desired. Therefore, if the final impression is not acceptable and
must be remade, the border molding material will often be lost during the process
of removing the impression material from the tray, resulting in the necessity of
repeating the border molding procedure.
2. Adhesive must be used to bond the material to the impression tray requiring
several minutes to set. This time may simply be lost to the clinician if the
impression procedures are not properly planned.
3. VPS does not have the viscosity or rigidity of modeling compound and therefore
cannot be used to correct borders that are under extended by more than 4-5 mm.
Also if not supported by the impression tray, VPS cannot be depended on to
form tray flanges 2-3 mm in thickness. This is especially noticeable in the
retromylohyoid areas, where the distal extent of the border molding and final
impression is often thinned by the tongue to a "knife edge." This may result in a
master cast with an indistinct shape in this area, which could result in a
completed denture with an inaccurate border length and thickness.
5- Wax
6. Other materials such as Iso Functional (GCCorporation,
Tokyo,Japan) can provide this functional molding of the denture
borders without trauma or undue tissue distortion.(Tissue Management and
Impression Techniques Journal of Prosthodontics 18 (2009) 97105)
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C-Technique of border molding
5- An acrylic base is constructed on a model from the preliminary
impression. It is helpful, but not essential, to use clear acrylic in order to
see any particular pressure points under the base when in position.
6- A properly extended custom tray is needed that is 2 to 4 mm short of full
extension to accommodate space for border-molding materials.
7- This may be carried out either in sections, recording one part of the
border at a time, or recording the entire border simultaneously.
It is unsuitable for recording the entire border simultaneously as it is almost
impossible to get the material softened over the full length of the border.
Recording the entire border simultaneously has two general advantages: First, the number
of insertions of the tray is reduced to one; second, developing all borders simultaneously
avoids propagation of errors caused by a mistake in one section affecting the border contours
in another.
Many clinicians find border molding half the tray at one time a much more
controllable procedure. Depending on the complexity of the impression and the
experience of the clinician, even smaller segments may be done with the VPS
material.
8- Tray wax spacer remains in place during border molding procedures . Do
not remove the wax spacer until final impression is made
9- Dry periphery of tray (Compound will not stick to tray otherwise)
10- Heating and applying the compound: Heat about one third the length
of the green stick compound until it just begins to slump-then apply to
tray periphery.
11- Do not overheat if catches fire or boils, it will not mold properly.
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12- Apply over periphery of tray, in a thickness just slightly narrower than
the compound stick .
13- Temper in a water bath (135-140F) for approximately 5 to 8 seconds
to Prevent burning and Hot water bath will keep compound soft for an
extended period .
14- allowed to stay in the mouth for approximately 15 seconds following
the border molding procedure.
15- The impression tray is removed and immediately placed in ice water
until rigid. It then must be examined and trimmed as necessary. The
material has a dull, matte, surface when properiy formed.
16- Trim excess over wax spacer or external material that is thicker than
4-5 mm .
17- Each area must be totally completed prior to starting another area
18- Assessing Peripheral Role :
- Proper thickness: average denture border usually is between 2 to 4 mm.
- the height of the border molding material above the tray should be no more
than 2-3 mm because that was the amount of space created between the soft
tissue and the impression tray prior to border molding.
- should smoothly flow from one area to the next without visible lines of
demarcation
- No evidence of overextension: the material is then rechecked intraorally to
ensure complete fill of the border and yet show.
If border is sharp or has seams, re-flame, temper and readapt intraorally . Repeat until periphery
is completed. The labial flange should not be thinner than 2 mm at tiie completion of the border
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molding procedure, or it will not adequately support the final impression material. It should also
not be more than 4 mm thick.
If the soft tissues are being displaced more than a slight amount, the material is overextended and
the border molding technique must be repeated.
If the impression tray is showing through the material, the material must be removed, the tray
shortened, and the border molding repeated.
VENT HOLES: Caution: Do not drill the palatal relief hole(s) in the maxillary tray until
the borders have been molded and peripheral seal demonstrated.
Purpose of the Vent Hole
1) To permit proper seating of the loaded master impression tray
while making the final impression.
2) To relieve the pressure over incisive papilla and the rugae.
3) To prevent entrapment of air bubbles in the impression.
Maxillary Border Molding:
1- The buccal space and the zygomatic process area:
a. Apply the green stick compound over the surface of the tray in the
Hamular notch area and on the buccal space and the zygomatic arch
area.
b. Insert and seat the tray and the cheek may be drawn in the
direction of the buccinators fibers. The patient is asked to move his
jaw to the opposite side. This motion will enable the coronoid
process to displace the material, which would interfere with the
jaw movement.
2- The buccal frenum area:
a. Green stick compound is added to the borders of the denture from the previously
molded area to a point anterior to the buccal frenum.
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b. In the region of the buccal frenum, the cheek is elevated and then pulled
outward, downward, and inward and moved backward and forward to simulate
movement of the frenum.
3- The anterior arch area and labial frenum:
a. Green stick compound is applied to the borders of the denture from the previously
molded area to the same area on the opposite side of the arch (cross the midline). This
area is border molded by pulling the upper lip outward, downward, and inward. A
side-to side movement is not indicated because the labial frenum does not function in
this manner.
b. Tray is inserted and seated. The vestibule is massaged in the direction of the fibers of
the orbicularis oris. Avoid pulling the lip down except in the corners of the mouth. In
these areas excess material squeezed laterally by the molding action in the vestibule may
create an overextension in the buccal frenum area. If this occurs re-soften and repeat .
4. The posterior border:
a. The green stick compound is added over the posterior section of the tray. Because
the tray has been trimmed to the proper length, to the vibrating line, the compound
should be placed within the tray and not extended beyond posterior extent of the tray.
The compound should be no more than 1-2 mm in thickness and 3-4 mm in width. Heat
is applied carefully to avoid distortion of the tray itself (if shellac is used).
c. The tray is inserted and seated firmly.
d. When the material has set torquing the tray may test the peripheral seal. A positive
resistance to dislodgement must be demonstrated before proceeding.
The addition of the border molding material over the posterior border:
Completes the peripheral seal by displacement of the tissue along the posterior border to
permit evaluation of the overall border seal.
Insures intimate fit of the tray in the posterior palatal seal area. Possibly aids in preventing
excessive posterior flow of final impression material.
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The Mandibular Border Molding:
1- The retro molar, disto-buccal and buccal shelf area:
a. Compound is placed along the border of the tray from the most
lingual extent of the retromolar pad to an area approaching the
buccal frenum.
b. The tray is inserted & seated and the patient is asked to close
against the downward force of the dentist's finger on the tray in the
premolar area. This motion permits the tissues displaced by closing
action to mold the disto-buccal portion of the tray ( masseter notch).
c. Along the external oblique ridge the border is molded by massaging the cheek to
displace the compound , which has extended beyond the external oblique ridge.
2. The buccal frenum area:
a. border molding material is added to tray, inserted and seated.
b. The cheek is grasped in the corner of the mouth and drawn upward
and inward, back and forth to permit full freedom of movement area.
3. The anterior labial arch:
The green stick compound is added and the patient is asked to suck or draw his lip
upwards and/or the dentist gently massages the lip in an upward direction.
4. The sublingual flange (to sublingual crescent area):
a. The border molding material is placed on one border of the tray.
b. The tray is inserted and seated into position.
c. The patient is asked to extend his tongue so that the tip of the tongue is placed just
outside the corner of the mouth on the side opposite that which is being molded.
d. The procedure is then repeated on the opposite side.
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5. The sublingual crescent area:
a. A piece of green stick compound is softened in a water bath, attached to the tray, and
molded with a finger into a shelf extended out area over the crescent area
b. The material is softened to a (lowing consistency, tempered,
inserted and seated into position.
c. The patient is asked to close and relax. The tongue should assume
its normal rest position with the tip approximating the position of the
lingual surfaces of lower anterior teeth.
When border molding with polyether impression material, the following
procedure should be followed:
1. An adhesive is placed on the both inside and outside of the border.
2. The polyether material is mixed with slightly less catalyst, and introduced into
a plastic "impression" syringe.
3. The polyether material is syringed around the border and across the posterior
palatal seal area. The material is quickly reshaped to proper contours with fingers
moistened in cold water.
4. The tray is placed in the mouth.
5. The border is inspected to ensure that impression material is
present in the vestibule. If insufficient material is present, excess
material from an adjacent site should be transferred with a finger
moistened in the patient's saliva.
6. When the impression material is set, the tray is removed from the mouth.
7. The border molding is examined to determine that it is adequate. The contour
of the border should be rounded. Any deficient sites can be corrected with a small
mix of polyether material added to the appropriate area. Overextensions are
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readily detected because the tray will protrude through the polyether material and
be adjusted as necessary.
Refining the maxilla custom tray
1- In the anterior region the lip is elevated and extended out, downward, and
inward.
2- In the region of the buccal frenum the cheek is elevated and then pulled
outward, downward, and inward and moved backward and forward to simulate
movement of the frenum.
3- Posteriorly, the buccal flange is border molded by extending the cheek
outward, downward, and inward. The patient is asked to open wide and move the
mandible from side to side.
Refining the mandibular custom tray:-
1- The labial flange is molded by lifting the lower lip outward, upward, and
inward.
2- In the region of the buccal frenum, the cheek
is lifted outward, upward, inward, backward, and
forward to simulate movement of the frenum.
3- Posteriorly, the cheeks are pulled outward,
upward and inward. The effect of the masseter muscle
on the border of the impression is recorded by asking
the patient to exert a closing force while a downward pressure is exerted on the
tray by the dentist.
4- The anterior lingual flange is molded by asking the patient to protrude the
tongue and then to push the tongue against the front part of the palate.
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Protruding the tongue determines the length of the lingual flange of the tray in this
region, whereas pushing the tongue against the anterior part of the palate causes the base
of the tongue to spread out and develop the thickness of the anterior part of the flange.
Protruding the tongue activates the mylohyoid muscle, which raises the floor of
the mouth. This helps in determine the length and slope of the lingual flange in the molar
region. Apparent protrusion of the tongue can be achieved by contraction of the intrinsic
muscles of the tongue, but this does not raise the floor of the mouth. Some clinicians get
the patient to make a k sound, as this activates the mylohyoid muscle.
5- The distal end of the lingual flange is molded by again asking the patient
to protrude the tongue.
This action activates the superior constrictor muscle, which supports the
retromylohyoid curtain. The patient is then asked to close as the dentist applies
downward force on the impression tray.
6- Finally, the patient is asked to open wide. If the tray is too long, a notch
will be formed at the posteromedial border of the retromolar pad. indicating
encroachment of the tray on the pterygomandibular raphe, and the tray must be
adjusted accordingly.
When the tray is removed from the mouth, the border molding is examined to
determine that it is adequate. The contour of the border should be rounded.
Stick impression compound is adjusted with a scalpel; the polyether is adjusted using
either a scalpel or a bur.
The material over the posterior area is not adjusted. This serves three functions.
First, it slightly displaces the soft tissues at the distal end of the denture to enhance
posterior border (palatal) seal. Second, it serves as a guide for positioning the tray
properly for the final impression. Third, it helps prevent excess impression material from
running down the patient's throat.
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I I I - The f i nal i mpr essi on:
The final impression should result in achievement of the final two previously discussed
objectives of impression-making namely; accurate reproduction of tissue detail and equalization
of forces. For routine edentulous final impression making, the materials used are zinc oxide and
eugenol paste and rubber base materials.
A- Preparing the Tray for the Impression
1- Any "relief wax" is removed from the tray. For the selective pressure technique, this
creates a void or chamber between the nonprimary stress-bearing tissues of the arches
and impression trays. This chamber minimizes the possibility of physical pressure from
the tray to the tissues during the impression-making procedure.
2- Any sharp ridges at the resin/wax interface are smoothed with an acrylic bur.
3- Additionally, approximately five #8 round bur sized holes are cut through the tray in the
chamber areas These holes allow the relief of hydraulic pressures that
will build because of the viscous impression material being squeezed
between the tissues and the impression tray.
4- No relief of the border molding material is normally required because
most impression materials will be minimally viscous and therefore no
extra space is required for the material. If a viscous impression material is selected, then
approximately 0.5 millimeter of the border molding material should be removed.
5- Adhesive specific to the particular impression material being used is applied to the entire
tissue side of the tray and extends onto the labial and buccal surfaces approximately 4
mm. All impression compound border molding material sbould be coated with the
adhesive.
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B- Materials used for final impression making:
Characteristics of an ideal material
minimally viscous,
polymerizing (setting) intraorally within 2-3 minutes,
being hydrophyllic,
being thixotropic,
not flowing once removed from the mouth,
not being excessively rigid,
not being excessively expensive,
being well tolerated by the tissues,
being exacting in recording and maintaining tissue details,
The ability to be poured in a dental stone more than once.
1-The alginate impression
It has already been discussed under the title of preliminary impressions. The peripheral
impression is made either by using composition tracing stick, polyether or silicon
impression materials
2-The Zinc Oxide-Eugenol Paste ( ZOE )
Indications:
a- As a final wash material when border moulded special trays are used
(functionally trimmed impression)
b- Relining of dentures.
c- In cases having pronounced nausea.
d- Muco-functional impression (Closed mouth technique).
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Contra-indications:
1- When more than a slight undercut exists as distortion will occur on removal
over undercuts.
2- Excessive salivation.
Procedure:
1- The acrylic special trays used for this material require no clearance and are
adapted directly on to the preliminary model.
2- The pastes are mostly supplied in two tubes, one containing basically zinc
oxide and the other basically eugenol.
3- For the lower impression about 6 cm and for the upper 10 cm of each are
squeezed on to the mixing block, thoroughly spatulated and evenly distributed
over the fitting surface of the carefully dried tray.
4-Before starting to mix the paste the patient's lips and neighboring skin should be
lightly covered with face cream or Vaseline to prevent the paste adhering to these
dry surfaces should it touches them during the insertion of the tray. Many
operators also treat their fingers in the same way.
Should some zinc oxide paste accidentally touch a patient's or operators dry skin,
a napkin moistened with chloroform , orange oil or Dettol solution can remove it.
5-These impression materials are sufficiently fluid to record the fine detail in the
mouth. There are probably little or no dimensional changes associated with the
setting process. The set material is not elastic, so will not record undercuts. This
material will not produce a satisfactory impression of the periphery unless
supported by a very accurately adapted tray.
6-Removal of the impression is sometimes a little difficult owing to the excellent
peripheral seal obtained, but it can be facilitated by introducing a few drops of
water from syringe around the periphery of the set impression.
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7-Some patients may complain of burning sensation when the impression is in the
mouth, this is due to the slight irritation caused by the oil of cloves or eugenol.
The treatment by mouthwashes is all that is required.
Functionally trimmed borders are first achieved using the following technique:
1- An acrylic base is constructed on a model from the preliminary impression.
2- It is helpful, but not essential, to use clear acrylic in order to see any particular
pressure points under the base when in position.
3- The borders are carefully trimmed to be 2 mm short of the correct peripheral
contour.
4- The peripheral impression is made using composition tracing stick so that the
maximum extent of the functional periphery
is recorded.
5- The central part of the base, bordered by
the tracing stick, is now filled with a thin
layer of zinc oxide-eugenol paste and the
final impression is recorded.
3-Rubber base impressions (Elastomers)
These are elastic impression materials, which are classified into three chemical
types: Polysulphide, silicone and polyether.
They are used in making secondary impressions for
complete dentures. Functionally trimmed borders are better
achieved before impression making.
The rubber base impressions will not adhere to the tray
and the use of an adhesive or perforation of the tray is
required.
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The impression material is usually supplied in two collapsible tubes and
occasionally as a base paste and a catalyst liquid. A uniform mixing is essential. These
materials are also supplied in a range of viscosities and after setting they are elastic in
behavior.
In general, elastomers can record fine details, and are tolerated well by the
patients. They should be displaced sharply from the tissues to ensure elastic behavior.
These materials are in general compatible with model and die materials and
consequently, no separating medium is required.
As the shelf life of these materials is not ideal they should be kept in a
refrigerator.
The spacer of the acrylic resin special tray should be 2-3 mm in thickness to
obtain the best results. Functionally trimmed borders are better achieved before
impression making.
4-Plaster of Pairs
Impression plaster is a good impression material primarily for the upper
edentulous jaw where there are no bony undercuts. Plaster of Paris had been used in the
past for routine edentulous final impression making because of its high fluidity and
accuracy. But some of its disadvantages limited its use to excessive flabby tissue cases
only.
If there are undercuts present, the plaster impression
will fracture on removal from the mouth. Impression plasters
may be unpleasant for the patient because they produce dry
sensation in the mouth.
Before pouring a model in plaster or dental stone, the plaster impression must be
treated with a separating medium. The possibility of scratching the model during removal
of the impression is present.
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It had been used in the past for many years as a final impression for complete
edentulous ridges. But some of its disadvantages limited it use. It can be used for making
impression for flabby tissues.
Impression plaster has the following properties which are clinically relevant:
(1) Rigid when set. However, if small bony undercuts are present the use of impression
plaster is not ruled out. The material which enters the undercut area will break off when
the impression is removed from the mouth and can then be re-attached to the impression
as mentioned above.
(2) Dimensionally stable.
(3) Low viscosity. Impression plaster is therefore a good material to use when a
mucostatic impression is required.
(4) Susceptible to excess saliva. It is difficult to obtain a satisfactory lower impression in
patients who salivate profusely because the saliva mixes with the plaster and a rough,
friable surface is produced.
Disadvantages:-
1- Produces dry sensation in the mouth.
2- Before casting a model in plaster or dental stone, the plaster impression must be
treated with a separating agent
3- If there are undercuts present, the plaster impression will fracture on removal
from the mouth with a fear of choking from small pieces of impression.
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Making the Final Impression
The selected impression material is mixed according to the manufacturer's
directions
Applied evenly to the tray to a thickness of approximately 3 mm, being careful to
avoid capturing air bubbles within the material.
Because most impression materials are hydrophobic, while the impression tray is
being loaded, the tissues to be captured in the impression should be freed of
moisture. The patient should swallow all excess saliva, and the tissues should be
carefully dried with 2x2 sponge gauze.
When inserting the impression tray, the clinician mast carefully observe the
seating of the tray onto the tissues. Before completely seating the impression, the
clinician must properly position the impression tray over the ridge so that the
anterior flange of the tray will seat properly and completely into the labial
vestibule.
When seating the mandibular impression tray, the clinician must take special
care to not capture any fatty roll of tissue in the masseter muscle area as part of
the impression. This can be accomplished by pulling this roll of tissue from
beneath the tray on one side of the arch, slightly seating that side of the tray,
pulling the opposing roll of tissue from beneath that side of the tray, and then
partially seating this side of the tray.
For the final seating, the patient should be asked to lift the tongue and, as the
impression is being seated, the patient should be directed to relax the tongue. This
procedure will minimize capturing the tongue, salivary glands, and other non
desirable areas within the impression.
A similar procedure is accomplished when making the maxillary impression
with the addition of having the patient move the mandible in extreme lateral
motions as part of the impression procedure.
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This movement will cause the coronoid processes to help contour the lateral
borders of the impression in the tuberosity areas.
Border molding of the impression must be initiated before the impression
material begins to polymerize and must continue until the material begins to
polymerize. If tissue manipulation is stopped prior to the initial polymerization,
the material may again flow beyond the desired extensions, causing excessive
thinning of the borders and overextension of the impression.
Manufacturer's directions are followed for mixing and setting times of all
materials.
Care is often required to minimize patient discomfort when removing an
impression. On the maxillary arch this discomfort may be caused by excessive
retention of the impression within the mouth. Generally an index finger can be
used to lift the tissues away from one of the flange areas, which breaks the border
seal by allowing air under the impression. On the mandibular arch this discomfort
may be caused by the impression extending into bilateral undercuts in the
retromylohyoid areas.
The impressions should be rinsed and then disinfected before further handling.
The maxillary impression is trimmed back to within 1 mm of the vibrating line.
Every impression must be objectively evaluated by the clinician to insure its
accuracy and remade when necessary.
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I V. Chec k i ng t he ac c ur ac y of t he i mpr essi on
The impression should accurately reproduce the tissue details.
REASONS FOR REMAKING IMPRESSIONS
1- Incorrect tray position in the mouth:
A thick buccal border on one side with a thin buccal border on the opposite side.
This indicates that the tray was out of position in the direction of the thick border
(poorly centralized).
A thin labial border with the tray showing on the inside surface of the labial
flange. This indicates that the tray was placed too far posteriorly and not centered
correctly over the anterior ridge.
A thick lingual border on one side with a thin lingual border on the opposite side.
This indicates that the lower tray was out of position in the direction of the thin
border.
A thin anterior lingual border with the tray showing on the inside surface of the
lingual flange. This suggests that the lower tray was too far forward in relation to
the residual ridge. It will be accompanied by a thick labial border. In a similar
manner, a thick labial border in the upper arch with the tray showing through over
the anterior slope of the palate. This indicates that the tray was too far forward in
relation to the residual ridge.
Pressure spots on the lingual surface of the maxillary labial flange usually indicate
that the tray was not fully seated. Pressure spots on the anterior part of the
mandibular lingual flange indicate that the mandibular tray is too far forward in
the mouth, in many instances as a result of action of the tongue,
If the tray is correctly positioned in the mouth, errors in the impression indicate that the tray
needs to be modified before another impression is made. The tray should not be modified unless
it was positioned correctly when the impression was made.
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2- A The tray showing through the impression material
Tray showing through the impression material over the fitting surface of the
tray and the borders showing through the final impression material. This
indicates that the tray has been seated on the residual ridge with too much
pressure.
Tray showing through the impression material over the border with the
correct thickness of material over the fitting surface of the tray, suggests that
the tray is overextended in that area.
If the tray shows through the impression material in a small area, scrapping could relieve that
area. If this area is large, the impression is preferably repeated.
3- Movement of the tray while the final impression material was setting it result in
wrinkled areas necessitate repeating the impression
4- Pulling the impression material away from any area of the tray.
5- Contact between cusps of teeth and the impression tray.
6- Incorrect border molding procedures.
7- Incorrect border foundation as a result of incorrect border length of the tray. A sharp
border usually indicates that the impression is underextended in that area.
8- Incorrect consistency of the final impression material when the tray was positioned in the
mouth (granular impression with poor tissue details).
9- A material unsupported by the borders of the tray:
Excess thickness of impression material over the fitting surface of the tray
and material unsupported by the borders of the tray. This indicates that the
tray was not seated down sufficiently on the residual ridge.
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The correct thickness of material over the fitting surface of the tray, but
material extending beyond the border of the tray so that it is unsupported by
the tray, suggests that the tray is under extended in that area.
10- Voids or discrepancies those are too large to be corrected accurately on the cast. Some
voids may be corrected by adding new impression material to the impression and
reinserting however any impression with a void this large generally should be remade in
its entirety. Small voids may be correctable on the master cast since they will result in
positive bubbles that can be removed with a cleoid/discoid instrument.
11- Using either too much or too little impression material.
12- Sticking the impression material to the teeth.
13- Layered impression.
14- Trapping lip, cheek, tongue or floor of the mouth.
15- Tearing of an area of impression.
16- Poor detail in the impression because of a poor mixing technique or because the material
had begun to set before the impression was fully seated
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Problems and solutions of alginate impression
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V. Pour i ng t he Fi nal I mpr essi ons
The impression should be poured as soon as possible to
avoid distortion of the impression. Beading and boxing are
of utmost importance to preserve the borders of the
impression and to produce the landmark areas
Boxing-in the impression and making the
casts
See IMPRESSION TRAYS
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Special Impression Techniques
Flabby ridge impression technique :
Two stage (Sectional) impression technique
One part impression technique
Controlled lateral pressure
Unemployed ridge impresion technique
Mandibular Flat Ridge impresion techniques
McCord and Tyson impresion technique
Butterfly impression technique:
Dynamic impression technique:
Functional Imp. Tech.:
1. Tissue conditioner imp. tech.
2. Neutral zone imp. tech.
Sectional Impression Tray and Sectional Denture for a Microstomia Patient
Modified Functional Impression Technique
A Layering Technique Using Multiple Viscosities of Impression Material
Accu -Dent System (Ivoclar)
Frame Cut Back Tray
Obtaining Impressions for Implant-Supported Restoration
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Flabby ridge impression techniques british dental journal volume 199 no. 11 dec 10 2005
Two part impression technique: Mucostatic and mucodisplacive combination
Two part impression technique: (Mucostatic and mucodisplacive combination)
Acrylic special tray is constructed having a window opposite the area of flabby
tissues Border moulding is carried out in the usual manner and zinc oxide and
eugenol impression is made and excess passing through the widow is trimmed
out.
The flabby area is recorded using plaster impression material applied with a
brush several times with the secondary impression in place. After the impression
plaster sets, an overall impression using a suitable stock tray loaded with
impression plaster is used to remove both sections together
light-bodied PVS was used if a medium-bodied one was used) and paint
or syringe these onto the displaceable tissue to record them in a
minimally displaced position. Once setting, it should be apparent that a
peripheral seal has been re-established.
The design of this modified special tray can vary from a completely uncovered section of
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the arch to a window overlying the unsupported mucosa.
In the fibrous anterior maxilla, modification of the handle position is often required.
A rim handle design has the benefit of aiding prevention of unset impression material
falling to the back of the mouth when the patient is supine.
The advantage of a window design means that the appropriate
border correction can be undertaken and checked around the
entire sulcus before the second stage of the impression is
completed.
One part impression technique (Selective perforation tray)
1. Preliminary impressions are taken in stock trays using low-viscosity alginate after
appropriate border correction.
2. A spaced special tray is fabricated from the primary cast for use with a low viscosity
impression material, such as impression plaster, low-viscosity silicone or alginate.
3. Pressure on the unsupported, displaceable soft tissue can be minimised further by the
use of perforations in the tray overlying these areas
Special tray is constructed on the primary cast Perforations are made in front of the
fibrous area Impression is taken with low viscosity silicone
Controlled lateral pressure
Tracing compound (green stick) is used to record the denture bearing area using a
correctly extended special tray.
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A heated instrument is then used to remove the greenstick related to the fibrous crestal
tissues and the tray is perforated in this region.
Light bodied silicone impression material is then syringed onto the buccal and lingual
aspects of the greenstick and the impression gently inserted.
The excess material is extruded through the perforations and theoretically the fibrous
ridge will assume a resting central position having been subjected to even lateral
pressures.
Palatal splinting using a two-part tray system
In 1964, Osborne described an impression technique involving two
overlying impression trays used for recording maxillary arches with
displaceable anterior ridges.
The aim of this technique is to maintain the contour of the easily
displaceable tissue while the rest of the denture bearing area is
recorded.
A primary model is constructed using the fitting surface contour of a
previous denture. From this a palatal tray is fabricated with wax being
used to create space on the palatal aspect of the mobile area and
extending to the ridge crest around the arch.
In this acrylic resin palatal tray, a low viscosity zinc oxide paste
impression is taken of the palate. An upward force is maintained until
it is apparent that the mobile ridge is just beginning to have pressure
applied to it. Once this has set, a second special tray impression is made completely
encompassing the first tray.
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It should be inserted from in front, backwards, and the presence of
the supporting zinc oxide should prevent backward displacement of
the mobile ridge.
A neat modification of this approach was described by Devlin in
1985, in which a locating rod is positioned in the centre of the
palatal tray, but proclined to allow the second special tray
impression to be guided in an oblique upward and backward
direction to envelope the palatal tray.
The palatal tray accurately locates the second part special tray
using a stop, thereby allowing for a pre-planned even thickness of impression material.
Selective composition flaming
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1. A preliminary impression in a fluid material such as alginate is cast producing a model of a
relatively undistorted ridge.
2. A 3-4 mm spaced rigid special tray is constructed and used to take a composition impression
of the primary cast.
3. The impression periphery is carefully softened and functionally
trimmed. The fibrous part of the ridge can be outlined on the impression
surface.
4. The composition overlying the firm denture bearing areas is softened
with a flame before the tray is seated under heavy pressure, attempting to
replicate functional force.
By performing the impression in this way, the original relatively
undistorted shape of the fibrous tissues is retained while the tissues more
capable of functional denture support are recorded in a displaced state.
Unemployed ridge impresion technique.
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Definition:
Fibrous (unemployed) mandibular ridge: this condition may be recognized by the presence of a
thin, mobile thread-like ridge which is essentially fibrous in nature.
When the customized tray has been adequately checked for peripheral extension, it is
loaded with tracing compound (green-stick) and an
impression of the denture-bearing area recorded.
Remove the greenstick relating to the crestal tissues and
perforate the tray in this region.
Downward finger pressure of the modified impression, in
the mouth, should elicit no discomfort. Inject light-bodied
PVS onto the greenstick or Zinc Oxide, and gently insert
the impression.
Excess material will be extruded through the perforations,
and the fibrous ridge will assume a resting central
position, having been subjected to even buccal and lingual pressures.
Mandibular Flat Ridge impresion techniques.
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Definition:
Flat (atrophic) mandibular ridge covered with atrophic mucosa. These ridges may be
complicated by folds of atrophic and/or non-keratinized tissue lying on the ridge.
McCord and Tyson impresion technique
This technique is specific for this clinical situation. The philosophy is
that a viscous admix of impression compound and tracing compound
removes any soft tissue folds and smoothes them over the mandibular
bone; this reduces the potential for discomfort arising from the 'atrophic
sandwich', ie the creased mucosa lying between the denture base and the mandibular bone.
The impression medium here is an admix of 3 parts by
weight of (red) impression compound to 7 parts by weight of
greenstick; the admix is created by placing the constituents
into hot water and kneading together.
Using a standard impression technique on a special tray , the
lower impression is recorded. The working time of this
admix is 1-2 minutes and this enables the clinician to mould
the peri-tray tissues to give good peripheral moulding
Once setting, applied a thin mix of Zinc Oxide impression material as a wash impression.
Butterfly impression technique:
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This technique is indicated in case of advanced resorbed ridge with projecting sublingual glands.
- A suitable metal tray is selected and the lingual border is made nearly flat to cover the
sublingual crescent area and a primary impression is made using alginate impression material.
- Using the resulting cast, an acrylic resin special tray is fabricated with a butterfly extension
over the sublingual crescent area and an occlusion rim is added to simulate the height and
position of the anterior and posterior teeth.
- The borders are adjusted so that the lingual flange and sublingual crescent area are in
harmony with the adjacent tissues during rest and function.
- Three applications of tissue conditioning material are used for making this impression with
closed mouth technique.
- Two application of a viscous tissue conditioning material.
Each application is allowed to remain in the mouth for 8-10 minutes pressure areas are corrected
after each application.
- Then, the third and final wash is made using either a soft tissue conditioning material or a light-
bodied rubber base impression material.
- The end result is an impression that has tissue placing effect, very thick and confirming buccal
borders, relatively thick lingual and sublingual crescent areas and covering the maximum
possible basal seat area within the functional limits of the adjacent tissues.
Dynamic impression technique:
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- This technique is used to record the range of muscle action as well as spaces into which the
denture can be extended without displacement,
- In this technique, complete utilization of the active and passive tissues is obtained as the
impression material is being shaped by the function of the muscles and muscle attachments
allowing properly formed denture borders.
- A special tray of activated acrylic resin is constructed on the primary cast.
- Three stops of impression compound are added to the fitting surface of the tray, one at the
anterior region and one at each side posteriorly in the first molar region to allow a room of two
millimeters between the tray and the surface of the cast.
- Mandibular rests of impression compound are placed bilaterally on the occlusal surface of the
tray in the molar region.
- Also, a compound tongue rest is added in the anterior region to secure a correct tongue position
during impression making.
- Final impression is made using a thin mix of alginate impression material. The loaded tray is
seated in the patient's mouth and pressed gently until the stops are firmly seated on the residual
ridge.
- Then, the patient is asked to close slowly until the mandibular rests firmly contact the
maxillary arch and keep his tongue in contact with the tongue rest.
- The patient is instructed to swallow 3-4 times and forcefully protrude the lips forwards.
The resulting impression covers the maximum possible basal seat area and the borders are in
harmony with the adjacent moving tissues.
Functional Imp. Tech.:
3. Tissue conditioner imp. tech.
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4. Neutral zone imp. tech.
Tissue conditioner relining imp. tech.
On occasion, dentures may exhibit looseness, not arising primarily from retention problems but
because of localized areas of poor functional adaptation.
For modification of Local areas, application of a thin mix of
a chairside resilient lining material (eg Visco-Gel, Dentsply
Limited Surrey UK) may be used. The mixed material is
added to the fitting surface of the denture and the patient is
instructed to wear the denture for one hour. After one hour of
functional moulding the denture is then removed from the
mouth and the conventional relining process completed.
Even Pressure by closing in CR/MI
Border Mould
Hold in light contact for 15 mins
Inspection to the fitting surface
the patient is instructed to wear the denture for one hour
Even 2 mm thick
No bare spots
Peripheral Roll
Maintain VDO
Remove the excess
Neutral zone imp. tech.
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Neutral Zone: The neutral zone is, in fact, the zone previously occupied by the
natural teeth, which hold in its place by the controlling action of the cheeks, lips, and
tongue.
Thus, the same forces that helped to position the natural teeth in the dental arches can
help to maintain the artificial teeth in their places.
It is designed for patients with poor track records of (lower) denture stability, a large
tongue or other anatomical anomaly.
Sectional Impression Tray and Sectional Denture for
a Microstomia Patient Journal of Prosthodontics 19 (2010) 161165
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Microstomia is is defined as an abnormally small oral orifice.
A limited oral opening can be caused by
surgical treatment of orofacial cancers,
head and neck radiation,
reconstructive lip surgery,
burns,
trauma,
microinvasion of muscles of mastication,
temporomandibular joint (TMJ) dysfunction syndrome,
and genetic disorders.
Scleroderma is a connective tissue disease of the skin, joints, and sometimes internal
organs. Facial skin and oral mucosa become thin and taut, and wrinkles disappear,
resulting in a mask-like appearance and a reduced oral opening.
Treatment modalities of microstomia
Microstomia Orthoses: It is dynamic opening devices used in treatment of microstomia.
surgery,
Modification of denture design : Sectional and collapsible dentures have been described
for these patients. different
Mechanisms for connecting sectional dentures include cast Co-Cr hinges, swing-lock
attachments, stud attachments, orthodontic expansion screws, pins, bolts, telescope
system, rods, clasps, cast locking recesses, and magnets.
Impression procedures
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The insertion of a standard complete arch stock impression tray may be impossible if there is
a severely limited oral opening. Management includes flexible modified stock trays and
sectional trays.
Primary impression: A flexible tray was prepared by manually dispensing silicone putty
impression material intraorally. The impression putty was soft during initial insertion. Once
placed intraorally, it was carefully positioned onto denture-bearing areas and molded to
appropriate contour using functional and manual manipulation. The impression was then
made with light body poly(vinyl siloxane) impression material, , which duplicated the details
to obtain a primary impression.
These were then stabilized in a non-displacing mix of dental stone prior to pouring them in
dental plaster to obtain the primary cast.
Final impression: Custom impression trays were
fabricated with autopolymerizing acrylic resin and tried in
the patients mouth.
It was noted that a maxillary tray could be introduced in
the patients mouth with some amount of difficulty;
however, a mandibular custom tray could not be placed. Therefore, it was planned to section
a mandibular impression tray into two halves to insert into the mouth. Press buttons were
fixed to the handle of the sectional custom tray so the tray could be
exactly reassembled.
Border molding was alternatively made for the right and left halves
of the sectional tray. Following this procedure, Zinc Oxide Eugenol
(ZOE) impression paste was used to make the definitive impression.
The impression paste was placed in the right half of the tray, which
was inserted initially.
After the impression material set, the left half of the sectional tray with impression paste was
inserted.
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After the impression was completed, the sectional trays were separated intraorally and
reassembled externally.
The impressionwas boxed and poured using ADA type 4 dental stone.
The conventional method was used to make the maxillary impression.
Jaw relations : Jaw relations and teeth setting were completed with a sectional
impression tray using the press button.
Denture design and fabrication
The denture was processed in a single piece using heatpolymerized
acrylic resin with a conventional compression molding technique
according to manufacturers instructions. The denture was then
deflasked, trimmed, and polished.
The patient could insert the maxillary denture; however, the mandibular denture could not be
inserted in the mouth. Hence, a mandibular sectional denture was designed in two pieces with
a locking mechanism using magnets.
Prior to sectioning the denture, a stone index was prepared by
investing the occlusal and polished surface of the denture in dental
stone for a correct alignment of sectioned segments. The denture
design incorporated sectioning in the molar region in step-design
fashion.
Stainless steel encased iron-neodymium-boron button magnets with a 5-mm circumference
were placed on the horizontal cut section to provide resistance to vertical dislodgement. The
two sections could be connected intraorally, providing a rigid connection due to a strong
attractive force
Sectional Impressions and Simplified Folding Complete Denture
for Severe MicrostomiaJournal of Prosthodontics 19 (2010) 299302
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The final impressions were made with sectioned acrylic resin custom
impression trays with interlocking handles to intraorally relate the left
and right sides.
A maxillary record base was then fabricated on the master cast using a
folding design. This was accomplished by incorporating a simple
hinge into the record base.
To keep the denture in the unfolded position in the mouth, a denture
lock mechanism was formed using a plunger attachment
Modified Functional Impression Technique Braz Dent J 16(2) 2005
A major requirement for final impression of
complete dentures is to develop the peripheral contours to
accommodate normal muscular function and to ensure
peripheral adaptation without allowing air penetration
between the future denture base and the mucous membrane.
Functional tray handles can be used with any individual
acrylic resin trays. These handles are made in a L-shaped metal master die (70 mm length and 7
mm in diameter), which is flasked in brass flasks to obtain the tray handle. Thereafter, the handle
is finished and polished.
Once the individual tray is prepared, the handle can be attached to its midline, positioned on the
area corresponding to the crest of the ridge. For the
maxillary arch, the handle can be fixed to the tray using
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acrylic resin. For the mandible, an acrylic resin base (15 mm high with a 10-mm-diameter upper
central hole) should be prepared and fixed to the individual tray on the residual ridge at its
midline. The functional handle is further attached to the upper central hole with a bolt that is 11
mm long and has a diameter of 2 mm.
This functional handle can be readily removed from the tray to facilitate molding of lingual and
sublingual flanges borders with low fusion impression compound. The patient can freely move
the tongue without interference from the tray handle. During this procedure, the tray is held in
place by digital pressure of the dentists right and left index fingers on the acrylic resin supports
existing in the region of the tray corresponding to the first and second mandibular premolar.
During impression of buccal and labial flange borders, the functional handle is reattached to the
tray and the patient is asked to perform a suction movement.
The final impression is carried out in two stages using two types
of materials. The first stage consists of border molding with low
fusing impression compound. In the second stage, a zinc oxide-
eugenol paste is applied to the main supporting surface of the
impression.
The impression is then completed with zinc oxide-eugenol paste
and the loaded tray is gently seated in the patients mouth. The
patient is asked to suck on the functional handle again, while the
dentist holds the tray in position.
For lower border molding, the functional handle is removed from
the base by disconnecting the bolt, in such a way that the patient
can move his/her tongue freely during the impression of the sublingual and lingual flanges. The
dentist uses the acrylic resin molar supports at both sides of the tray, to keep it in position during
this phase of the impression procedure.
For vestibular border impression, the handle is reattached to help introduce and hold the tray in
place into the mouth and to facilitate suction by the patient.
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For lower impressions, during suction, the tray is balanced by the dentists thumb pulling up and
the index finger pressing down, a procedure opposite to that used for upper impressions.
As the border of the impression has been completed, the next step is to record the main
supporting surface of the final impression. The tray is loaded with zinc oxide-eugenol paste and
gently seated into the patients mouth. Once the tray is properly positioned with the material
overflowing, the handle is removed again for recording the lingual and sublingual flanges. At
this time, the dentist keeps the tray in position by pressing the resin molar supports while the
patient performs tongue movements, as previously described, for approximately 20 s.
Finally, the handle is quickly reattached to the tray without removing the tray from the patients
mouth and the patient is asked to repeat the suction movements with the operator firmly holding
onto the tray handle.
A Layering Technique Using Multiple Viscosities of Impression
Material (Compendium / August 2006 Vol. 27, No. 8)
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It is a newly designed type of edentulous impression tray is used to
Capture all the fine detail of the edentulous arches in a single
appointment.
Eliminating the necessity and expense of two appointments and
the fabrication of custom impression trays.
Employs the use of different viscosities of polyvinyl siloxane
impression material to capture the fine anatomic details with the appropriate amount of
pressure (related to the type of tissue) and optimal vestibular extension.
the appropriate viscosity of impression material selected is based on evaluation of the
tissue character and mobility classification
Evaluation and Classification of Tissue Quality
The tissue character can be assessed using digital/tactile evaluation.
The clinician uses tactile manipulation to assess the character of
the tissue overlying the bony support in the edentulous arches and
classifies the tissue as either coarse and fibrotic, average, or thin and
fragile.
The soft tissue overlying the residual ridges should be assessed
using a blunt instrument to determine the relative amount of
displacement or mobility. After tactile assessment, the tissue can
then be classified and recorded as one of the following: attached,
low mobility, low displacement; average, clinically acceptable
displacement; or high mobility, high displacement.
Soft tissue that is categorized as attached and less mobile overlying the alveolar ridge generally
results in better adaptation of the removable prosthesis.
Requirement
a-It is important to use an impression material that
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maintains dimensional stability
have high percentage of recovery from deformation.
It is also important that the clinician be allowed to apply multiple viscosities sequentially
and simultaneously
will set to form a homogeneousmass of impression material, regardless of the viscosity
used.
The materials selected for this technique must exhibit high tear strength (resistance to
tearing) across the multiple viscosities used in this procedure.
The use of the multiple viscosities of impression material should be such that there is a
colamination between the layers of material and an anatomically correct and detailed
reproduction that captures all aspects of the edentulous arches.
polyvinylsiloxane (PVS) materials appear to meet all of the requirements that support the use of
this layering impression technique. The impression material used to demonstrate this technique is
a hydrophilic, PVS material and a specially designed disposable edentulous tray. The authors
chose Aquasil Ultra PVSa.
Four different viscosities of impression material were used to build and complete the final
impression. High viscosity (green), medium viscosity (purple),low viscosity (teal), and ultra low
viscosity (orange)
b-Impression trays
Recently developed edentulous impression trays were used to accomplish final
maxillary and mandibular
The trays are available in five different sizes for the maxillary and mandibular
arches.
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A unique sizing caliper has been developed to measure the maxillary and mandibular arch sizes.
The corresponding tray size number is displayed, and the appropriate tray
is selected for initial try-in
Clinical Application
1- Create tissue stops : The high viscosity PVS impression material with
low strain in compression is used initially to create tissue stops before
proceeding.
The tissue stops
create adequate tissue relief for the impression material,
Help to reposition the impression intraorally, and center and
stabilize the tray on the edentulous residual ridge.
The tissue stops provide the clinician with a predictable position on
tray re-insertion, helping to prevent over-seating the tray during
functional border molding.
2-border molding:
High viscosity PVS is then added to the borders of the
maxillary impression tray, then border molded.
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The medium or heavy viscosity PVS is placed on the borders of the mandibular
impression tray, then border molded.
After removal of the border-molded impression tray, it should be examined to determine if any
areas of the tray are showing through the impression material. Areas of show-through should be
trimmed away one to two millimeters prior to taking the final impression of the loadbearing
areas
3- Material selection
the appropriate viscosity of impression material selected is based on
evaluation of the tissue character and mobility classification
For example, the premaxilla and anterior mandibular areas displayed
poor tissue character and mobility, which required the extra light
viscosity material, Lower-viscosity wash material is used when the
tissue is fragile and/or highly mobile, which is a situation that often
occurs when replacing an old lower denture or when no teeth have
been present for a long period of time.
while the posterior maxillary and mandibular arches displayed
average tissue character and mobility, which suggested the need for
low or average viscosity PVS material
Multiple viscosities of PVS impression materials are being
dispensed in the maxillary tray. In this instance, the ultra low
viscosity is applied to the premaxilla area, which had been evaluated
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as loose and having a spongy character upon tactile evaluation. The low viscosity was
applied to the mid-maxillary area where the tissue exhibited average tissue character
and average mobility.
To preserve and protect the peripheral detail of the vestibular borders of the
impressions, each final impression is boxed using the alginate boxing method.
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Accu -Dent System (Ivoclar)
The Accu-Dent System 1 is an irreversible hydrocolloid-based
impression system that is recommended by the manufacturer for
producing complete denture master casts.
The system uses the Accu-Gel impression materials, which are
chemically compatible, irreversible hydrocolloid materials that
differ in viscosity.
The low-density (syringe) material is injected into the vestibular areas while the high-
density (tray) material is used in the tray to support the syringe material and form a type of
"custom tray" in the mouth.
The system comes with special, autoclavable, plastic, perforated
impression trays that Ivoclar Vivadent claims can be easily modified for
special cases.
The Accu-dent impression materials are said to be accurate not only for
preliminary impressions but also for final impressions for denture
fabrication.
The Accu-gel impression materials met ANSI/ADA requirements
for alginate materials but failed to meet the higher detail reproduction
and gypsum compatibility standards of ANSI/ADA No. 19 for typical
final impression materials.
ADVANTAGES:
Kit comes with all items needed for making irreversible hydrocolloid impressions.
Is a suitable impression material for the fabrication of immediate dentures.
Impression trays were rated highly by clinical evaluators.
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Easy to mix and dispense.
Well tolerated by patients.
Acceptable working and setting times.
Meets ANSI/ADA Specification No. 18 requirement for
gypsum compatibility and detail reproduction for
irreversible hydrocolloid impression materials.
DISADVANTAGES:
- Does not meet ANSI/ADA Specification No. 19 requirement for
gypsum compatibility and detail reproduction for elastomeric
impression materials.
- Impression material is not suitable for the fabrication of
complete denture master casts.
- Tray material is too viscous.
- Requires water cooler than room temperature for mixing.
- Impression material more expensive than other commonly-used
irreversible hydrocolloid products.
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Frame Cut Back Tray PRACTICE IN PROSTHODONTICS, Vol.43, No.5 2010.9
(hereafter called FCB Tray) or as commonly called a frame-less tray
it is designed to reduce the frame of Tray around above the retromolar pad and to prevent from
deforming the pad by relieving impression pressure applied to the pad toward externally from the
Tray. And next feature has another reduction of about two thirds of frame size around the buccal
shelf area in order to prevent from overextension into the buccal side.
If overextension of mucous membrane made buccally in the external direction, it tends to lose
closure of denture base on and around the retromolar pad.
Features of FCB Tray (distributed by Morita Corp.)
Frame reduction in the retromolar pad,
Buccal frame reduction,
Extensive tongue space,
Recess that tongue tip touches,
Line indent to indicate locating tray when seated,
Tray handle that is easy to bite
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Modification in Impression Techniques
Hayakawa & Watanabe (2003)
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2- Zarb et al 2004
4-Alternate Custom Tray Design
Shetty et al (2007)
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Obtaining Impressions for Implant-Supported Restoration
There are many choices of impression technique BDJ, VOLUME 187, NO. 9, NOVEMBER 13 1999
The standard approach is an impression made of the implant abutment using a transfer
impression coping.
There are two types of implant transfer impression coping: pick-up and re-seating copings.
A- indirect (closed tray)
In the closed-tray technique, impression posts (straight or conical)
are secured onto the implant abutments and remain attached to the
implant fixtures throughout the procedure
1- a custom tray is fabricated ensuring that there is adequate
relief to surround the height of the transfer impression
posts
2- Using a syringe, light-body, low-viscosity impression
material (Aquasil LV, DENTSPLY Caulk, Milford, DE)
is delivered to the mouth. Each transfer post should be
adequately surrounded by the impression material,
including the sulcus
The soft tissue replication is enhanced with a dual-phase material (Aquasil
Monophase/Aquasil LV, DENTSPLY Caulk, Milford, DE).
When working with multiple implant abutments, it is absolutely necessary to achieve a passive
or tension-free relationship between the superstructure and the underlying fixtures.
3- Complete impression with medium viscosity Aquasil
Monophase
4- After setting, the impression is removed from the patients
mouth, leaving the transfer posts attached to the implants.
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Upon inspection, sharp, accurate margins of the occlusal surface
and shoulder of the transmucosal abutment should be replicated in
the impression.
5- Each transfer post is carefully removed from the patient. It is
advisable to remove one post at a time and attach each to the
specific transfer analog.
6- The analog/post combination is then placed back into the
impression in the same site that it occupied in the mouth,
generally with an audible click verifying a positive seat
The re-seating impression coping
It is used with a conventional impression tray and syringing technique and the coping remains in
place on the implant after the impression material has set and the impression removed from the
mouth.
The transfer coping is then unscrewed from the implant and attached to the
laboratory replica outside the mouth and the coping/replica is re-inserted into the
impression before pouring with dental stone.
This technique is useful in clinical situations where there is limited space to allow for
screwdrivers to undo the long retaining screws of the pick-up technique.
B- Direct (open tray); the pick-up implant impression coping
The open-tray technique requires a tray which has been fabricated
to accommodate the larger two-piece transfer post design.
The transfer post for an open-tray technique consists of a square shaped
post and a fixation screw allowing precise connection to the implant. The
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tray should have an open window to allow for the internal screw to be removed, as the body of
the transfer post will remain within the impression
The Aquasil LV is delivered via syringe to surround each transfer post, as previously described.
The custom tray is then filled with the impression material (Aquasil Monophase) and delivered
over the square transfer posts and lower arch. The transfer post bodies will then be incorporated
into the impression.
It is used with a open faced impression tray. The tray allows access to a retaining screw that
secures the impression coping to the implant.
The retaining screw must extend 23 mm above the impression tray
opening. Impression material in injected around the impression
copings first and then the tray is seated in the mouth. After the
impression material has set and before removing the tray, the retaining
screw is unscrewed leaving the pick-up impression coping inside the impression.
The implant laboratory replica is then attached to the coping before pouring the impression with
dental stone.
The direct technique may use splinted or non splinted implant transfer copings.
The materials used to splint copings are composite resin, plaster, or acrylic resin.
Spector et al indicated that splinting is unnecessary once the acrylic resin used for splinting the
copings suffers polymerization shrinkage, which can cause some distortion, because splinting the
pick-up transfer copings can take more clinical time.
However, Assif et al showed that the technique using acrylic resin to splint pick-up impression
copings was significantly more accurate than the unsplinted technique. Although some previous
investigations showed no difference between implant impression techniques with splinted or
unsplinted pick-up impression copings
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`
Digital intraoral scanning (Digital impression)
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Factors which complicate impression making
1- Uncooperative patient 2- Excessive salivation
3- Dry mouth (xerostomia) 4.Nausea during Impression Making
Uncooperative patient
Some patients exhibit intolerance to prosthodontic procedure. This is may due to
fear or psychological problem
Consultation with physician and premedication is usually prescribed
Excessive salivation (Sialorrhea)
Excessive amounts of saliva, particularly of the thick mucous type, will displace the alginate
impression material and will contribute to an inaccurate impression especially in partially
edentulous patients.
1- Clinical management
Placing cotton rolls in upper buccal vestibule to control saliva from the parotid
gland
Placing cotton rolls in the floor of the mouth to control saliva from sublingual and
sub mandibular salivary gland
Ask the patient to rinse with astringent and cold mouth wash
Use saliva ejector
packing the mouth with unfolded 2 x 2 inch gauze:
In the maxillary arch one gauze strip is placed in the right buccal vestibule and
another in the left vestibule. The dentist must wipe the palatal area just before
making the impression.
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In the mandibular arch one gauze strip is placed in each of the buccal vestibules
and another is placed in the linguoalveolar sulcus by having the patient raise the
tongue, placing the gauze in the sulcus, and then having the patient relax the
tongue to hold the gauze in position. The gauze is removed immediately before
the impression is made.
2- Drugs
The excessive saliva can be controlled by having the patient rinse the mouth with
an astringent mouthwash followed by a rinse of cold water
The parasympathetic nervous supply to the salivary glands is mediated by
cholinergic terminals. Therefore, antisialogogues are primarily anticholinergic
drugs, such as atropine and scopolamine, or drugs that have anticholinergic
properties (phenothiazines and ganglionic-blocking agents) in addition to other
effects. Oral administration of anticholinergic drugs in acceptable doses reduces
salivary output but not arrest salivation.
With excessive amount of thick mucinous saliva from the palatal salivary glands, the patients
should be instructed to rinse with an astringent mouth rinse. Then 2 x 2-inch sponges moistened
in warm water should be used to place pressure over the posterior palate in an attempt to milk the
glands. This is followed by an ice water rinse immediately before the impression is made.
With copious amounts of saliva, the use of an antisialagogue in combination with mouth rinses
and gauze packs effectively controls this salivation. (A 15-mg Pro-Banthine tablet taken 30
minutes before the impression appointment)
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Dry mouth (Xerostomia)
Persistent dry mouth commonly referred to as xerostomia. Xerostomia is known with
others names such as Aptyalism, Asialia, Dry mouth, Hypo salivation, oral dryness,
salivary secretion decease.
If the teeth are too dry, alginate has a tendency to stick to them. Therefore the teeth
should not be air dried before making an impression.
Function of saliva
Help in Food digestion
Protects teeth from decay
Prevents infection by controlling bacteria and fungi III the mouth (antibacterial)
Help in chewing, swallowing
Lubrication of the oral mucosa
Retention of removable dentures
Diagnosis of xerostomia
It may based on evidence obtained from the patient's history, examination of the oral cavity and \
or silometry (collection device placed over salivary gland duct orifices, and saliva is stimulated
with citric acid).
The normal salivary flow for unstimulated saliva from the parotid gland is 0.4 to 1.5 ml
/min. the normal flow rate for unstimulated "resting" whole saliva is 0.3 to 0.5 ml/min, for
stimulated saliva Ito 2 ml/min. values less than 0.1 ml/min are typically considered xerostomic,
although reducedflow may not always be associated with complaints of dryness.
Symptoms
Patients often complain of a sticky, dry sensation in the mouth. They encounter problems with
chewing, swallowing, tasting or speaking.
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Causes of dry mouth
Medications: Many commonly prescribed medications, particularly in elderly
individuals, have xerostomia as a possible side effect.
Aging: Salivary flow may diminish in some individuals with age.
Illnesses: Specific illnesses and disease processes are associated with xerostomia, such as
chronic diarrhea, liver dysfunction, diabetes, anemia, Sjogren's syndrome.
Radiation therapy: The radiation treatment of cancer patients, particularly when affected
areas involve the head and neck regions, may result in dry mouth. The type and amount
of radiation used will determine the extent of damage caused to the oral salivary glands
and, in turn, the degree of saliva reduction.
Oral habits: as Chronic mouth breathing and inadequate fluid consumption.
Why is saliva important to denture wearers? In order for dentures to be comfortably stable in
the mouth, intimate contact between the dentures and the underlying gums must be achieved
during chewing, swallowing, and speaking. When the denture fits accurately, the physical
adherence of saliva to the denture and to the gums provides a force which aids in denture
retention and stability. In the absence of salivas the lubricating effects, the gum, cheek and lip
tissues may become irritated as the dentures move during chewing, swallowing and speaking.
Management of dry mouth
Modify medications: consultethe patients physician topermit substitution to an equally
effective drug that does not cause dry mouth, or causes it to a lesser extent.
Saliva can be stimulated by :
1.Mechanical (Masticatory, Gustatory sialagogues) Stimulants
Foods which require mastication (apples, carrots, celery, hard breads and rolls, meats,
etc)
Sugarless Gums Sugarless Tablet
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2. Chemical Stimulants
Mouth-Kote Solution : Mucopolysaccaharide Sol., contains citric acid
Optimoist Solution : Contains citric acid
3. Electrical Stimulant
4. Pharmacologic Stimulant, sialagogues (parasympathomimetic)
Salagen (Pilocarpine HCl); Cholinergic agonist
Evoxac (Cevimeline HCl); Cholinergic agonist
5. Oral Moisturizers / Salivary Substitutes
Solutions
WATER
Regularly drinking of water may both hydrate tissues and facilitate
some increase in saliva production.
Salivart
Contain carboxymethyl cellulose and hydroxyethyl cellulose Oralube
Xero-Lube
Plax Water-glycerin agent
Gel Oral Balance Glycerate polymer
6. Acupuncture
Are there alternative denture treatments for patients suffering from xerostomia?
Those patients who are not able to comfortably wear conventional dentures, due to severe
xerostomia, should consider implant-supported dentures. The increased denture stability offered
by dental implants may reduce tissue irritation caused by movement of the denture during
chewing, swallowing and speaking. These patients should understand that when dental implants
are used to support dentures, intense oral hygiene practices are required to maintain healthy
implants in the presence of reduced salivary production.
Consultation with a qualified dentist will help the patient determine which treatment approach is
best for them.
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Nausea during Impression Making, Pakistan Oral & Dental Journal Vol 27, No. 1\\ IJMDS- 2009;1(1) 54-65
Gagging is an involuntary contraction of the muscles of the soft palate or pharynx that results in
retching. it is a normal protective reflex to prevent foreign bodies from entering the trachea. In
some cases this problem is so severe that it requires definite treatment.
Gagging has been generally classified as either
somatogenic, or
psychogenic. Psychogenic gagging is induced by anxiety ,fear, and apprehension
Etiology of gagging.
1. Local and systemic disorders
2. Anatomic factors
3. Psychological factors
4. Physiologic factors
5. Iatrogenic factors
A. Local and systemic disorders-
1. Nasal obstruction
2. Postnasal drip
3. Sinusitis
4. Nasal polyp
5. Mucosal congestion of URTract
6. Dry mouth
7. Chronic GI disease
8. Chronic gastritis peptic ulceration
9. Carcinoma of stomach
10. Hiatus hernia
11. Uncontrolled diabetes
12. Catarrh and alcoholism
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B. Anatomic factors-
Anatomic abnormalities, oral and pharyngeal sensitivity predispose a patient to gag when
dentures are poorly constructed.
1. A long soft palate
2. Sudden drop at the junction of hard and soft palate
3. An atonic and relaxed soft palate elicits gagging by allowing the uvula to contact the
tongue and the soft palate to touch the posterior pharyngeal wall.
C. Psychological factors- like fear, noise, and smell can also trigger this response.
Some Systemic conditions that have psychosomatic components are-
1. Temporomandibular pain dysfunction syndrome
2. Atypical facial pain
3. Denture intolerance
4. Burning mouth syndrome
D. Physiologic factors-
Extraoral stimuli:
The mere sight of a mouth mirror or impression tray is stimulus enough to cause some
patients to gag..
Acoustic stimuli- The sound of the wife gagging was sufficient to precipitate an attack of
gagging in the husband.
Olfactory stimuli - certain smells may cause a patient to gag. The smell of various dental
substances, cigarette smoke on the dentist fingers and even perfume have been reported
as olfactory stimuli to the gag reflex.
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Intraoral stimuli-
The palate is divided into hyposensitive and hypersensitive regions. Line drawn through
the fovea palatinae demarcated relatively hyposensitive anterior and hypersensitive
posterior portion.
The tongue was similarly divided into the hyposensitive anterior and hypersensitive
posterior one third.
Landa reported that the upper surface of the posterior one third of tongue is the most sensitive
area in oral cavity.
5. Iatrogenic factors-
Sensitive tissues may be stimulated because of rough or careless technique and temperature
extremes of instruments or because of-
From prosthodontic point of view,
use of thin consistency of impression material,
large size impression tray or
Tactile stimulation of soft palate, posterior part of tongue, fauces can also induce
gagging.
Inadequate PPS and loose denture
Overloaded impression trays
Unstable & poorly retained prosthesis-produced movement of the denture base, which
produces a tingling sensation and gagging.
Overextended border of prosthesis particularly in the posterior area of palate and
retromylohyoid space, distolingual part of mandibular denture- this impinges one or more
of the trigger areas and thus produce gagging.
Placing maxillary teeth too far in a palatal direction and mandibular teeth too far
lingually, so that dorsum of the tongue is forced into pharynx during the act of
swallowing.
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Symptoms
Extra oral symptoms-
These include excessive salivation, lacrimation, coughing, fainting or in minority of patients, a
panic attack and sweating; at times a full-body response may occur.
Intra oral symptoms-
The patient who gags may present with a range of disruptive reaction; from simple contraction of
palatal or circumoral musculature to spasm of the pharyngeal structures, accompanied by
vomiting.
Trigger Zone of gag reflex-
Gagging may be elicited by nontactile and tactile stimulation of certain intraoral structures.
Five intraoral areas are known as trigger zones:
palatoglossus & palatopharyngeal folds,
Base of tongue,
Palate,
Uvula and
Posterior pharyngeal wall
Nontactile sensations such as-
Visual,
Auditory and
Olfactory stimuli
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Gagging severity index (GSI) : The gagging reflex is:
I -Very mild, occasional and controlled by the patient
II.- Mild, and control is required by the patient with reassurance from the dental team
Ill.- Moderate, consistent and limits treatment options
IV -Severe and treatment is impossible
V -Very severe: affecting patient behavior, dental attendance and making treatment impossible.
Management
Before starting any dental procedure detailed history must be taken. Enquire any un pleasant
previous dental treatment experience.
A positive history about gagging will require certain precautionary measures.
a) Psychological management
A firm sympathetic manner of self-confidence on the operator's part.
Assure the patient that no difficulty will be experienced if instructions are
followed and that the discomfort will be minimized as much as possible, being
in any case, only for a short time.
Behavior modification- Generally the objective is to reduce anxiety and
unlearn the behavior that provokes gagging. Relaxation, distraction,
suggestion and systemic desensitization.
Hypnosis
Praise patient
Pleasant environment
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Acupuncture-Acupuncture is a system of
medicine in which a fine needle is inserted
through the skin to a depth of a few
millimeters, left in place for a time,
sometimes manipulated and then withdrawn.
Dental treatment was then carried out and the
effectiveness of acupuncture is assessed.
The technique involves the insertion of one, fine, single-use disposable needle of
7mm length into the anti-gagging point of each ear to a depth of 3 mm. The needles
are manipulated for 30 seconds prior to carrying out dental treatment. The needles
remain in Situ throughout treatment and are removed before the patient is discharged.
Acupressure- stimulate the points with gentle finger pressure rather than fine
needles and therefore is a less invasive technique.
To make use of it locate the REN24 point.[ Chengjiang (REN-24)
is an effective acupressure point for controlling the gag reflex during
impression making. ]
It is situated in the horizontal mentolabial groove. Approximately
midway between the chin and the lower lip. Apply light finger pressure with the
index finger progressively increase the finger pressure until the patient feels
discomfort and distension.
The acupressure should start at least 5 min before impression making, continue
through the impression procedure, and be terminated only after the impression has
been removed from the patients mouth. Pressure can be applied by the patient,
dental assistant, or dentist.
Placebo effect
The placebo or suggestive effect of treatment can be very powerful. A recent
systematic review has confirmed that the placebo effect is mediated via
endogenous opioids.
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b) Clinical techniques
Marble technique- Singers marble technique is a method by which the gag reflex
can be exhausted. It consist of seven steps-
at Ist visit- no oral examination of any kind was made at the first office visit.
Five rounded, multicolored, glass marbles approximately inch in diameter were
placed on a tray in front of the patient. The patient was told to put the marbles in
his mouth, one at a time at his leisure, until all five marbles were in his mouth.
Since the fear of swallowing the foreign object can induce a gag reflex, the patient
was assured that if he swallows the marble, it could not harm him. Continual
assurance that he would be able to wear dentures was given to the patient at each
weakly visit. He was urged to keep five marbles in his mouth continuously for one
week, except when eating and sleeping.
Roofless Denture- maxillary denture can be reduced to a U-shaped border
situated approximately 10mm from the dental arch.
Matte finish denture : a smooth highly polished surface which is coated with
saliva may produce a slimy sensation which is sufficient to cause gagging in
some patients; a matte finish has been advocated as more acceptable in this
situation.
Training bases- patient is supplied with a series of small to full sized denture
bases. A thin acrylic denture base without teeth is fabricated and the patient is
asked to wear it at home, gradually increasing the length of the time the
training base is worn. Initially 5 min once each day, then twice each day and
so on. After 1 week; 3 min each day, then 15 min, 30 min & 1 hr. anterior
teeth are added and when the patient is able to tolerate it, posterior teeth are
added.
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Progressive desensitization: As sensitive patients will experience the same
difficulty at each succeeding visit and as the wearing of the finished denture
will be difficult, it is advisable to construct a fitting base plate in acrylic on
the first impression and give it to the patient with instructions to practice
wearing it for increasingly longer periods each day until it can be worn for at
least an hour without discomfort.
Modification of edentulous maxillary custom tray- to prevent gagging-attach
a disposable saliva ejector to the base plate in the midline of the tray. It is
easy to fabricate these trays using disposable saliva ejectors at their distal
aspects so that the excess impression materials flow through these ejectors
without triggering the soft palate area.
Increasing the interocclusal distance by either remounting and grinding the
teeth or remaking the denture when the discrepancy was gross. the
interocclusal distance was inadequate in patients with serious gagging
problems.
Teaching the patient to swallow with their mouth open- it has been
suggested that all patient who gag characteristically swallow with their teeth
clenched, using the teeth, lips and cheeks as a buttress for the tongue to push
against. Teaching the patient to swallow with teeth apart, the tip of the tongue
placed anteriorly on the hard palate, and orbicularis oris relaxed, has been
advocated.
soft blow down splint can be used both in dentate and edentulous patients. It
can be fabricated and adjusted very easily. It guides the tongue to more
favourable position rather than pharyngeal guarding posture.
Soft swallow method by asking the patient to hold the tip of the tongue
behind the upper anterior teeth and undulate the tip back and forthand then do
swallowing with the teeth apart is also found successful to prevent gagging.
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c) Pharmacological management
1. Locally acting- peripherally acting drugs/ local anesthesia:
They may apply in the form of sprays, gells or lozenges or by injection. The
effectiveness of these agents is limited. When mucosal surface is desensitized, the
patient is less likely to gag.
The deposition of LA around the posterior palatine foramen has been used for patient
who gags.
However, the administration of a local injection may not be possible and may itself
provoke gagging. Further more injection of LA solution may distend the tissue
resulting in an inaccurate impression, which may compromise retention of prosthesis.
A topical anesthetic containing benzocaine (14%), butyl aminobenzoate(2%0 and
tetracaine hydrochloride (2%) can be sprayed on a gauze pad and placed on the back
of the upper arch until the area is obtained.
LA solution and impression material mix : Dispense 1 capsule of LA solution 8ml
of 2% lidocaine with 1 part in 100,000 epinephrine to the plastic measuring cylinder
and then add water to the correct volume. Now to this solution add impression
material, mix thoroughly. Insert the loaded tray gently in the patients mouth and
press until set.
2. Centrally acting drug- it is only a short term solution for severe gagging problem and
should not be used routinely
1. Tranquilizers like chlorpromazine are useful in patient under strain/tension 25-
100mg
2. Semi hypnotic, antihistamines, parasympatholytics.
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3. General anesthesia- a minority of patient does not respond to any form of sedation
or behavioral therapy and dental treatment under GA may be appropriate as a last
resort.
3. Conscious sedation-. The use of conscious sedation with inhalation, oral or intravenous
agents may temporarily eliminate gagging during treatment while maintaining reflexes that
protect the patients airway.
Oral sedation may be useful in mild gagging
Intravenous sedation is often much more predictable than oral sedation, and canbe
of use in patient were inhalation sedation is ineffective.
1. Desensitize the surface of the mucous membrane with:
a- Phenol mouth washes of one part phenol to eighty parts of cold water.
b- Sucking a tablet made for this purpose.
c-The application of a surface type of local anaesthetic either in the form of cream or
spray. the hard palate, soft palate, cheeks, lips and tongue were swabbed with 2%
pentocaine solution in order to produce topical anesthesia.
d) Surgical technique
Leslie advocated an operationto shorten and tighten the soft palate on healing
the removal of the uvula, This solution has not been accepted.
e) Prosthodontic Management
Reduction of stimuli
The patient should blow the nose to clear any nasal obstruction and then
encouraged in deep, nasal breathing.
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Explain to the patient that, as soon as the impression is seated, the head may
be brought well forward over the lap and that a bowl will be provided to hold
under the chin to catch any saliva that may run out of the mouth.
Carry out the impression technique using as little material as possible. Avoid
touching the dorsum of the tongue with the back of the tray and seat the
impression as quickly as possible.
Avoid using impression material of thin consistency.
Select appropriate size of the impression tray. Over extensions should be carefully
avoided.
Use fast set material
Use saliva ejector to remove excess saliva
Have the patient sit in upright position with the head tilted slightly downward to
prevent material running to throat
Patients dislike plaster of Paris more than any other material, even when it is flavoured, the
alginates are tolerated slightly better; composition is usually tolerated well, probably owing to its
putty-like consistency and its heat; zinc oxide paste seems to be disliked least of any but this may
be largely due to its only being used in a tray which already fits, though its flavour of cloves
undoubtly helps in some cases.
Distraction maneuvers
Talking to the patient and engaging him in some topics of special interest to distract him
Asking him to breath deeply and audibly through the nose
Asking the patient to raise his hand or foot
Asking the patient to tap his foot rhythmically on the floor
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Progressive desensitization:
Construct a fitting base plate in acrylic on the first impression and give it to the
patient with instructions to practice wearing it for increasingly longer periods each day
until it can be worn for at least an hour without discomfort.
Singers marble technique: the patient is asked to practice with marble in his mouth,
gradually the number of marble increased
Patient is allowed to take the tray home and practice insert tray in the mouth every day
Patient is instructed to make presuure on the palate by tooth brush witout making
himself rech.
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Summary
Procedures that will help to prevent gagging include:
1. The dentist should:
a) Not mention the subject of gagging
b) Ask whether the patient has had impressions made previously.
2. Before the impression is made:
a) Ask the patient to use astringent mouth rinse and cold-water rinses
b) Seat the patient in an upright position with the occlusal plane parallel with the floor.
c) Ask the patient to take a deep breath and hold the breath while the dentist quickly
checks the size and fit of the tray.
d) Correct the maxillary tray with modeling plastic and leaving sufficient unrelieved
modelling plastic at the posterior border.
3. The impression material must:
a) Have the consistency of thick whipped cream
b) Fast-setting alginate.
c) Set up to a rubbery consistency in few minutes.
4. During the impression procedure:
a) Not overfill the tray with impression material.
b) Seat the posterior part of the tray first and then rotate the tray into position.
c) Force excess alginate in an anterior direction.
d) Ask the patient to: Keep the eyes opened and focused on some small object.
Breathe through the nose.
5. The leg lift procedure is used before and during the making of the impression.
6. Giving all instructions to the patient in a firm, controlled manner.
7. The use of an anesthetic spray is usually contraindicated.
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Relief Areas
Relief means release or elimination of pressure from a specific area in the denture-
supporting structure. The mucous membrane covering the denture bearing area is varying
in thickness, softness and sensitivity.
So denture relieves are made to reduce pressure on the hard and the sensitive areas.
Hard areas : Areas covered by thin mucoperiosteum are usually hard and require relief to avoid
pain and/or rocking of the denture. The hard areas which require relief include:
1- Median palatine raphe.
2- Maxillary tuborosity if prominent.
3- Zygomatic process of the maxilla
4- Torus palatinus and torus mandibularis.
5- Mylohyoid ridge of the mandible.
6- Prominent genial tubercles
7- Any bony nodule.
Relation between ridge and median palatine raphe
If the alveolar ridge is covered by highly compressible mucosa, more relief than average is
needed over the hard median palatine raphe. If the alveolar ridge is firm and the palate center is
compressible, little or no relief is needed.
Sensitive areas : Relief of pressure over sensitive areas is needed for patient comfort and to
avoid pain. The sensitive areas requiring relief include:
1- Incisive papilia.
2- Enlarged rugae areas (especially when they are undermined).
3- Mental foramen areas (especially in flat lower ridges).
4- Crest of thin lower ridge.
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Methods of relief
A- Automatic relief
This type of relief can be obtained at the time of making the impression by using a
muco-compression impression technique.
B -Direct relief
1) In the impression
By scraping the final impression to the desired width and depth over areas
corresponding to the hard or sensitive areas. This method is only used with
plaster of paris impression material.
2) On the cast (The commonly used method)
The area to be relieved is outlined on the cast and
covered by one or more layers of tin foils of the
desired shape and thickness. The tin foil is
burnished over the cast by a blunt instrument and
fixed in place by cement.
Depth and shape of the relief
The depth of relief depends mostly upon resistance or yield of the area to be relieved as
compared with that of the surrounding area. The probable amount of settling of the dentures must
be considered in estimating the depth of the relief areas to prolong the denture services.
The shape of the relief is determined according to the extent of the hard or the sensitive
areas. Generally, in the upper model the relief area will normally be pear-shaped with the
broadest part anteriorly. It should not extend to the crest of the ridge except over the incisive
papilla.
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Advantages of relief
1- Preventing pain and rocking of the denture and giving comfort to the patient.
2- Improving the denture stability and preventing it from teetering.
3- Compensating for tissue displacement over the ridge during settling of dentures and due to ridge
resorption, as resorption takes place mainly in the alveolar process and the central area of the
palate changes very little throughout life.
4- Compensating for some technical discrepancies occuring during processing or repairing the
denture. Relief in the maxillary denture compensates for the shrinkage of acrylic resin during
processing. Shrinkage makes the upper denture slightly narrower across the tuberosities and
higher in the palatal vault areas.
Relief is also required to compensate for stresses and strains produced in the impression material.
Pressure is high in more confined areas, as in the center of the vault. Most impressions, if not
relieved, will produce undesirable heavy pressure in the center of the palate.
Disadvantages of relief
It may affect the retention gained by accurate adaptation of denture base and oral tissue
because there is no actual contact between denture base and the tissue at the areas of relief.
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Posterior Palatal Seal [PPS] (Post-damming)
The posterior palatal seal area is that area of the soft tissue
along the junction of the hard and soft palates on which pressure
within the physiological limits of the tissue can be applied by the
denture to aid in the retention of the denture.
Post dam is a slight elevation at the posterior border of
maxillary denture.
The post-dam should be placedin the region of compressible tissue
just distal to the hard palate, but it must beanterior to the vibrating line.
Peripheral seal is the area of contact between the lip and cheek mucosa and the denture
borders that prevent passage of air between the base and the tissues.
The peripheral seal depends on proper extension (width and height) of the denture borders that
fill the mucobuccal space and contact the cheek tissue laterally. There are no cheek tissues
posteriorly to seal the denture border. Therefore, the posterior palatal seal is necessary.
Functions of post-damminmg
1- It slightly displaces the soft tissue at the distal end of the
maxillary denture to enhance theposterior border seal
2- Increases retention of the denture by atmospheric pressure. As
the denture borders terminateon resilient tissue so it maintain a proper denture seal.
3- Prevents air and food from getting under the denture
4- Decreases reflex irritationand gag by:
a- Decreasing patients awareness of this area, as no separation occurs between
denture base and soft palate during normal functional movement.
b- Reducing the thickness of the denture base conspicuous to the tongue.
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4- Compensates for dimensional changes that are inherent in the laboratory procedures,
and for minor denture base functional movements
5- During taking the impression, the post dam acts as a guide for positioning the tray and
prevents the impression material from sliding into the pharynx
If the denture/tissue contact (seal) around the denture borders has been lost and air is
freely allowed between the denture and the underlying tissues. A loss of this seal is often caused
by resin shrinkage during polymerizadon.
Acrylic resin shrinks toward the area of greatest bulk of the denture, which is
generally around the denture teeth. On the maxillary arch, this shrinkage usually results in the
creation of a good seal around the labial and buccal sides of the denture and loss of seal at distal
extent of the denture as it crosses the palate. In this area, as the resin shrinks toward the denture
teeth, it tends to lift away from the cast resulting in a future loss of the seal and hence loss of
denture retention.
This shrinkage must be anticipated and steps taken to help ensure that resin/tissue contact
will exist following processing. Some newer injection molding techniques minimize this
problem. Be sure to check with the material manufacturer regarding recommendations
concerning palatal seal areas.
Dimensions of post-dam
The post dam extends from the hamular notch on one side to the other
hamular notch of the other side. The post dam is usually narrow in its
central part (due to the posterior nasal spine), wider as it extends laterally
on each side, and narrow again as it approaches the hamular notch to fade
out behind the tuberosity called butterfly post dam or Cupids bow.
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The post dam should be wide to avoid cutting or irritating the tissues (about 4mm
wide in its widest part) the depth or thickness of the post dam should vary for different
individuals and, for the same individual from the different parts. The average thickness is
1 mm.
Depth of post-dam: The post dam is deepest at a point 1/3
of the distance from the posterior edge of the groove and the
midpoint between the midline and hamular notches. It becomes
gradually shallower anterposteriorly and laterally.
The depth or thickness of the post dam should vary in
different individuals and different parts of the same mouth
according to compressibility of the tissue. The mucosa at the
midline of the palate is less compressible than that at the sides, so
that the deepest area of the seal is located on either side of the
midline (1.5-2 mm). Its depth is about 0.5 mm at the midline and
at hamular notches.
The post dam is deepest at the posterior limit and gradually
becomes shallower as it progresses forward to merge with the rest
of soft tissues at the anterior limit
CLASSIFICATION OF SOFT PALATE
The width of the posterior palatal seal depends on the curvature of the soft
palate. The soft palates are classified into three classes based upon the angle that the soft
palate makes with the hard palate.
Class I;
It indicatessoft palate that is rather horizontal as it extend posteriorly with
minimum muscular activity.
Thesoft palate has a gentile curve and allows a broad post dam.
There is considerable separation between anterior & posterior vibrating
line does having white PPS area yielding more retentive denture base.
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Its width will be 1mm at the midline, 5-6 at the widest portion on the sides
and o.5 mm medial to the hamular notch.
Class II;
Thesoft palate has a medium degree of curvature and allows for a medium
width of the post dam (3-4 mm at the widest area).
Palatal contour lie between classI &classIII.
Class III;
It is seen in conjugation with high V shape palatal vault. There is few mm
separation of anterior & posterior vibrating line thus there is small PPS
area & less retention.
The soft palate has abrupt curvature and allows a narrow area for post
damming (1-2 mm at its widest area).
ANATOMIC & PHYSIOLOGIC CONSIDERATION
The PPS is divided in two anatomic separate boundaries-
1.Post palatal seal 2. Pterygomaxillaryseal
The post palatal seal is extending formonetuberosity to other.
Pterygomaxillary seal
Band of loose connective tissue lying between the pterygoid hamulus of sphenoid bone
and distal portion of maxillary tuberosity
Extend through pterygo maxillary notch continuing for 3-4 mm anterolaterally
approximation the mucogingival junction. It also occupies the entire width of
pterygomaxillary notch.
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The vibrating line runs from about 2 mm buccal to the center of the hamular notch on one
side of the arch, follows the junction of the hard and soft palates across the palate, and
ends about 2 mm buccal to the center of the opposite hamular notch.
Vibrating lines
The PPS lies between the anterior and posterior vibrating lines.
It is an imaginary line across the posterior part of the palate marking the division
between the movable and immovable tissues of the soft palate. This can be
identified when the movable tissues are functioning
It should be described as area not line
Anterior vibrating line
Located at the junction of attached tissues overlying the hard palate and slightly
movable tissues of the immediately adjacent soft palate. This should not be
confused with anatomic junction of hard and soft palate.
It can be located by patient performing Valsalva Maneuver or instructing patient
to say Ah in short vigorous bursts. This places the soft palate inferiorly at its
junction with hard palate.
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Due to projection of posterior nasal spine the anterior vibrating line is not a
straight line between the hammular processes. The anterior vibrating line is
always on soft palatal tissues. As soft palate extends posteriorly the action of
palatal muscles become more exaggerated.
Posterior vibrating line
It is an imaginary line at the junction of aponeurosis of
tensor veli palatini muscle and muscular portion of soft
palate. it is straight line
It represents the demarcation between that part of soft palate has limited or
shallow movement during function and the remainder of soft palate that is
markedly displaced during functional movements.
It can be visualized by instructing patient to say Ah in normal unexaggerated
fashion. The posterior vibrating line marks the most distal extension of denture
base.
Techniques used in locating the vibrating line.
1- The clinician will often visualize the position of this line by having the patient say
"Ahh" and noting that thesoft palatal tissues will usually lift while the hard palatal tissues
remain immobile.
2- The Valsalva maneuver in which the patient is asked attempt to blow air through their
nose while the nostrils are gently pinched closed. While gently holding the tongue down with
a mouth mirror, the clinician will often easily visualize the line because the soft palate will
drop dramatically at the vibrating line using this technique.
3- Other features indicating the position of this line may include a rather sharp color
change between the hard and soft palatal tissues at the vibrating line
4- Presence of the fovea near the line. According to Lye the fovea palatine are located on
average of 1.31mm anterior to anterior vibrating line.
5- Lastly, and often the easiest to visualize, may be the rather significant angular change
between the rather flat hard palate and the moderately to severely sloping soft palate. This
junction indicates the vibrating line.
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2. A ="clinical" junction of hard and soft palates.
3. B=ah-line ,
4. C=fovea palatinae ,
5. D: anatomical junction of hard and soft palates.
The distal end of the denture : should extend at least to vibrating line and in some
instances it may extend 1 to 2 mm posterior to vibrating line .[ ZARB]
The position of fovea palatine also influences the position of posterior border of the
denture. denture can extend 1-2mm across it. In patients with thick saliva, the fovea palatine
should be left uncovered or else thick saliva flowing between the tissue and the denture can
increase the hydrostatic pressure and displace the denture.
Posterior extent of denture in this region should end in the hamular notch & not extend
over the hamular process as this can lead to severe pain during denture wear
Determining the position of the post-dam
The soft palate is divided into non-movable anterior part that is
adjacent to the hard palate and movable posterior part.
The operator first discovers the position of the vibrating line by
asking the patient to say a prolonged ah, with the mouth widely opened,
and noting the line from which the soft palate moves.
The tissue in front of this line is exposed with a blunt instrument
and the area of soft compressible tissue noted. For future reference it is
useful to mark this line on the palate with an indelible pencil.
The posterior border can be accurately located if it is possible to see
the two small pits (fovae palatinae) one on each side of the midline on the
anterior part of the soft palate. The fovae are usually, though not invariable,
present and are situated just anterior to the vibrating line thus marking the
posterior limit of the denture.
The posterior palatal seal should extend from one hamular (pterygomaxillary) notch to
the other, following the contour of the hard palate anterior to the vibrating line. The fovea
palatinae are usually located anterior to the vibrating lines.
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Methods of post-damming
A- CONVENTIONAL APPROACH
After the special tray is fabricated there are certain instructions given to the patients:-
1 To rinse with an astringent mouth wash that is remove to stringy saliva that might
prevent clear transfer marking.
2. Location of pterygo maxillary notch is done by moving the T burnisher posterior angle
to the maxillary tuberosity until it drops into the pterygo maxillary notch. This is necessary
as there are times when small depression in the residual ridge may resemble pterygo
maxillary notch.
3. Identification of posterior vibrating line the patient asked to say AH in normal
unexaggerated fashion
4. Identification of the anterior vibration line. This is done by asking the patient to say
AH with short vigorous bursts (Valsalva Maneuver can also be used)
5- PROCEDURE
o A line is placed with an indelible pencil (Thomson sanitary colour transfer
applicators) through the pterygo maxillary notch & extended 3-4 mm antero-
laterally the tuberosity approximating the mucogingival junction same is done on
the opposite side. This complete the out lining of pterygo maxillary seal.
The posterior vibrating line is marked with an indelible pencil by connection the
line through the pterygomaxillary seal with line just drown demarcation the post
palatal seal
o The resin or shellac tray inserted into the mouth & seated firmly to place. Upon
removal from the mouth, theindelible lines will be transferred to the tray.
o Sometimes it is necessary to redefine transfer marking. The tray in return to master
cast to complete the transfer of the complete posterior border.
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The tray is trimmed until the posterior vibration line so that it decides the post
extent denture border.
o Returning to the mouth the palatal fissure is palpated with the T barnisher or
mouth mirror to determine their compressibility in width & depth.
o The termination of glandular tissue usually coincides with the anterior vibrating
line. The anterior vibrating line now marked and transeferred to master cast .this
complete the transferring the outline of posterior palatal seal.
The visual outline is in the shape of cupid bow the area between the anterior
posterior vibrating line is usually narrowest in the mid palatal region because of the
projection of the posterior nasal spine.
Kingsley scraper used to score the cast the deepset area are located on either side
of midline, one third the distance anteriorly from the posterior vibrating line. It is
usually scraped to a depth of approximately 1-1.5 mm . The tissue covering the
medial palatal raffae as little sub mucosa & cannot withstand same compressive
force as the tissue lateral to it
This area is scraped to depth of approximately 0.5-1 mm within the outline of cupid
bow & cast is scrapped to depth of half amoung to palatal tissue in that area can be
compressed being tapered posteriorly.
Failure to taper the seal posterior mainly to tissue irritation.
ADVANTAGE
1. The trail base will be more retentive. This can produce more accurate maxillo
mandibular records.
2. Patient will be able to experience the retentive qualities of the trail base, giving
them the psychologic security of knowings that retention will not be a problem in
the completed prosthesis.
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3. The practioner will be able to determine the retentive qualities of the finished
denture, leaving nothing to chance at the insertion appointment.
4. The new denture wearer will be able to realize the posterior extent of the denture
which may ease the adjustment periods.
DISADVANTAGES
1. It is not a physiologic technique & therefore depends upon accurate transfer of the
vibrating lines & careful scraping of the cast.
2. The potential for over compression of the tissue is great.
B-FUNCTIONAL METHOD:
This method is carried out at the time of impression making.
After finishing the impression, post dam area will be determined anda
strip of melted wax or low fusing compound is traced on the
impression over the post dam area.
The impression is seated in the mouth under gentle pressure
until it hardens. Meanwhile, the patient is asked to raise the soft palate
by breathing deeply from the nose.
The added material will spread out and form a raised
strip across the distal end of the impression. The final
impression with the posterior border seal is carefully boxed and
poured in stone.
Advantages:
1-The displacement of the tissues is within its
physiologic limit. Over compression of the tissues is
avoided.
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2-posterior palatal seal is incorporated in the trial denture base for added
retention.
The rational for the placement of a seal in the impression tray as follows:-
1. To establish positive contact posteriorly to prevent the final impression material
from sliding down the pharynx.
2. To serve as a guide for positioning the impression tray, especially if a shim has
been used within the tray to establish the borders.
3. To create slight displacement of the soft palate.
4. To determine if adequate retention & seal of the potential denture border is
present.
C- FLUID WAX TECHNIQUE
The marking are recorded in final impression one of the four type of wax can be used for
their technique:-
1. Iowa wax white developed by Dr. Earl S. Smith.
2. Korecta wax no. 4, orange developed byDr. O.C. Applegate.
3. H.L. physiologic paste, yellow-whitedeveloped by Dr. C.S. Harkins.
4. Adaptol green developed by Nathan G.
These wax are designed to flow at mouth temperature temperature. The melted wax is
painted into the impression surface & in the outline at seal area , the wax applied in
slightly & excess of the estimateddepth & allowed to cool to blow mouthtemperature to
increase its consistency& make it more resistent of flow.
The impression is carried to mouth & held under gentle pressure 4-6 minute to allow the
material flow position of head & tongue during this is procedure.
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The soft palate should be impression in it most functionally depressed positions that is by
keeping frankfort plane 30 below the Hz & the tongue is firmly positioned against
mandibular anterior teeth.
ADVANTAGE-THIS POSTION
Soft palate is impression in its most functionally depressed position.
The flow of saliva & impression material into the pharynx is prevented.
After 4-6 minutes impression tray is removed from the mouth & examined for uniform contact.
If the tissue contact has not established the wax will appear dull.
If the tissue contact has been established it will appear glossy.
If excess wax protruded out of the tray it should be removed.
A Secondary impression is reinserted & held for 3-5 minutes under gentle pressure followed
by 2-3 minutes of firm pressure applied to mid palatal area of the impression tray, upon removal
of tray from the mouth it is careful examined to see wax terminate in feathered edge near the
anterior vibrating line.
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Advantages
1. It is physiologic technique displacing tissues within their physiologically acceptable
limits.
2. Over compression of tissue is avoided.
3. Posterior palatal seal is incorporated into the trail denture base for added retention.
4. Mechanical scrapping of the cast is avoided.
Disadvantages
1. More time is necessary during the impression appointment.
2. Difficulty in handling the materials & added care during the boxing procedure.
D- ARBITRARY METHOD:
This method is carried out during jaw relation recording
or at the try-in stage.
The vibrating line is observed in the patient's
mouth as the patient says a series of short "ah" and marked
by indelible pencil.
The trial denture base is inserted so the indelible
pencil line marked on vibrating line of the soft palatewill
be transferred from the soft palate to the trial denture base,
and then to the cast (The posterior limit o f the post dam).
The tissues anterior to the vibrating line are palpated
with a mouth mirror to determine their compressibility both
in widthand depth and marked with the indelible pencil, then
transferred to the cast (The anterior limit of the post dam).
The cast is then scraped to the desired depth and width.
-
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E-SCRAPING OF MASTER CAST:
This technique is the least accurate and un-physiologic as the
technician attempts to place the posterior palatal seal. A line is
drawn across the posterior border of the cast between the two
hamular notches passing behind the fovea palatinae.
Another line is drawn anterior to the first line in the shape
of butterfly. The cast is scrapped by a sharp knife or carver to the
post dam between theses two lines.
The post dam is usually narrow in its central part (due to the projection of
posterior nasal spine), wider as it extends laterally on each side, and narrow again as it
approaches the hamular notch to fade out behind the tuberosity. It is sometimes called
butterfly (Cupid's bow) post dam .
Damming of the lower denture
A lower denture may be post-dammed at each distal extremity by slightly compressing the
retromolar pads. The amount of compression must be determined at the time of impression
taking.
Adding a posterior palatal seal to an existing denture:
The deficiency may be either in depth or in length of the denture base, or in both. Prior to
taking any corrective measures, the dentist should evaluate the entire prosthesis. If, in addition to
an insufficient posterior border, one or more of these criteria are not met, then it is more than
likely that a new prosthesis will have to be made. If the correct esthetic and phonetic
requirements have been fulfilled, the proper vertical dimension and centric relation position's
established, and the remaining denture borders correctly extended, then one should undertake the
correction of the posterior seal area. This can be done by three methods:
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a. Light cured resin can be utilized for intraoral correction of the posterior palatal seal.
Self cure acrylic resin is irritant to the mucosa. The denture is tested in the mouth till
sufficient peripheral seal is obtained.
b. Impression material can be used for this purpose (compound impression or wax) and
then duplicated in self cure acrylic resin.
c. Scraping a cast poured on the denture as before, and then the cast is provided with
escape ways to allow excess self-curing repair material to escape. The cast is coated with
separating medium and self-cure repair material is added to the denture at the posterior
portion. The denture is then seated firmly on the cast excess material will escape through
the escape ways.
ERRORS IN RECORDING OF PPS
1. UNDER EXTENSION
This is the most common cause for poor posterior palatal
seal. It may be produced due to one of the following reason:-
1. The denture does not cover the fovea palatina, the tissue
coverage is reduced & the posterior border of the denture is not in contact with the soft
resilient tissue which will move along with the denture border during functional
movements.
2. Reduce the patient anxiety to gagging.
3. Improper delineation of the anterior & posterior vibrating line.
Prevention: Excessive trimming of the posterior border of the cast.
2. OVER EXTENSION
1. The denture base can lead to ulceration of the soft palate & painful deglutition.
2. The most frequent complaint from the patient will be that swallowing is painful &
difficult.
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3. The hamuli are covered by the denture base , the patient will experience sharp pain,
specially during function.
4. The pterygoid hamuli must never be covered by the denture base.
5. The overextension can be removed with a bur & then carefully repolished.
Prevention: These region are trimmed & poslished
3. UNDER POSTDAMMING
1. This can occur due to improper head positioning &
mouth positioning. E.g. the mouth is wide open while
recording the posterior palatal seal the mucosa over the
hamular notch becomes stretched. This will produce a
space between the denture base & tissue.
2. Inserting a wet denture into a patients mouth &
inspecting the posterior border with the help of mouth
mirror. If air bubble are seen to escape under the
posterior border it indicates under damming.
Prevention: The master cast can scraped in the posterior palatal area or the fluid wax
impression can be repeated with proper patient position.
4. OVER POSTDAMMING
1. This commonly occur due to excess scraping of the master cast. It occur more commonly
in the hamular notch region.
2. Pterygo maxillary seal area, then upon insertion of the denture the posterior border will
be displaced inferiorly.
Prevention: Reduction of the denture border with a carbide bur, followed by lightly
pumishing the area while maintaining its convexity.
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Positioning the posterior border of the upper denture [BASKER]
If an existing denture is under-extended in this region there may be uncertainty as to
whether the patient can tolerate the desired correction of the underextension.
Under such circumstances, if a fully extended new denture is fitted which subsequently
cannot be tolerated, the palate of the replacement denture will have to be shortened. The
post-dam will be lost as a result, the border seal broken and the retention of the denture
reduced.
As an insurance against this eventuality it is wise practice to cut two post-dam lines,
one in the position of that on the old denture and one at the vibrating line. If, after
wearing the new denture for a few days, the patient reports that the new position of the
posterior border is intolerable, the extension of the palate can be cut back to the old post-dam
line without the danger of breaking the continuity of the border seal.
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Recording Bases and Occlusion Rims
Record blocks are generally made of occlusion rims attached to well fit trial denture base.
The recording base (trial denture base) is a temporary form that closely resembles the final
base of the denture under construction. It is used for recording maxillo-mandibular jaw
relationships and for setting the artificial teeth.
Requirements of an ideal recording base
1- Dimensionally stable, both on the cast and in the mouth.
2- They must be rigid and strong.
3- They must be well adapted to the cast and accurately fit the denture area.
4- They should retain their shape at mouth temperature.
5- They should have smooth and round borders.
6- They should be non-irritant
7- They should be easy to manipulate.
8- Easily contoured and polished
9- should be of proper thickness (about 2 mm in the hard palate area and 1 mm over crest
and facial slope of ridge to avoidinterfere with teeth placement
Types of recording bases
I- Temporary recording bases
These bases are used during the various steps and will later be replaced by the permanent denture
base. The materials used for temporary bases are:
1- Shellac baseplate
2- Cold curing acrylic resin
3- Vacuum formed vinyl or polystyrene.
4- Baseplate wax.
5- Swaged tin baseplate.
II- Permanent recording bases
It is the base of the finished denture. The materials used for permanent bases are:
1- Heat-curing acrylic resin
2- Casted metal (gold, chromium-cobalt alloy and chromium nickel).
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Temporary recording bases
1- Shellac baseplate
It is a commonly used material for recording bases.
Construction
1- All undercuts of the casts should be blocked out.
2- To prevent the shellac from sticking to the cast, the cast should be treated by
one of the following methods:
a- Dusting the cast with talcum powder
b- Soaking the cast in water for few minutes
c- Adapting a layer of tin foil (0.001 inch) to the cast.
3- The shellac is softened on a flame then adapted to the cast by wet fingers. The
adaptation is started with the palatal portion of the maxillary cast or with the
lingual surface of the mandibular cast followed by the crest of the ridge and the
reflections.
4- The material is trimmed with scissors leaving approximately 5mm beyond the
edge of the cast.
5- This excess is heated and folded onto themselves to form a smooth rounded
border. Overheating should be avoided to prevent burning of the shellac.
To increase strength and rigidity of shellac base plates, reinforcing wires of 12-14
gauge should be embedded across the posterior palatal seal area for the upper trial denture
base and in the lingual flange of the lower one .
Advantages
1- Easily and quickly made.
2- Stronger than wax.
3- Laboratory time is saved.
4- Inexpensive.
Disadvantages
1- It is difficult to obtain good retention.
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2- It is not adequately strengthened, distortion may occur when left for a long time in the
mouth.
3- It is a brittle material.
4- The bond between the shellac base and the wax is less than that of acrylic base.
2- Cold-curing acrylic resin
Non -flasking method (Finger adapted dough method)
1- The cast is prepared by blocking out the undercuts with
wax and applying a separating medium.
2- The auto polymerizing resin is mixed and allowed to
reach the dough stage, then rolled to a sheet of 2-3 mm
thick.
3- While the acrylic sheet is still soft, it is adapted to the
cast and the excess resin is trimmed with sharp knife.
4- After polymerization has been completed, the acrylic
base is removed and retrimmed with bur, the external
surface of the resin base can be polished with wet pumice.
5- The thickness of the resin base over the crest of the ridge is reduced to about
1mm.
Flasking method
1- A wax is adapted to the cast and flasked. After setting of the investment
material wax elimination is carried out.
2- An autopolymerizing resin is mixed in a glass jar and packed into the mold
when it reaches the doughy stage, then the flask is closed.
3- Resin is allowed to polymerize under pressure for 20 to 30 minutes.
4- The base is removed from the flask, trimmed, and polished. If undercut is
present that will interfere with seating the base on the cast, it must be relieved
before seating is attempted.
This method requires considerable time for, fabrication and more costly.
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Since breakage of the master cast is possible with this technique it is advisable to duplicate the
cast and to construct the recording base on the duplicated model.
Alternating application of cold-curing powder and liquid (sprinkle-on method):
1- Undercuts are blocked out and tin foil or petrolatum is applied to the cast.
2- A thin layer of powder (polymer) is dusted over a small surface area of the
cast and sufficiently wetted with liquid (monomer) to produce a slight flow.
3- Alternate applications of powder and liquid are made until a thickness of 2 to
3mm has been developed.
4- The completed base is kept to polymerize, then removed, trimmed and
polished.
Well adapted base can be formed using this method; since any shrinkage that occurs in first
application is partially compensated for by each subsequent application and polymerization
shrinkage is kept minimal.
Advantages
1- They are strong and have accurate fit.
2- Do not soften or warp at mouth temperature.
3- They are not easily distorted
4- Any type of occlusal rims can be mounted to it.
Disadvantages
1- The retention may be reduced due to blocking out of the undercuts on the cast.
2- They may take up space needed for setting the teeth, necessitating some grinding
of the resin base in required areas.
3- Vacuum -formed vinyl or polysterene
1- The cast is prepared by blocking out the undercuts.
2- The cast is placed in its position on the vacuum machine.
3- Vinyl or polysterene sheet is inserted in the frame located below the heat
source.
4- Heating should be continued until the sheet is softened and begins to sag.
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5- The supporting frame carrying the softened sheet is lowered onto the cast and
the vacuum is turned on to adapt the sheet.
6- The heater is turned off and the base is allowed to cool then removed and
trimmed.
The vacuum method is very easy, fast and gives accurate results.
4- Baseplate wax
1- The wax is softened over a flame and adapted.
2- Excess wax is trimmed and the borders are rounded.
3- A strengthening wire is adapted in the posterior palatal seal
area of the upper base or incorporated into the lingual flange
of the lower base to increase both the rigidity and the
resistance to distortion.
These types are used in conjunction with wax occlusal rim. To prevent the wax from sticking to
the cast, talcum powder is applied to the cast.
Advantages
1- Easily to construct.
2- Inexpensive.
Disadvantages
1- It is softened and distorted at mouth temperature.
2- It does not withstand the pressure requiredfor recording jaw relationship.
3- It is very weak and not commonly used.
To increase stability and retention of shellac, resin, or wax-recording bases reline the
recording base with soft liner, zinc oxide eugenol or light bodies rubber base . The lining
procedure is done over the master cast after blocking out the undercuts and covering the cast
with a well-adapted layer of tin foil.
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5- Swaged tin base plate
1- Three tin layers of gauge (5) can be swaged one above the other on a
metal die and trimmed to the proper extend.
2- The inside layers can be cemented together with wax or zinc oxide
egeanol.
Advantages
1- It does not warp at mouth temperature.
2- It gives a uniform thickness.
3- It has a suitable fitness.
Stabilization of temporary recoding bases:
Tin foil is adapted to the cast. A thin mix of zinc-oxide paste is distributed on the fitting
surface of the base plate. Then the base is placed and pressed on the foiled cast. The paste will
adhere to the foil. The excess material is removed and the base is left till the material set.
In case where the residual ridge exhibits moderate to severe undercut, light-bodied
rubber base impression material or soft denture liner is used to adapt the record base. The
fitting surface of the base is painted by adhesive before applying the lining material.
The "flexible augmented flange technique" for fabricating complete denture record
bases Ouintessence Int 2001:32:361-364
A technique for fabricating complete denture record bases that features flanges
augmented with resilient liner is reintroduced and recommended. It is coined the "flexible
augmented flange technique."
The technique takes advantage of the elastic properties of tissue conditioner, available
anatomic undercuts in definitive casts, and the rigidity of record base resin to create
stable, retentive, well-fitting, and comfortable record bases that minimally abrade casts.
Tissue conditioner, which strongly bonds to the intaglio surface of record base flanges,
replaces blackout wax to form augmented flanges with flexible inner sections that are
sufficiently elastic to engage and then release from undercuts. The flexibility of the inner
section of theflanges permits a traumatic insertion and removal from a patients mouth,
despiteoverall record base rigidify.
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Permanent denture bases
1-Heat-curing acrylic resin
These recording bases are permanent and become part of the finished denture.
Technique
1- The wax pattern of desired shape is directly
adapted onto the cast without blocking out the
undercuts.
2- The definite outlines are obtained and the
pattern is invested in a flask. The wax is eliminated with hot water,
and then tin foil substitute is applied. The mixed acrylic resin is
packed into the mold and processed according to the manufacturers
directions.
3- The denture base is removed from the cast and finished.
4- The artificial teeth are attached to the acrylic base by wax to form the
trial denture. When satisfactory, the trial denture is flasked, processed.
Either cold-curing or heat-curing resin may be used to attach the teeth to the
processed base.
Advantages
1- The bases are rigid, accurate and stable.
2- It does not warp at mouth temperature.
3- The bond between the wax rim and the base is strong.
4- Any type of occlusal rim can be used.
5- Retention and stability can be tested in the mouth before the finishing of
the denture.
Disadvantages
1- Time consuming
2- Warpage always occurs when acrylic resin is reprocessed. However, this
can be prevented by attaching the teeth to the base by cold-curing acrylic
resin. It is not advisable to finish the denture on these bases.
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2- Cast alloys
These recording bases are permanent and become part of the
finished denture.
Technique
1- Refractory casts are first prepared from the
final cast. A wax pattern is formed on the
refractory cast, spurred, invested, burned out and the molten
alloy cast into its mold.
2- On cooling, the casting is removed from the investment,
finished and polished and then returned to the final cast.
Occlusion rims are attached to these metal bases to register the
jaw relationship. The artificial teeth are attached to the metal
base by acrylic resin.
Advantages
1- The bases are rigid, accurate and dimensionally stable.
2- They add more weight to mandibular denture and more thermal
conductivity to maxillary denture.
Disadvantages
1- They are more costly than other types of bases.
2- They require more time for fabrication.
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Occlusion Rims
They are horseshoe shaped occluding surfaces attached to the temporary or final denture
base for the purpose of recording jaw relations and arranging of teeth.
The occlusion rims are used for:
1- Establishing accurate maxillo mandibular jaw relations (vertical dimension and centric
relation).
2- Establishing the proper lip and cheek support (fullness of the lips and cheeks).
3- Choice of teeth
a- High and low lip lines; the distance between each of them and the occlusal plane
determines the length of the upper and lower teeth.
b- Canine lines; the distance between the canine lines determines the width of the
maxillary anterior teeth.
c- The distance between the canine lines and the posterior end of the occlusion rim
determines the mesiodistal width of the posterior teeth.
4- Arrangement of the artificial teeth; occlusion rim helps in the determination of:
a- The proper occlusal plane.
b- The neutral zone and the shape of the arch.
c- The labial surface of the teeth.
d- Position of mid line of the arch for the correct placement of the central
incisors.
e- Generally the occlusion rims form the medium in which the teeth are set up.
Types of occlusion rims:
1-Base plate wax rim:
Procedures of construction:
1. Dry the record base thoroughly as wax will not adhere to a wet surface.
Roughen the area of the record base where the wax will be adapted.
2. Uniformly soften a sheet of hard pink baseplate wax. Flame the wax on a
Bunsen burner flame slowly by passing the wax quickly through the flame many
times. When the wax is thoroughly softened, fold the wax in half. Continue to
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flame the wax to soften it. Repeat the folding and warming until the required roll
is formed.
3. Form thewax into a horseshoe shape and adapt the wax to the record base over
the ridge crest area. Begin at one posterior end and continue to the anterior and to
the opposite end.
4. Seal it to the record base with molten wax using a hot spatula. Add wax as
needed to contour the rim. Sticky wax can also be used to attach the occlusion
rims.
5. The rim should approximate the position of the natural teeth. Remember the
facial surfaces of the maxillary central incisors are 8-10 mm anterior to the center
of the incisive papilla. The wax rim must be anterior to the crest of the maxillary
ridge.
6. Use a heated wax spatula to develop a flat occlusal plane.
7. Adjust the height and width of the wax rims to the previously mentioned
dimensions.
Method of construction
1- Ready made rims: by a device called occlusion rim former .
2- Freehand molded rims: wax rolled and shaped to the arch form .
2-The composition (compound) rim:
The use of compound rim is indicated when it is desired to obtain more than one
jaw relation record or when Gothic arch tracing is to be taken.
3-Plaster and pumice rim:
When a functional recording of mandibular movements are to be made, a mixture
of plaster and pumice rims is used. In this technique the patient grind the maxillary and
mandibular rims together and produces the occlusal plane conforming to the mandibular
movements.
This plaster-pumice combination is mixed (equal parts) with water into a thick
consistency and a roll of it is placed on to the base. These plaster-pumice rims shouldbe
used through 24 hours before they became hard.
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The following factors should be considered during fabrication of occlusion rims:
1- The relationship of the neutral teeth to the alveolar bone
The fabrication of successful, functional and esthetic prosthesis can be
accomplished if the artificial teeth are placed in the same position that was
occupied by the natural teeth they are replacing.
The upper and lower anterior teeth are inclined slightly forward of the alveolar
bone.
The maxillary posterior teeth are positioned slightly buccal to the alveolar ridge.
The mandibular posterior teeth are inclined inward.
2- Relation of occlusion rims to edentulous ridge
The occlusion rims replace the natural teeth both in dimension and in their relationship to
anatomic structures. These relationships should be re-established by the occlusion rims even if
resorption of the residual ridge has occured.
Characteristics of occlusion rims:
1-The occlusion rims should be approximately the same size and shape as the natural
teeth being replaced.
2- Wax rims are smooth and have a flat occlusal surface. They are about as wide
buccolingually as denture teeth wider in the posterior, narrower in the anterior.
3-occlusal rim must be centered buccolingually over and parallel to residual ridge crest.
4- The occlusal rim is properly sealed to the baseplate without any voids
Maxillary occlusal rim
1. Labial surface of the natural central incisors
averages 6-8 mm anterior to the middle of the
incisal papilla.
2. The rims incline at approximately a 15" angle
labially to provide adequate support for the lip
3. Theplane of occlusion on the maxillary arch
should be approximately 22 mm in height, as measured from the bottom of the
notch createdby the labial frenulum.
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4. The posterior maxillary wax rim height is 16 mm
from the deepest point of the buccal flange. (The
maxillary occlusion rim should be approximately 12
mm in height from the record base at the crest of the
ridge in the tuberosity areas).
5. It should gradually taper toward the occlusal plane
and be approximately 8-10 mm in width in the
posterior, and 6-8 mm in width in the anterior region.
6. The upper rim terminates at the anterior aspect of the maxillary tuberosity. The
posterior of the maxillary occlusion rim should slope occlusally at approximately
a 45 degree angle from the record base, beginning approximately 8 mm from the
posterior extent of the record base. This will generally provide space for the
mandibular record base once placed intraorally
Mandibular occlusal rim
1. plane of occlusion runs parallel with base of cast, which
was trimmed to be parallel with residual ridges
2. the plane of occlusionanteriorly on the mandibular arch
should be approximately 18 mm in height, as measured
from the bottom of the notch created by the labial frenulum,
3. in the posterior mandibular region the height is equal to a point representing two
thirds the height of the retromolar pad.
4. It should be approximately 8-10 mm in width in the posterior, and 6-8 mm in
width in the anterior region.
5. rimsincline at a 15" angle labially to provide adequate support for the lip.
6. The lower rim terminates anterior to the retromolar pad. The rims are beveled
posteriorly towards the base to not interfere during recording of jaw relationships
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N.B.: In the lower jaw resorption occur more labially in anterior region and equally at
buccal and lingual in premolar region and more lingually in molar region.
The occlusion rim is is contoured as a guide for arranging artificial teeth which placed
labially anteriorly and on the ridge in premolar area and lingually at molar area. Boucher
One line is drown from the lingual to retromolar bad and extend anteriorly to a point just
lingual to premolar region, this line aid in poisoning the lingual surface of posterior teeth
Height : Width: ( U. & L. )
a- Upper: ant. =20-22 mm a-ant. =4-6 mm
post. =16-18 mm
b- Lower: ant. =16 mm. b-post. =8-10 mm
post. =14 mm or 2/3 the
retromolar pad height
Maxillary and Mandibular Occlusion Rim Measurements
CUSPID LINES
HIGH LIP LINE
MIDLINE
OCCLUSAL
PLANE
MIDLINE
22 mm
(APPROX
.)
18 mm
(APPROX.)
18mm (APPROX.)
VERTICAL
DIMENSION
LABIAL CONTOUR
OCCLUSAL
PLANE
JAW RELATION 7 COMPLETE DENTURE THEORY AND PRACTICE
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JAW RELATION
Jaw relation is defined as, "Any relation of the mandible to the maxilla"-GPT.
Various Terms Used in Jaw Relation
Orientation relation "The mandible which is kept at its most posterior portion, it can
rotate in the sagittal plane around an imaginary transverse axis passing through or near
the condyles".
Vertical relation amount of separation between maxilla and mandible in frontal plane
Horizontal relation "Maxillomandibular relationship in which the condyles articulate
with the thinnest avascular portion of their respective discs with the complex in the
anterosuperior direction against the slopes of articular eminence."
Centric jaw relation "The most posterior relation of the mandible to the maxillae at the
established vertical dimension" -GPT.
Eccentric jaw relation "Any jaw relation other than centric jaw relation" -GPT.
Median jaw relation "Any jaw relation when mandible is in the median sagittal plane".
Posterior border jaw relation: "The most posterior relation of the mandible to the maxillae
at any specific vertical relation"- GPT.
Protrusive jaw relation "A jaw relation resulting from a protrusion of the mandible"- GPT.
Rest jaw relation "The habitual postural jaw relation when the patient is resting
comfortably in an upright position and the condyles are in an neutral, unrestrained
position in the glenoid fossa"- GPT.
Unstrained jaw relation "The relation of the mandible to the skull when a state of
balanced tonus exists among all the muscles involved". "Any jaw relation that is attained
without undue or unnatural force and which causes no undue distortion of the tissues of
the temporomandibular joint" -GPT.
Jaw relation record "A registration of any positional relationship of the mandible
in reference to the maxilla. These records may be any of the many vertical, horizontal,
orientation relations." -GPT.
Terminal jaw relation record "A record of the relationship of the mandible to the maxilla
made at the vertical dimension of occlusion and at the centric relation. "-GPT.
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THEORETICAL CONSIDERATIONS
Basic mandibular positions
(1) Rest position. It is the vertical and horizontal position the mandible assumes when
the mandibular musculature is relaxed and the patient is upright.
When the mandible is in the rest position there is a space between the occlusal surfaces
of the teeth which is known as the freeway space or interocclusal rest space. This space
is wedge-shaped, being larger anteriorly where the separation between the teeth is most
commonly within the range 24 mm.
(2) Muscular position. The muscular position is the vertical and horizontal position of
the mandible produced by balanced muscle activity raising the mandible from the rest
position into initial tooth contact.
(3) Intercuspal position. The intercuspal position is the vertical and horizontal position
of the mandible in which maximum occlusal contact occurs. In the denture wearer, the
intercuspal and muscular positions should coincide.
(4) Retruded contact position. With light tooth contact maintained, movement of the
mandible in a posterior direction from the intercuspal position is usually possible. This
posterior position is known as the retruded contact position and is separated from the
intercuspal position by approximately 1 mm.
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The rest position
Clinical significance
(1) Constructing or assessing dentures.
(2) Relaxation of the masticatory apparatus.
Control of the rest position: The rest position of the mandible at any one time is
the result of a balance of forces .
Passive forces
(1) Muscles attached to the mandible.
(2) Gravity.
(3) Reduced intra-oral air pressure.
(4) The elastic properties of the capsules and
ligaments of the temporomandibular joints.
Active forces
(1) Mass of the mandible.
(2) Changes in position of the mandible.
(3) Pain, drugs and emotional stress.
Variation in the rest position
(1) Short term variables.
Patient supine Reduced
Head tilted
a. Back Increased b. Forwards Reduced
Insertion of lower denture or record block Increased
Stress Reduced
Pain Reduced
Drugs Variable
(2) Long-term variables. If the same dentures are worn for many years and are
not maintained, a reduction in the occlusal vertical dimension occurs as a result
of alveolar resorption and occlusal wear. The rest position of the mandible adapts
to this change and takes up a position closer to the maxilla.
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BIOLOGIC CONSIDERATION IN JAW RELATION AND JAW
MOVEMENTS
Mandibular movements
It is complex in nature, vary greatly among individual and within the same
person.
Dynamics of mandibular movements :
A. Muscles move the mandible.
B. Up bolstered bone guides it.
C. Ligaments and fascia limit it "other anatomical structures such as the coronoid
process are also limiting factor.
D. Nervous function controls it.
Purposes of mandibular movements :
A. Functional
1. Chewing " mastication"
2. Swallowing "deglutition"
3. Speech " phonetics"
4. Facial expression.
5. Wetting the lips.
B- Non-functional: or Para functional or perverted
1. Bruxism
2. Clenching
3. Habits " pipe smoking, pencil biting, and other habits"
Determinants of mandibular movements :
1. Posterior determinants (right and left TMJ), not under control of
dentist except via oral surgery.
2. Anterior determinants (Teeth) can be modified by dentist-phonetics
and esthetics are limiting factors.
3. Proprioceptive neuromuscular mechanism (TMJ, pulps, and
periodontal tissues send nerve impulses to muscles to work-conditioned
reflex) can be directly modified to a degree by modifying teeth.
4. Emotional status, stress or tension of the patient (C.N.S.). Emotional
stress contributes to bruxism, muscle spasms, and TMJ. complaints.
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Factors that regulate mandibular movement
Any mandibular movement is the result of the interaction of a number of biologic
factors. These include:
A. Influence of opposing tooth contacts.
B. Influence of TMJ.
C. Muscular involvement in mandibular movements
D. Influence of mandibular ligaments
E. Neuromuscular regulation
F. Influence of the tongue.
A. Influence of opposing tooth contacts:
The manner in which the teeth contact is related not only to the occlusal surface
of teeth, but also to muscles, TMJ, and neurophysiologic components including
the patients mental well being.
Variations in condylar movement have been observed when deflective occlusal
contacts or steep incisal guidance from opposing canines change the pathway of
mandibular movements. Thus the inclined planes of artificial teeth must be so
positioned that they are in harmony with other factors that regulate mandibular
movement, failure to develop this kind of occlusion can disturb the stability of
complete dentures.
B. Influence of TMJ:
The joint is much more stable with the teeth in occlusion than when the jaw is
open.
In occlusion, teeth stabilize the mandible on maxilla and no strain is thrown on
the joint when an upward blow is received on the mandible.
Forward movement of the condyle is prevented by the prominence of the
eminentia and by contraction of the posterior fibers of temporalis.
Backward movement is prevented by TMJ ligament and contraction of the
lateral pterygoid muscle.
In the open position, the joint is less stable rotating and the condyle lies forward
on the slope of the eminentia.
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Movements of the joint:
1. Rotation, which occurs in the lower compartment of TMJ
due to tight attachment between meniscus, capsule and
condyle. Every point of the mandible makes an arc around the
stationary center of rotation
2. Translatory; which occurs in the upper compartment of TMJ due to loose
attachment between the capsule, skull and meniscus.
Every point of the mandible moves a certain distance in the
same direction.
Movement up to 8 mm. between condyle and meniscus from
retruded to full opening was revealed.
The flexibility of the condylar movements and the fact that
there are 2 condyles makes three-dimensional space in which any one point of
the mandible can move with considerable freedom. It can move from one limit or
border position to another without going through a central or median position
such as the rest position. This type of movement is called circumductory
movement.
Axes of mandibular rotation
Rotational movements of the mandible are made around three axes.
1. Transverse axis:
During opening and closing movements the
mandible moves in the sagittal plane around
transverse axis that passes through both condyles.
Transverse axis can be located when opening
and closing movements occur with the mandible in its
most retruded position (Terminal hinge axis).
2. Vertical axis
In lateral excursion, the mandible rotates around a
vertical axis passing through the condyle on the working side.
Since it is physiologically impossible to make a lateral
mandibular movement with no translation of the condyle on
the working side, again the vertical axis is moving and tilting along with
the mandible.
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3. Sagittal axis:
During a lateral mandibular movement, the condyle on the
balancing side that is moving forward and medially
also moves downward because of the slope of the
articular eminence.
This downward movement of the condyle on
the balancing side causes the mandible to rotate
around a sagittal axis passing through the condyle on
the working side.
The sagittal axis also moves with working side condyle as it
translate, laterally, anteriorly, posteriorly, upward or downward
depending on the movement itself and the anatomic form of the glenoid
fossa, the condyle and the articulator disc.
C Muscular involvement in mandibular movements
The masseter and medial pterygoid:
The direction of both muscles in slightly
backward so that equal contraction of both pairs
produces a forwards as well as an upward movement.
Stronger contraction of the left medial pterygoid and
right masseter will result in upwards and lateral
movements of the mandible to the right. The masseter
has 3 parts, superficial, intermediate and deep.
Contraction of deep fibers produces a backwards pull
on the mandible, aided by the distal fibers of temporalis.
The temporalis and lateral pterygoid:
- These are the muscles, which produce horizontal
movements, and positioning of the condyles and
mandible as the teeth comes into occlusion.
- Temporalis provides upward and backward
movements of the mandible with less power.
- Some lateral pterygoid fibers are inserted into
the anterior part of the meniscus through the
capsule causing movement of these tissues.
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- The lateral pterygoid muscles acting together pull the condyles
forward and downward.
- When the left muscle contracts, while the other relaxes the mandible
moves to the right, this contraction helps to pull the mandible bodily to
the right "Bennet movement".
A significant feature of lateral pterygoid is its sole responsibility for
protraction of the condyle; there is no opposing muscle inserted
posteriorly in the condyle to retract it which is provided by contraction of
posterior temporalis and deep fibers of the masseter muscle and partly by
relaxation of lateral pterygoid.
Digastric and geniohyoid muscles :
- They depress the mandible in a down and backward direction- the hyoid
bone has to be fixed and this is achieved by the opposing contractions of
the stylohyoid and infra-hyoid muscles.
- When the mandible is fixed in the intercuspal position, the contraction
of these muscles will raise the hyoid bone, which occurs during
deglutition.
Suprahyoids :
Geniohyoid, digastric, mylohyoids and steriohyoids,
all these muscles function as a group to elevate the
hyoid bone and to depress the mandible when the
hyoid bone is fixed.
Infrahyoids :
Thyrohyoids, sternohyoids, sternothyroid and omohyoid, their function is
to lower the hyoid bone and larynx and to steady the hyoid bone, which
will allow then the suprahyoids to depress the mandible
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Summary for muscular involvement in mandibular motion:
1- Mandibular elevators:
Muscle Origin Insertion Action Innervation
Masseter Maxilla
Zygomatic
arch
Ramus
Angle of mandible
Elevation Mandibular division of
trigeminal nerve
Medial
pterygoid
Medial
surface of
pterygoid
process of
sphenoid and
maxilla
Ramus
-Angle of mandible
Elevation Mandibular division of
trigeminal nerve (V)
Temporalis Parietal bone -Ramus -Coronoid
process of mandible
Elevation Mandibular division of
trigeminal nerve (V)
2- Mandibular depressors:
Muscle Origin Insertion Action Innervation
Lateral
pterygoids.
Lateral
surface of
pterygoid
plate.
Greater wing
of sphenoid
bone.
Condyle process of mandible. Depression. Mandibular division of Trigeminal
nerve (V).
Digastrics. Digastric fossa
of mandible.
Mastoid notch of the
temporal bone.
Hyoid bone attached by the
intermediate tendon.
Depression Facial nerve (VII). Trigeminal nerve
(V).
3-Mandibular protrusion:
Muscle Origin Insertion Action Innervation
Inferior Lateral
pterygoid.
Greater wing of
sphenoid bone
Lateral surface of
pterygoid plate.
Condyle process of
mandible.
Protrusion. Mandibular division of trigeminal
nerve (V).
Masseter Maxilla
Zygomatic arch
Ramus and angle
of mandible.
Protrusion andibular division of trigeminal
nerve (V).
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Medial pterygoids Medial surface of
pterygoid process
of sphenoid
bone.
Maxilla.
Ramus and angle
of mandible.
Protrusion. Mandibular division of trigeminal
nerve (V).
4-Retraction of the mandible:
Muscle Origin Insertion Action Innervation
Temporals. Parietal bone. Ramus and coronoid
process of mandible.
Retraction andibular division of
Trigeminal nerve (V).
Digastrics. Digastric fossa
of mandible.
-Mastoid notch
of the temporal
bone.
Hyoid bone attached
by the intermediate
tendon.
Retraction Facial nerve (VII).
Superior Lateral
pterygoid
Greater wing of
sphenoid bone.
Condyle process of
mandible.
Retraction Mandibular division of
trigeminal nerve (V).
5-Lateral movement:
Muscle Origin Insertion Action Innervation
Temporals. Parietal bone
Ramus and
coronoid
process of
mandible.
Retraction.
Mandibular division of
trigeminal nerve (V).
Medial pterygoids
Medial surface of
pterygoid process
of sphenoid bone.
-Maxilla.
Ramus and
angle of
mandible.
Retraction.
Mandibular division of
trigeminal nerve (V).
Inferior Lateral pterygoid
Lateral surface of
lateral pterygoid
plate.
-Maxilla.
Condyle process
of mandible
Retraction.
Mandibular division of
trigeminal nerve (V).
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D. Influence of mandibular ligaments
They provide limits or borders of the circumductory mandibular movements and
are of value when transferring mandibular movements and position to
articulators.
E. Neuromuscular regulation of mandibular movements
- The impulses, may arise at the conscious level producing voluntary mandibular
activity, or arise from subconscious level of C.N.S. producing involuntary
movements or modification of voluntary movements.
- There are nerve endings within the capsules, which relay information on
positions and movement of the condyles to the C.N.S.
- Certain receptors in mucous membranes of the oral cavity can be stimulated by
touch, thermal changes, pain or pressure. These receptors are named
extroceptors.
- Other receptors located in the periodontal ligament, mandibular muscle and
ligaments provide information about location of the mandible in space and are
called proprioceptors.
- The impulses that are generated by stimulation of these oral receptors travel to
the sensory nucleus of the trigeminal nerve (in case of extroceptors) or to the
mesencephalic nucleus (in case of proprioceptors) from these 2 nuclei the
impulses can be transmitted:
1. By way of thalamus to the conscious level producing voluntary
change in the position of the mandible.
2. To the motor nucleus of the trigeminal nerve and directly back to the
mandibular muscles (in a reflex arc) producing involuntary movements
(e.g. away from a source of pain while making jaw relation record or a
modification in the physiological resting position because of soreness of
the mouth from dentures.
3. A combination of the two types.
F. Influence of the tongue on mandibular movements
e.g.procedure of asking the patient to place the tongue against the posterior part
of the trial denture base in order to obtain the centric relation.
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Basic mandibular movements
four movements of great importance to complete denture service:
A. The hinge-like movement: This is used in opening and closing the mouth for
the introduction of food and to a limited degree, for crushing of certain types of
brittle food.
B. Protrusive movements with tooth contact until the protruded contact position
and retrusive gliding movement to the intercuspal position. The protrusive
movement is used for grasping and incision of food.
C Right or left lateral movements for use in reduction of fibrous as well as other
types of foods.
D. Bennet movement: The bodily side shift of the mandible..
There are another 2 movements:
I. Backward gliding movement from the intercuspal position to the retruded
contact position (ligamentous position or hinge axis position).
2. Unilateral vertical movement of the condyle in the glenoid fossa. This
movement can occur when a resistant object is placed between posterior teeth on
one side and pressure is applied on the opposite side the interocclusal distance on
the working side will be more than on the non-working side. This movement
cannot be reproduced in a mechanical substitute for TMJ.
Another classification of Basic mandibular movements :
a. Opening and closing movements.
b. Forward movement with tooth contact, protrusion and backward gliding
movement to the intercuspal position,
c. Backward gliding movement, retrusion from the intercuspal position
,
d. Lateral gliding movements from the intercuspal position.
Another classification of mandibular movements
1. Contact and non contact movement
From a practical point of view, it is essential to distinguish between movements
taking place with contact, between the upper and lower teeth (contact movement,
gliding movements or articulation) and movements without contact of the
opposing teeth.

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2. Border and intra-border movement
Movements on the boundaries of the movement space are called border
movements. Movements within the boundaries of movement space can be
designated as intra-border movements. Border movements of the mandible are
reproducible .The border movements constitute the general framework inside
which the functional movement patterns take place.
3. Rotational and translatory movement
The terminal hinge movement can be performed over a range, which separates
the upper and lower incisors from 20 to 25 mm. (from the retruded contact
position (R.C.)
Further course of the posterior opening occurs when the posterior border
movement exceeds the range of the terminal hinge opening and the condyles
translate downward and forward (From the maximum hinge opening to the
maximal open position .
The small movement from the rest position (postural position) to the intercuspal
position (centric occlusion), in most cases is largely a rotation.
In further opening from the postural position relatively more translation takes
place, whereas the last part of the habitual opening movement is mainly rotation
4. Functional, parafunctional and non functional movement
Functional movements occur during functional activity of the mandible. They
usually take place within the border movements and therefore are considered free
movements. They include swallowing, speech and chewing. While
parafunctional movement include bruxism and clenching.
Arcs of mandibular closure
A. Skeletal arc of closure:
It is determined by skeletal structures and C.N.S. It is the arc of closure taken
by the mandible if there are no tooth interferences or deflection. This closure
is into centric relation or terminal hinge position. The functional act of
swallowing occludes the teeth in this position on the arc of closure.
Centric relation has been given many names such as: the posterior border
position, retruded mandibular position, hinge axis position, ligamentous
position and retruded contact position when the teeth are present.
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It is the most retruded physiologic relation of the mandible to maxilla to and
from which the individual can make lateral movements. It can exist at
various degrees of jaw separation. It occurs around terminal hinge axis.
It is unstrained anteroposterior bone-to-bone relation. Stuart and Stallard
defined centric relation as " the rearmost, midmost and uppermost
untranslated hinged position of the condyles ". It is a strained relation that
can be statically repeated-for some people centric relation may induce feeling
of strain and for others it is not possible because of tired or stiff muscle.
Many authorities now feel that the latter position of the first definition "from
which lateral movements can be made" is not applicable, because lateral
movements are possible from practically all-mandibular positions.
The position of centric relation remains constant or nearly so, throughout life,
except in the event of injury or disease of the TMJ.
B. Adaptive arc of closure
It is an arc directed by a conditioned reflex, guided by proprioceptive
neuromuscular mechanism. Such closure is into centric occlusion or
maximum intercuspation of teeth. This adaptive arc of closure is the one
used in chewing or when you tell the patient to close his back teeth
together.
It can be changed by various stimuli thus altering the conditioned reflex
"protective mechanism", i.e. if a tooth becomes sensitive either pulpally
or periodontally, the neuromuscular mechanism will program a new
conditioned reflex to protect the involved tooth.
It is referred to as habit centric, and is learned during infancy and is
permanently imprinted in the higher centers of C.N.S. controlling the
masticatory functions.
Because it is changeable, so its clinical reproducibility is in doubt and not
used as reference for mounting casts on articulators.
C. Voluntary arc of closure :
Voluntary control over mandibular movements, which is normally never
used. It requires thought and therefore cannot be carried out over long
periods of time "like voluntary control over respiration.
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Recording mandibular movement
a) Graphic methods :
1- Gothic arch tracing was introduced by Gysi as an extra-oral
method to program an adjustable articulator.
2- A pantograph is an instrument used to graphically record, in one or
more planes, paths of mandibular movement and to provide
information for the programming of an articulator.
pantograph used for registering the left and right border
movements of the mandible while the teeth are separated by a
central bearing screw. It also registers the protrusive movement,
which is not a border movement but begins and ends at a border
position.
The pantograph consists of
- An upper and lower frame each consisting of three bars bolted
together. The side arms of the lower frame can be adjusted so
that the condyle pointers touch the axis marks.
- The lower frame is, in fact, the axis
locator to which are added six
writing tables, three on each side, in
different planes.
- The upper frame carries six styli at
right angles to each opposing table.
- The frames are attached to the upper and lower teeth
respectively by means of clutches either seated securely or
temporarily cemented.
They are separated by central bearing screw adjusted to the
closest distance between the teeth but permitting unrestricted
lateral movement between the clutches.
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In some pantographs the writing tables are attached to the
upper frame & the six styli on the lower.
Pantography is the most accurate and complete means of recording jaw
movement and border positions available.
Types of pantograph include mechanical, electronic-stylus, and
optoelectronic.
Mechanical pantography is accurate and reliable, but the time and complexity
involved in recording movements and setting the articulator from the tracings
are major shortcomings.
An electronic-stylus, computerized pantograph was developed to quickly
analyze patient movements and minimize articulator-programming errors by
generating numerical condylar values.
Optoelectronic computerized pantographs have been developed. It can
quickly, accurately and reliably determine the transverse horizontal axis
(THA), posterior condylar settings. It can be used in diagnosis of TMJ
disorders.
An electronic pantograph (Cadiax Compact- 3-D TMJ registration system)
was introduced to produce joint analysis quickly for the diagnosis of TMJ
disorders as well as for articulator programming.
3- Minigraph:- It consists of only two anterior recording plates which are
related to casts mounted to the hinge axis. It can be applied when a full
pantographic tracing would not be feasible.
4- Mandibular motion analyzers as the Whip-Mix quick set recorder
and the Panadent quick analyzer recorder
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b) PHOTOGRAPHIC METHODS
Luce first introduced a photographic method with a single camera and one
stationary photographic plate in 1889. In 1914 Thouren introduced another
method, which included photography using a number of successive
photographic plates-cinematography.
c) ROENTGENOGRAPHIC METHODS
In 2007, Yuuda introduce a new four dimensional (4D) visualizing system of
stomatognathic function
In 2008, Terajima introduce a new 4-dimensional (4D) analyzing system of
stomatognathic function by using 3D CT of the cranium and mandible, dental
surface imaging from a noncontact 3D laser scanner, and mandibular
movement by using a 6 degrees of freedom jaw-movement analyzer.
d) ELECTRONIC AND TELEMETRIC METHODS
A novel robotic articulator that reproduced a six-degree-of-freedom jaw
movement was developed and it has been demonstrated to be a useful
device. The Virtual Articulator (VA) is intended to be an analyzing tool for
the complex static and dynamic situations during the occlusion.
e) MAGNETOMETRY
In 2006 a new technique for recording the kinematics of the TMJ and
incisors, using an electromagnetic tracking device (3Space Fastrak,
Polhemus, Inc.), laptop-based data collection software (The Motion
Monitor, Innovative Sports Training, Inc), and custom dental appliances.
f) ELECTRONIC METHODS
The new opto-electronic system called "Mac Reflex" (Qualisys AB,
Partlle; Sweden) was described by Hamborg &Karlsson in 1996. This
equipment consists of three basic units: two video cameras with a detecting
lens sensitive to infrared light, a video processor, and a software package
in a Macintosh computer.
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MANDIBULAR MOVEMENTS IN DIFFERENT PLANES
A- Mandibular movements in relation to the sagittal plane
The posterior border movement:
The posterior opening movement starts with
intercondylar axis rotation and is then followed by both
translation and rotation of the condyles. Since during
the first part of the movement the hinge axis is in its
midmost location, the movement is designated the
terminal hinge movement.
The terminal hinge movement can be performed
over a range, which separates the upper and lower
incisors from 20 to 25 mm. (from the retruded contact
position (R.C.) to the maximum hinge opening.
Further course of the posterior opening occurs
when the posterior border movement exceeds the range
of the terminal hinge opening and the condyles translate downward and forward
(From the maximum hinge opening to the maximal open position
The anterior border movement :
This is the movement path made by the incisal point from
the protruded contact position till the maximal opening
position distance about 4.5 cm.
Superior border movement;
A. Forward:
It starts from the habitual intercuspal position (centric occlusion) and the
incisal point has to move downward and forward along the incisal path and then
straight forward to clear the incisors (edge-to-edge. The incisal point then moves
upward to reversed vertical overlap and forward to the protruded contact
position. This path becomes more regular with attrition of teeth and loss of
vertical overlap.
The incisal path is the path taken by the incisal edges of the lower incisors on the
palatal surface of the upper incisors until the teeth touch edge to edge.
The incisal path angle (incisal guidance) is the angle between the incisal path and the
horizontal.
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B. Backward:
There is a short movement path that can be recorded between centric
relation and centric occlusion when the teeth are brought into contact in centric
relation and the patient squeeze his jaws together into centric occlusion. The
movement is called "slide in centric" it is often combination of forward and
lateral movements. The average distance of slide is about 1mm.
Centric relation. Intercuspal position.
Edge to edge position Reverse overlap
The habitual (automatic) opening and closing :
These paths are carried out inside the movement space i.e. intraborder
movement. The small movement from the rest position (postural position) to the
intercuspal position (centric occlusion), in most cases is largely a rotation. In further
opening from the postural position relatively more translation takes place, whereas the
last part of the habitual opening movement is mainly rotation.
Envelope of function:
Normal function takes place within only a small area of the border Movement
diagram begin around intercuspal position. Rest position is located approx. 2-4 mm
below intercuspal position.

Mandibular movement in sagittal plane (Posselt's diagram).Left; CR; Retruded contact.
CO; intercuspal position. F; Full protrusion. MO; Maximal open position . MHO;
Maximum hinge opening. R; Rest position. Right; envelope of function.
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Mandibular movements in sagittal plane for class II jaw relation:
A. Class II jaw relation patients: Tracings of the sagittal plane jaw movements differ
considerably from that generally published for a class I jaw relation:
1. The maximum opening is less due to the smaller size of the mandible.
2. The protrusive movement is greater and configuration varies according to the
amount of horizontal and vertical overlap.
3. The arc of hinge opening is smaller due to the size of the mandible.
4. The interocclusal clearance is greater.
B. Class III jaw relation patients: The mandibular movements in the sagittal plane is
different from the class I jaw or class II jaw relationships
1. The protrusive movement is smaller.
2. The maximum opening is greater because of the length of the mandible.
3-The arc of hinge opening is greater because of the jaw size.
4-The interocclusal rest space is less.
Class I Class II Class III
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B- Mandibular movements in relation to horizontal plane
Registrations of the horizontal border movements can be carried out by pantograph,
The incisor point border movements (in the horizontal plane:
On the anterior horizontal plate
The border movements for the incisor point can be traced on the anterior
horizontal plates of pantograph or by Gothic arch or Gysi's tracing in the
horizontal plane.
The point "A" corresponds to centric relation (also
called the arrow point in Gysi's tracing).
As the mandible moves in retrusive lateral excursions
and the condyle moves from B 1 to B2,
The incisal point records the line from A, to D. From D
the mandible can be moved forward and medially to
point F. A similar tracing can be done for the other side
to point E from point A.
Envelope of function:
The incisal point is at point C.R, when the condyles
are in centric relation and at point C.O. when the
teeth are in centric occlusion.
The small dark area MR2 is the approximate region
of function during the latter stages of mastication.
The larger stippled area MR1, extending to point
I.E.C. (incisal point contact is the approximate region of function in earlier stages of
mastication).
The pantographic tracing on the posterior horizontal plate:
o On the balancing side the orbiting condyle usually does not follow
a straight line, but rather some form of curved path as indicated in
the pantographic tracing.
o The timing of mandibular side shift (Bennet movement) affects the
amount lateral condylar path angle.
o Enlarged horizontal pantographic tracing near the condyle. I.S.S., the immediate
side shifts. PSS, the progressive side shifts. C.R, centric relation. P, protrusive.
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LL, left lateral. RL, right lateral. The immediate side shift is usually 1mm at the
center of rotation.
o When the mandible shifts to the side its movement can be described in two
segments, an immediate side shift and a progressive side shift.
o During the immediate side shift, the major direction of movement is
mediolateral, although some anterior direction is evident.
o As the progressive side shift begins and continues the major direction of
movement is anterior, although some mediolateral direction continues.
The pantographic tracing on the posterior vertical plate:
It shows the path of the descending condyle in the vertical plane during
protrusion and lateral movement. The balancing condyle (NW) shows a steeper
downward and forward path than the protruding condyle. This difference (about 5
degrees) demonstrates the Fischer angle.
Enlarged pantographic tracing on the
vertical plate. CR, centric relation. P; protruding
path. NW; non working condyle path, and W;
work condyle path. The difference between the
protruding and balancing condyle paths is the
Fischer angle.
Tooth contacts during articulation In bilateral balanced occlusion:
On the working side the movement of these
teeth is linguobuccal, i.e., much more laterally than
anteriorly and the mandibular buccal cusps oppose the
maxillary buccal cusps and inclines. The upper and
lower cusps pass each other with minimal lift or
change in the occlusal vertical dimension in the
working side.
On the balancing side the molars and premolars of
the mandible move obliquely forwards and medially
(diagonally). The mandibular buccal cusps and inclines are in
contact to the maxillary lingual cusps and inclines.
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The path of this movement causes a separation between the opposing balancing
segments determined jointly by the slopes of the ridges involved and the downward and
inward path of the balancing side condyle.
Each working and balancing path made by a cusp on the opposing tooth traces a
miniature Gothic arch .
The lower canine cusp and mesial cusp ridge glides along the disto-lingual
surface of the upper canine on the working side and pass between the canine and first
premolar cusp ridges. The working side lateral and central incisors maintain contact. On
the balancing side contact is lost
During protrusive movement:
The incisal edges of the lower incisors and canines make articular contact with
the lingual surfaces of the upper incisors and canines.
The mesial buccal and lingual cusp ridges of the lower molars and premolars make
articular contact with the distal buccal and lingual cusp ridge of the upper teeth.
C- Mandibular movement in relation to the frontal plane
In regard to border movement in the frontal
plane, it roughly resembles a shield.
The tracing begins with the teeth in centric
occlusion at point co. As the mandible is moved to
the right with the opposing teeth maintaining
contact, the dip in the upper line of the tracing is
created as the upper and lower canines pass edge to
edge.
The mandibular movement is continued as
far to the right as possible. Then the opening occurs
at point MO, the mandible is moved in an extreme left lateral position as it is closed
until the opposing teeth make contact. Then with the opposing teeth maintaining contact,
the mandible is moved from the extreme left lateral position back to centric occlusion
co.
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The dotted line indicated by the upward pointing arrows represents
the upward component of a masticatory cycle as the patient chewed a
bolus of food on the left side. The masticatory cycle moves over to the
right when the patient opens from centric occlusion as indicated by
downward dotted line (downward pointing arrows).
With excellent occlusions and with uninhibited masticatory movements,
the masticatory cycle has a fairly uniform, wide oval form, tear drop
appearance
Envelope of Motion
By combining mandibular border movements in the three planes (sagittal,
horizontal, and frontal), a three-dimensional envelope of motion can be produced that
represents the maximum range of movement of the mandible. Although the envelope has
this characteristic shape, differences are found from person to person. The superior
surface of the envelope is determined by tooth contacts, whereas the other borders are
primarily determined by ligaments and joint anatomy that restrict or limit movement.
Clinical applications of mandibular movement
1-The rest position lies within the parcel of movement. Its significance is the constancy
of its vertical and horizontal relationship to the maxilla and its value is a reference
position for vertical dimension determination.
2-The opening and closing retruded arc movement (terminal hinge opening) is
reproducible and is used for determining the transverse hinge axis.
3-The retruded condylar position (terminal hinge position) is a repeatable and reliable
and is used to record the centric relation.
4-On protrusion and lateral movements the condyles move downward and forward at a
measurable angle (horizontal or sagittal condylar path angle) to the horizontal
plane. The angle of descent can be measured by inserting a wax wafer between the
posterior teeth just prior to protruded or lateral occlusion and by transferring this
record to casts mounted on an adjustable articulator.
5- The horizontal condylar path can be traced on a card attached
to the patients face by means of face bow and similar
devices. The angle of the path to a horizontal reference plane
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is measured and transferred to the articulator. quick set analyzer used to trace the
condylar path.
6-During lateral movement the balancing condyle moves medially making an angle
with the median plane (the lateral condylar path angle or Bennett angle). This
angle can be recorded and transferred to the articulator using right and left lateral
interocclusal record.
7-The Bennett shift (immediate side shift) cause the condyles to shift away from the
midline and produce a medial shift in the final position of the translating condyle.
This will case balancing interference if the Bennett movement was not recorded and
transferred to the articulator.
To record the Bennett shift an interocclusal record in extreme lateral jaw position is
made. The records are then put between mounted casts and the wall of condylar
boxes are adjusted approximately. An alternative method is to measure the jaw
movement on the hinge axis over the surface of the skin in front of the ear using face
bow.
8-All mandibular movements take place within the envelop of motion and seldom reach
a border except in retruded closure which sometimes used in forceful closure.
However, if cusp interference prevents movement towards a border position
disturbance may result in musculature. So the border movements should be recorded
and transferred to the articulator.
9-The pantographic tracing can be transferred to an articulator so that various
adjustment angles and axes of rotation are copied on the articulator.
The pantronic is an electronic pantograph, which provides a computer printout of
numerical condylar measurements.
10-Intra-oral plastic record (stereographic record) of the lateral border and protrusive
movements is achieved by cutting studs, which mould pathways into fast-setting
acrylic resin. These records are used to customize the condylar guidance of
gnathalogical articulator.
11- The incisal path angle should be kept minimal in balanced occlusion. However,
esthetics may necessitate large vertical overlap. This calls for large overjet to
decrease the incisal guidance.
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Condylar path angles and Bennett movement
Condylar path: path traveled by the mandibular condyle in the
temporomandibular joint during various mandibular movements.
Sagittal (horizontal ) condylar path is defined as the path followed by the
mandibular condyles during protrusive movement or balancing condyle during lateral
movement.while the sagittal condylar path angle is the angle between the sagital path
and occlusal plane.
Lateral condylar path angle: The Bennett angle (Progressive Side Shift) refers
to the angle, in the horizontal plane, between the sagittal plane and the downward,
inward and forward path of the nonworking condyle.
The condylar movement:
The protruding condyles:
Translation of the condyle forward and downward occurs
during protrusion. The path of the condyle during this
movement is termed the horizontal (sagittal) condylar path.
It forms an angle with the horizontal plane termed the horizontal condylar path
angle. This angle varies in individuals and even in the same individual.
A separation of the posterior teeth occurs during protrusion
due to the downward and forward translation of the condyles.
This is called Christensens phenomenon and used to record
horizontal condylar path angle.
When the mandible moved to the right, the right condyle is therefore called the rotating
condyle, since the mandible is rotating around it. The left condyle during this movement
is called the orbiting condyle, since it is orbiting around the rotating condyle.
The working condyle:
During lateral movements, the working side or rotating condyle may
rotate around sagittal and vertical axes and move laterally The lateral component
is termed the Bennett movement. The first part is called immediate sideshift and
is measured on average at 0.5 mm. The progressive sideshift describes a more
gradual lateral movement.
The balancing condyle: The balancing condyle moves down, forward and
inward and makes an angle with the median plane when projected
perpendicularly on the horizontal plane. This angle is called Bennet angle.
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Importance of Condylar path angles
Importance of sagittal Condylar angle
Okeson stated that the condylar guidance is considered to be a fixed factor,
because it is unalterable in the healthy patient. It can be altered, however, under
certain conditions (e.g. trauma, pathosis, and surgical procedure). The anterior
guidance is considered to be a variable rather than a fixed factor. It can be altered
by dental procedures, such as restoration, orthodontia, and extractions.
Accurate determination of the condylar guidance is necessary for proper
positioning of teeth and for restorations to be in harmony with mandibular
movements.
A higher condylar guidance angle in a patient with dentures may be better than a
lower angle because the posterior teeth may need adjustment with the higher
angle, whereas the anterior teeth may require adjustment with a lower angle.
Balkwill believed that it was impractical to measure the angle of the condylar
inclination in the living subject. However, he introduced an instrument for measuring
the angle formed between the plane of two lines drawn from the articulating surfaces of
the condyles to the [incisor point] and the [occlusal plane] which is near enough to use.
He estimated this angle, now known as Balkwills Angle, to be an average of 26
degrees.
Effect of variation in HCPA on complete denture occlusion
The variation of the condylar path angle will affect the relationship between
the upper and lower teeth in mandibular excursion. a change in the condylar
path inclination of l0 degrees resulted in a vertical change of 0.5mm at the
molar area in lateral excursions.
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Importance of lateral Condylar path angle
The degree of lateral shift depends on the Bennett angle, the greater the
Bennett angle the more the lateral shift.
This angle used to adjusts the Bennett shift on the adjustable articulator.
Effect of variation in LCPA on complete denture occlusion
The arbitrary decrease of the Bennett angle of the balanced condylar
guidance, leads to more rotation and less Bennett shift of the working
condyle. Therefore increase the posterior working cusp inclines.
If protrusive interocclusal record is used alone to simulate right and left
lateral condylar inclinations without adjusting the lateral condylar
inclination, then the occlusion developed in the laboratory might be heavy
on the working side and light on the balancing side.
Factors affecting condylar path:
Steepness of the articular eminences : The flatness or steepness of the articular
eminences dictates the path of condylar movement as well as the degree of
rotation of the disk over the condyle.
Age : The patients eminence angle was relatively stable over time (changing
rapidly only due to disease or acute trauma. some authors believe that the
condylar path inclination angle (CPIA) increases with age. There is no
significant differences between the right and left sides either in the child group or
the adult group.
Gender : there is no significant differences in the condylar path inclination angle
between male and female.
Condylar guidance and TMJ disorder: The condylar path in patients with
anterior disk displacement with reduction (ADDW) was steeper than in subjects
with normal disk position.
Condylar guidance and mandibular morphology: Condylar guidance appears
to vary with variations of the morphology of the temporomandibular joint.
Mean Condylar Guidance
Sagittal condylar path angle
it ranged from 22-65, with the average of 38. According to Gysi, the sagittal
condyle path in the individual varies from 40 to 65 with 33 average inclination
Lateral condylar path angle: The mean Bennett angle is 7.5.
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Sagittal condylar path inclination in consideration of Fischer's angle
Fischers angle is defined as the angle formed by the intersection of the
protrusive and non-working side condylar paths as viewed in the sagittal plane.
It is believed that the lateral condylar path in the sagittal plane on the non-
working side is longer in length and steeper in inclination than the protrusive
condylar path. Bergstrom called the difference in condylar inclination between
these two paths the Fischer angle, the value of which was about 5 degree,
Determining the sagittal condylar path inclinations
1- intraoral or positional wax method
Anterior check bite method (protrusive intraoral record) is preferred as the
usual method for reproducing them in a semi-adjustable articulator. However, it
has often been suggested that the sagittal condylar path inclinations obtained by
this method are unstable
The various materials used for the intraoral method have been wax (some
supported with metal)modeling compound, zinc oxide/eugenol paste, and
polyether impression materials
The ideal amount of protrusion for making the record is the exact equivalent of
the amount of protrusion necessary to bring the anterior teeth end to end.
- A 2 mm was the functional range of movement, and it is the most suitable
distance for physiologic reasons. But if this functional range of movement is
recorded, the condylar paths on the articulator cannot be adjusted by means
of such a record except within a wide range of errors.
- The mechanical limitations of most articulators require a protrusive
movement of at least 6 mm so the condylar guidance can be adjusted.
- Some authors found these values provide the best information because this
area belongs to the central part of the eminence and therefore enables an
exact measurement.
Intraoral recording are dependent on many factors:
The resilience of the mucosa
Pressure exerted during recording,
The kind of saliva
The accurate "fitting" of the baseplates or the prostheses plates have
The consistency of the "checkbite" material of great importance.
Lack of muscle coordination in the patient
Type of articulator used
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2- A graphic method
mandibular facebow
pantograph

Mandibular motion analyzers as the Whip-Mix quick set recorder and the
Panadent quick analyzer recorder.
In 1999 a simplified recording device was introduced, electronic hinge axis
tracing device (Cadiax compact ) in measuring the horizontal condylar
inclination (HCI) and the Bennett angle. The Cadiax Compact is purported to
calculate condylar settings over 3 condylotrack distances, 3, 5, and 10 mm from
the centric relation position.
3- Digital mandibular movement analyzing systems:
Digital six degree of freedom mandibular movement analyzing system Gnatho-
Hexagraph could be used to measure sagittal condylar path inclinations
4- The radiographic method :
By tracing the condyle and fossa in centric occlusion and superimposed on the
tracing of the protrusive position. A tangent drawn to the 2 condyle outlines
gave the condylar path.
Determining the lateral condylar path inclinations (Bennett angle)
1- Interocclusal record : When the Bennett angle was measured by interocclusal
records, the immediate side shift and the progressive side shift could be recorded
simultaneously
2- Hanau fromula: The Hanau formula determine the average lateral condylar
guidance as related to the horizontal condylar guidance. [L = H/8 + 12] where L :
lateral condylar inclination in degrees; H : horizontal condylar inclination in degrees
as established by the protrusive record.
3- Gothic arch method: The right and left lateral condylar guidance on the
articulator are derivecl from the forrnula L = 1.06 BP - 46. where BP is the angle
between the lateral border parhs of the patients and the articulator protrusive path.
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Bennett movement
Bennett movement : it is lateral bodily shift of the mandible.
The first part is called immediate sideshift and is measured on average at 0.5
mm. The progressive sideshift describes a more gradual lateral movement.
a) amount:
up to approximately 3mm.
b) direction:
The lateral movement may have a retrusive or protrusive or
more straight laterally. The movement may end at any point in
the 60-degree triangle outward superior or inferior. The
envelope of these possible movements is analogous to a right
circular cone with the vertex at the condyle. Sagittal displacement of the rotating
condyle may occur to any point within the cone.
c) Timing of mandibular lateral translation: It may be:
1-Progressive side shift occurs at a rate/ amount proportional to the forward
movement of the working condyle as it leaves centric relation.
2-Immediate side shift where the non working condyle moves almost straight
medially as soon as it begins to leave centric relation.
3- Early side shift where the greatest portion of lateral movement occurs in the
first 4 mm of forward movement as the non working condyle leaves centric
relation.
4- Distributed side shift where the greatest rate of the shift is distributed
throughout the first 4 mm of forward movement as the non working condyle
leaves centric relation.
Schematic representation of the condylar shift on the working side. Movements
up to approximately 3 mm may occur to any point within the 60-
degree circular cone.
Line AR represents the center of rotation of the condyle.
Viewed from the horizontal plane (H), the movement from W may be
straight lateral (SL), lateral and protrusive (LP), or lateral and retrusive (LR). Viewed in
the vertical plane (V) the movement from W may be straight lateral, lateral and inferior
(LI), or lateral and superior (LS).
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The importance of Bennett movement
The immediate mandibular lateral translation of the articulator changed the width
of the central groove and the origin of the distobuccal groove on the occlusal
surface of the mandibular first molar in the horizontal plane.
The magnitude of this movement was almost directly proportional to the amount
of immediate mandibular lateral translation that was programmed in the condylar
element.
Alteration of the progressive mandibular translation from 0 to 25 degrees
changed the angle of cusp travel and, therefore, the angle of the distobuccal
groove of the opposing mandibular first molar from 50 to 36 degrees in the
horizontal plane.
Effect of mandibular lateral translation movement on cusp height:
The lateral translation movement has three attributes amount, timing, and
direction. The amount and timing are determined in part by the degree to which
the medial wall of the mandibular fossa departs medially from an arc around the
axis in the rotating condyle. They are also determined by the degree of lateral
movement of the rotating condyle permitted by the TM ligament. The more
medial the wall from the medial pole of the orbitating condyle, the greater the
amount of lateral translation movement and the looser the TM ligament attached
to the rotating condyle, the greater the lateral translation movement. The
direction of lateral translation movement depends primarily on the direction
taken by the rotating condyle during the bodily movement.
As the amount of lateral translation movement increases, the bodily shift of the
mandible dictates that the posterior cusps be shorter to permit lateral translation
without creating contact between the maxillary and mandibular posterior teeth. A
lateral movement with laterosuperior direction of the rotating condyle will
require shorter posterior cusp than will a straieht lateral movement, likewise
lateroinferior movement will permit longer posterior cusps than will a straight
lateral movement. When the lateral translation movement occurs early, a shift is
seen even before the condyle begins to translate from the fossa. This is called an
immediate lateral translation movement or immediate side shift. lf it occurs in
conjunction with an eccentric movement, the movement is known as a
progressive lateral translation movement or progressive side shift. The more
immediate the side shift, the shorter the posterior teeth.
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Effect of mandibular lateral translation movement on ridge and groove
direction:
It influences the directions of ridges and grooves. As the amount of it increases,
the angle between the laterotrusive and mediotrusive pathways generated by the
centric cusp tips increases. The direction that the rotating condyle shifts during a
lateral translation movement influences the direction of laterotrusive and
mediotrusive pathways and resultant angles if the rotating condyle shifts in a
lateral and anterior direction, the angle between the laterotrusive and
mediotrusive pathways will decrease on both maxillary and mandibular teeth. if
the condyle shifts laterally and posteriorly, the angles generated will increase.
It was further demonstrated that the immediate mandibular lateral translation of
the articulator changed the width of the central groove and the origin of the
distobuccal groove on the occlusal surface of the mandibular first molar in the
horizontal plane. The magnitude of this movement was almost directly
proportional to the amount of immediate mandibular lateral translation that was
programmed in the condylar element.
Recording of Bennett shift
The immediate Bennett shift [IBS] adjustment on adjustable articulators can be set by
measurement of
pantographic tracings,
intcrocclusal wax records,
direct measurement with simple device that measures Bennett shift near the
skin over the nonworking condyle (Whip-Mix Quick Set Recorder) has been
introduced
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RECORDING JAW RELATIONSHIPS
There are three different types of jaw relations they are listed in order of the procedure:
Orientation jaw relation.
Vertical jaw relation.
Horizontal jaw relation.
RECORDING JAW RELATIONSHIPS
1. Check denture foundation.
2. Establish facial contour.
3. Establish occlusal plane.
4. Maxillary face-bow record.
5. Determination of vertical dimension of centric occluding relation.
6. Determine centric relation at the accepted vertical dimension.
7. Locking device ( recording the C.O.R. )
1- Checking denture foundation and establishing
facial contour
After the occlusion rims have been completed the upper base-plate is inserted in the
patients mouth and the following checks and further steps of procedure are carried out:
1- Check the base plate for retention and stability:
If it does not appear to be satisfactory it would be wise to check on the steps
of procedure up to this stage to determine whether an improvement over the
condition could be made and, if necessary, the impression should be retaken
before undertaking succeeding procedures.
2- Correct shaping of the labial, buccal and palatal surfaces of the wax rim
Labial fullness: If retention, stability and outline-form of the base are
satisfactory, the labial and buccal positions of the occlusion rim are shaped
until a pleasing and harmonious lip and facial contour is established.
Adequate lip support depends upon the position and inclination of the labial
face of the wax rim. For achieving correct shape
Lips should be unstrained
Naso-labial angle 90.
The labial surface of the rim almost always inclines labially from
the border of the record base at about a 15 degree angle and
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It is approximately 6-8 mm labially from the center of the incisive papilla. [RAHN]
The tips of maxillary canine are 1 mm anterior to the center of incisive papilla.
Boucher
It is essential that the position of the labial surface of the rim is compatible with the
stability of the record block. The further forward the rim the greater will be the displacing
force of the lip muscles acting on the labial surface. Also it should be remembered that the
displacing force occurring on incising food when the finished denture is worn will also be
increased. If prognosis for retention of upper denture is unfavourable as a result of
extensive post-extraction resorption of bone it may be necessary to place the rim palatally
for greater stability.
Shaping the buccal surface
The record rim posteriorly should be shaped so that it fills the buccal
sulcus and slightly displaces the buccal mucosa laterally. This will
contribute to retention by achieving an efficient facial seal.
The rim itself will usually be slightly buccal to the crest of the ridge by
an amount proportional to the amount of resorption that has occurred.
Reference to biometric guides will help to identify an appropriate position. However,
care should be taken not to place the rim too far buccally, as it will then be outside the
neutral zone and increased force from the buccinator muscle will cause displacement.
The buccal and palatal surfaces of the rim should be shaped to converge
occlusally so that pressure from the cheeks and tongue has a resultant force
towards the ridge, thus aiding neuromuscular control.
Check support is probably not affected as much as lip support since the buccinator is
stretched between the pterygomandibular raphe and modiolus muscles. The buccal
surface of the rim is slightly slanted toward the palate to create an acceptable space
between the rim and the cheeks. This space is called buccal corridor and created
between the buccal surface of posterior teeth and corner of the mouth when the patient
smiles. Heartweal
Shaping the palatal surface
It is essential to create adequate space for the tongue by
ensuring that the rim is not placed too far lingually
reducing the width of the rim where necessary by removing wax
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2- Occlusal plane height and orientation
1- Establishing the level of the occlusal plane :
The anterior height of the rim:
The length of the upper occlusion rim is established to 2
mm. below the upper lip when it is in a relaxed position.
When most individuals with natural teeth say five fifty
five the incisal edges of the maxillary central incisors
contact the vermillion border of lower lipat the junction of moist and dry mucosa.
Heartweal
A greater length of teeth than normal will be shown if the patient has:
- A short upper lip.
- Superior protrusion.
And less will be shown in patients:
- With a long upper lip.
- In most old people, due to attrition of the natural teeth and some loss of tone of the
orbicularis oris muscle.
Touches wet line of lower lip when F or V sounds
A very effective way of establishing the position of the incisal
edge in the vertical plane is to measure the distance on the existing
denture between the incisive papilla and the incisal edge with a
specially designed gauge (Alma gauge).
If this instrument is not available a measurement of the
distance between the incisive papilla to the incisal edge can be made
using figure-of-eight calipers.
The posterior height of the rim
It made to be concide with Campers line
At first molar , it is established at inch below the orifice of Stensens duct
Factors affecting the height of occlusal plane:
1. Aesthetic appearance in relation to the length of the upper lip, interpupillary line
and ala-tragal line.
2. Function,
a) Chewing, the relation of the occlusal plane to the tongue.
b) Speech, the relation of the occlusal plane to the lower lip.
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3. Principle of physics and mechanics.
a) Leverage action.
b) Parallelism.
Test the length of the upper lip can be estimated by placing the
index finger on the incisive papilla with relaxed upper lip
extending down over the finger. The finger length covered by the
upper lip indicates the length of the upper lip.
2- Adjustment in the coronal plane: The anterior plane:
From the frontal view of the patient, the occlusion rim is
adjusted parallel to an imaginary line
Joining the pupils of the eyes (inter pupillary line) or the
supra-orbital ridges.
Alternatively, at right angles to the long axis of the
patients face.
Fox plane can be used
Failure to follow these guidelines, will result in an unsightly, lopsided appearance of the
finished dentures.
3- Adjustment in the sagittal plane : The Antro- posterior plane:
From a sagittal view of the patient, the occlusal rim is
adjusted to be parallel to the naso-auricular line (ala-tragus or
Compers line). It is an imaginary line running from the
inferior border of the ala of the nose to the superior border of
the tragus of the ear. The line drawn on the face is referred to
as Campers Line, named so after Petrus Camper, who first
recognized this line in 1780.
Hanau refers to this imaginary line as the plane of
orientation. Swenson wishes to call the plane established with
the occlusion rim the orientation of the plane since it is a
plane to be determined. It is advisable to use an occlusal plane
indicator (Fox plane) for obtaining the correct anterior and antero-posterior planes.
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The upper denture tends to move anteriorly and lower denture tends to move posteriorly
due to occlusal force, a shunting effect occurs leading to denture instability. If the occlusal
plane is higher in anterior region and is tipping posteriorly, the shunting effect will be the
opposite.[HAYAKAWA]
Failure to conform to this guideline is likely to detract from the aesthetic result. It
can also have adverse consequences for stability; for example, if the occlusal plane on the
lower denture is tilted up posteriorly it may become so high that the denture is displaced by
the tongue rather than being controlled by it.
Determination of the occlusal plane
Factors must be considered:
1- Aesthetic base: the height of occlusal plane should be 1-2 mm. below the upper lip
anteriorly
2- Functional base (chewing and speech):
During chewing: The height of occlusal plane should be convenient and at a level
familiar to the tongue to perform its action easily and stop food escaping to the
floor of the mouth. The occlusal surface of the teeth should be below the greatest
convexity of the tongue. This also improves the stability of lower denture.
During speech, the tongue pushes against the sides of the teeth to produce a seal
for better pronunciation of words.
3- Physical and mechanical (leverage action and parallelism)
Principle of Physics and Mechanics
1) Leverage action : The amount of leverage or torque exerted on occlusal plane is a
function of the height of the plane above the ridge. Torque X = force (f) x Distance
from fulcrum (R).
The nearer the occlusal plane to the basal bone of the jaws, the less the leverage
action and the better the stability.
2) Parallellism : The occlusal plane should be parallel to both supporting ridges. In
this way the biting forces are vertical on the ridges and there is no tendency for
horizontal displacement of the dentures.
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3) Arch form
Both the width of the occluding surfaces and the contour of the arch
form of the occlusion rims should be individually established to
simulate the desired arch form of artificial teeth
If the occlusal plane is parallel to the lower and upper ridge the
denture will gain optimum stability. [HAYAKAWA]
6- Guidelines
When the rim has been trimmed to these planes it indicates the plane
of orientation for setting up the artificial teeth. The adjustments to the
upper block are complete with the recording of certain guidelines:
a- The center line :
A vertical line is scored on the labial surface of the upper rim
where it is crossed by an imaginary line from the center of the
eyebrows to the center of the chin and immediately below the center
of the philtrum, the labial tubercle and incisive papilla or labial
frenum.
b- The high lip line: gum line , smiling line
This is a line just in contact with the lower border of the upper
lip when it is raised so high as possible as in smiling or laughing.
It is marked on the labial surface of the rim and indicates the
amount of denture that may be seen under normal conditions and thus
helps in determining the length of teeth needed.
c- The corner lines: cuspid line, canine line
These mark the corners of the mouth when the lips are relaxed and
are supported to coincide with the tips of the upper canine teeth but are
only accurate to within 3 or 4 mm. These lines indicate the width taken by the six anterior
teeth from tip to tip of the canines.
d- The low lip line: speaking line, relaxed lip line [Heartweal]
It is horizontal line that extends between the commissures of the lip at the inferior
border of the upper lip during serious speaking or relaxation.the maxillary rim is extended
1-2 mm below this line
it is used to determine the vertical incisal length.
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Mandibular Occlusion Rim Adjustment
Posteriorly, the occlusion rim intersects 1/2 - 2/3 up the retromolar pad .
Anterior height even with the corners of the mouth when the lip is relaxed.
1-2 mm horizontal overjet in anterior & posterior in centric position
Note
Eliminate contacts between record bases, record base/occlusion rims
The occlusal plane J Prosthet Dent 2007;98:348-352
Usually, the term, plane, is related to a flat surface. However, this is not the case
with the occlusal plane. Instead of a flat surface, the plane of occlusion represents
the average curvature of the occlusal surface.
The position of the anterior teeth is determined by esthetics, the demand for anterior
guidance, and phonetic considerations. Posterior teeth positions are defined by 2
curves, an anteroposterior curve, referred to as the curve of Spee, and the
mediolateral curve, referred to as the curve of Wilson.
Based on anthropological observations in 1919, Monson proposed that the
anteroposterior curve forms part of a 3-dimensional sphere, the center of rotation of
which is located in the region of the glabella. The radius of this curve is reported to
be an estimated 4 inches (10.4 cm), as proposed by Monson.
The 3 most commonly used methods for establishing an acceptable plane of
occlusion are
direct analysis on natural teeth through selective grinding,
indirect analysis of facebow-mounted casts with properly set condylar
paths,
indirect analysis using the Pankey-Mann-Schuyler (PMS) method with
the Broderick occlusal plane analyzer (BOPA) with a semiadjustable
articulator to determine the correct curve of Spee for the occlusal plane.
The BOPA has now been adapted to only a few articulator systems,
such as the Denar Anamark Fossae
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VERTICAL JAW RELATION
It is defined as, "The length of the face as determined by the amount of separation of the jaws" -
GPT. It can also be defined as the amount of separation between the maxilla and
mandible in a frontal plane.
A] Factors Affecting Vertical Jaw Relation
Teeth : These act as occlusal vertical stops and establish the relationship of the mandible to the
maxilla in a vertical direction in dentulous patients.
Musculature : The opening and closing muscles tend to be in a state of minimal tonic contraction.
This determines the vertical jaw relation.
Muscles that produce elevation of the mandible (closing muscles) and gravity also help to
control the tonic balance that maintains the physiologic rest position.
B] Importance of Vertical Jaw Relation
The effects of altered vertical dimension:
Decreased vertical dimension
Decreased lower-facial height.
Angular chelitis due to folding of the corner of the mouth.
Pain, clicking, discomfort of the temporomandibular joint
accompanied with headache and neuralgia. (Customs syndrome).
Loss of lip fullness.
Obstruction of the opening of the Eustachian tube due to the elevation
of the soft palate due to elevation of the tongue/mandible.
Loss of muscle tone.
Corners of the mouth are turned down.
Thinning of the vermilion borders of the lip.
Decreased volume or cubical space of the oral cavity.
Comparatively lesser trauma to the denture-bearing area.
Cheek biting.
Inefficiency: reduces biting force
Impaired hearing : due to loss of cubical space of the oral cavity with tendency to push the
tongue toward the throat with encroachment of adjacent tissue which may lead to
obstruction of opening of Eustachian tube
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In all above cases the complete denture is constructed as treatment denture with increasing
the vertical dimension gradually
Increased vertical dimension
Increased trauma to the denture-bearing area.
Increased lower-facial height.
Cheek biting
Difficulty in swallowing and speech.
Pain and clicking in the temporomandibular joint.
Increased volume or cubical space of the oral cavity.
Stretching of facial muscles.
Clicking of teeth may occur during speech and mastication.
Generalized soreness of the residual ridge .
.Difficulty in swallowing and gagging sensation (Discomfort).
Loss of biting power and muscular fatigue.
Interference with speech.
Pain under the basal seat and trauma to the supporting structures.
Accelerate bone resorption.
C] Vertical Jaw Relation Recording:
Vertical Jaw Relation can be recorded in Two Positions
Vertical dimension at rest position
Vertical dimension at occlusion
Both these relations should be recorded. In a normal dentulous patient, the teeth
do not maintain contact at rest. The space between the teeth at rest is called the 'free-way
space.
The free-way space exists only at rest. During occlusion, the teeth come in contact with
one another and the space is lost. The same relationship should be produced in the
complete denture.
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Once the vertical dimension at occlusion is recorded, it should be verified with the
vertical dimension at rest (the vertical dimension at occlusion should always be 2-4
mm lesser than the vertical dimension at rest). The denture is fabricated in vertical
dimension at occlusion so that the free-way space is formed at rest.
I. Vertical Dimension at Rest
It is defined as, "The length of the face when the mandible is in rest position"
This is the position of the mandible in relation to the maxilla
when musculature are in a state of tonic equilibrium. This
position is influenced by the muscles of mastication, muscles
involved in speech, deglutition and breathing.
The balance between gravity and the resting muscle tone = REST POSITION
The physiologic rest position accurately referred as range of posture rather
than single rest position because EMG activity indicate that the clinical rest position
in not correspond to minimal muscle activity which is lower than clinical rest
position by several millimeter. Boucher
Interocclusal rest space: interocclusal clearance formerly known as freeway space
The distance between the occluding surfaces of the maxillary and mandibular teeth
when the mandible is in its physiologic rest position
VD at rest = VD at occlusion + interocclusal distance*
The vertical dimension at rest should be recorded at the physiological rest position of
the mandible and the patient at upright position to avoid effect of gravity.
The mandible is at the physiological rest position when the muscles that open and close
the jaw are in state of minimal tonic contraction. A range of reduced muscle tension has
been reported up to an interocclusal record of 10 mm.
In patients with prolonged edentulousness, the mandible shifts to a habitual rest
position. The complete denture should not be fabricated using the habitual rest position.
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Hence the physiological rest position should be determined in these patients before
recording vertical jaw relation.
When functional movements (swallowing, wetting the lips) are performed, the mandible
comes to the physiological rest position before going to the habitual rest position.
Variables Affecting V D R
Short Term Variables
1. Position of the patient's head .
2. Respiration .
3. Stress Situations .
Long Term Variables
1. Loss of the properioceptives impulses from the periodontal ligament .
2. Age .
Interocclusal distance may vary and may be affected by many factors, including
age, physical/emotional conditions, fatigue, medications, and expected normal
variation
The position of the mandible is influenced by gravity and the posture of the
head. Hence while recording vertical jaw relation the patient should be
asked to sit upright, with his/her head upright and eyes looking straight in
front. The Reid's base line should be parallel to the floor.
Since we are recording a physiological rest position, all the muscles affecting this
record should be relaxed.
Presence of any neuromuscular disease in the patient can influence the rest position.
The patient cannot maintain the physiological rest position for an indefinite period of time.
Hence, it should be recorded quickly.
Incorrect measurement of the rest position can lead to faulty recording of the vertical dimen-
sion at occlusion and can lead to injury to the supporting structures and the
temporomandibular joint.
Vertical Dimension at Occlusion: It is defined as, "The length of the face when the teeth
(occlusal rims, central-bearing points, or any other stop) are in contact and the mandible is in
centric relation or the teeth are in centric relation" - GPT.
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The vertical dimension at occlusion is a constant position and can be maintained for
indefinite time. Unlike vertical dimension at rest, the mandible need not be in centric relation
while recording this relation.
For Measuring the vertical dimension
Patient sitting upright as Soft tissue position affected by posture
Check with three techniques to ensure acceptable OVD
No one technique 100% correct
Measuring the vertical dimension at rest:
Facial measurements after swallowing and relaxing
Tactile sense
Measurement of anatomic landmarks
Speech
Facial expression
Measuring the vertical dimension at Occlusion
Mechanical methods
Pre-extraction records
Profile photographs
Profile silhouettes
Radiography ;
Articulated casts
Acrylic face mask (suggested by Swenson)
Ridge relation
Distance from the incisive papilla to mandibular incisors.
Parallelism of ridges.
Facial measurements Dakometer Willis gauge
Sorensens profile guide
Measurement from former dentures
Physiological Methods
Power point Using wax occlusal rims
Physiological rest position Phonetics
Aesthetics Facial esthetics
Willis method (Facial proportions)
Swallowing threshold Tactile sense or neuromuscular perception
Patient's perception of comfort. Electromyography
5- Gnathodynamometer ( bimeter ).
6- Functional performance ( point and gauge ).
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I. Measuring the vertical dimension at rest
A- Facial Measurements after Swallowing and Relaxing [two-dot technique]
The patient is asked to sit upright and relax.
Two reference points are marked with the help of a triangular piece of
adhesive tape on the tip of the nose and the tip of the chin.
The patient is asked to perform functional movements like wetting
his lips and swallowing.
The patient is instructed to relax his shoulders. This is done to relax the
supra- and infrahyoid muscles.
Once the patient performs the above-mentioned movements, his
mandible will come to its physiological rest position before going to its
habitual rest position. The distance between the two reference points is
measured when the mandible is in its physiological rest position.
Small dots under columnella & mid-symphisis .Use Boley Gauge, not
ruler
B- Tactile Sensation
The patient is asked to stand erect and open his mouth wide till he feels discomfort
in his muscles of mastication.
Next, the patient is asked to close his mouth slowly. The patient is instructed to stop
closing when he/she feels that his/her muscles are totally relaxed and comfortable.
The distance between the two reference points is recorded and compared to the
measurement recorded by the swallowing method.
This method relies on patient's perception of relaxation, and will vary for each
individual. Hence, at least one additional method should be carried out to confirm
these readings.
C- Anatomic Landmarks
The distance (A) between the pupil of the eye and the rima oris
(corners of the mouth) and the (B) distance between the anterior nasal
spine and the lower border of the mandible should be measured using a
Willis guide.
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If both these distances are equal, the jaws are considered at rest.
Its accuracy is questionable in patients with facial asymmetry.
The shape of the chin may prevent positive location of the
sliding arm of the Willis gauge. So Sliding arm may be modified
to allow more accurate positioning.
D- Speech
There are two methods by which the rest position can be recorded with the help of
speech.
In the first method the patient is asked to repeatedly pronounce the letter 'm',
a certain number of times and the distance between the two reference points is
measured immediately after the patient stops.
In the second method the dentist keeps talking to the patient and he measures the
distance between the reference points immediately after the patient stops talking.
E- Facial Expression
The following facial features indicate that the jaw is in its physiological rest
position:
Skin around the eyes and chin should be relaxed. It should not be stretched,
shiny or excessively wrinkled.
The nostrils are relaxed and breathing should be unobstructed.
The upper and lower lips should have a slight contact in a single plane. If the
mandible is protruded, the lower lip will be in front and without contact. If the
mandible is retruded, the upper lip will be in front.
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II. Measuring the vertical dimension at Occlusion
A-Mec hani c al Met hods
These methods are called so because they do not require any functional movement. They are
measured using simple mechanical devices.
a- Pre-extraction Records
Profile photographs
These photographs are made before extraction. They should be taken in maximum
occlusion as the patient can easily maintain this position during photographic
procedures. The photographs should be enlarged to the actual size of the patient
and the distance between the anatomical landmarks should be measured and
compared with that of the patient.
Profile silhouettes
silhouette means outline. An accurate silhouette is made with cardboard or
contoured with wire using the patient's photograph. This silhouette can be used as
a template and positioned on patient's face while recording vertical dimension.
Radiography
Cephalometric profile radiographs are used to determine the vertical jaw
relation. But their use is limited due to the inaccuracy in the technique.
Articulated casts
When the patient is dentulous, the maxillary cast is mounted in the articulator
using a face-bow transfer. An inter-occlusal record is made in the patient's mouth. This
inter-occlusal record is used to articulate the mandibular cast with the maxillary
cast. This is used as the pre-extraction record.
After extraction the edentulous casts are articulated in a separate articulator. The
inter-arch distance between the edentulous casts is compared with that of the
articulated dentulous casts.
Acrylic face mask(Swenson's technique) : By using facial impression and cast
Niswonger's method : It can be applied if a small red tattoo is used on the skin.
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b) Ridge relation
It is defined as, " The positional relationship of the mandibular ridge to the maxillary ridge" - GPT.
It can be measured by two methods namely:
Distance from the incisive papilla to mandibular incisors.
Parallelism of ridges.
Distance from the incisive papilla to mandibular incisors
Incisive papilla is a stable landmark that does not change a lot with the resorption of the alveolar
ridge.
The distance of the papilla to the maxillary incisor edge is 6 mm. Usually the vertical overlap
between the upper and lower incisors is 2 mm (overbite). Hence the distance between the inci-
sive papilla and the lower incisors will be approximately 4 mm. Based on this value, the vertical
dimension at occlusion can be calculated.
Distance between the incisive papilla of the maxilla and the incisal edge of the
lower incisor can be used as a reference to determine vertical jaw relation
Key: a =usually 6 mm, b =usually 2 mm, Hence c =4 mm
Ridge parallelism
The mandible is parallel to the maxilla only at occlusion. The mandible of the patient
is adjusted to be parallel to the maxilla. This position associated with a 5
opening of the jaw in the temporomandibular joint gives a correct amount of
j aw separation.
In patients where the upper and lower teeth are extracted together, the upper and
lower ridges will be parallel because the length of the clinical crowns of the
opposing anterior and posterior teeth will be equal.
Sears suggests that an indication of the correct vertical height can be obtained
from the parallelism of the upper and lower posterior ridges plus a 5degree opening in the
posterior region.. Excessive divergence from the parallel, seen when the casts have been
set on an articulator, indicates that the vertical height is probably wrong and should again
be checked.
This method cannot be taken as a standard in patients who had periodontal
disease and in patients who lost their teeth at different periods of time.
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C. Facial measurements
Dakometer The instrument is positioned on the bridge of the nose \vi: compound.
The chin piece is screwed till it touches the front of the A A spring pressure gauge
controls pressure. An incisor attachment ream position of the central incisors.
..Records are noted and the compoun nosepiece preserved for reassembly after
extraction.
Willis gauge One arm contacts the base of the nose. The other arm moved along the
slide till it touches the base of the chin. Willis gauge not accurate as there may be
variations in applying pressure
Sorensens profile guide This is another device for recording fad
measurement.
Golden proportion: The Golden Ruler enables the dentist to
measure the vertical dimension easily and simply.
D -Measurement from former dentures
Patient's existing denture is a valuable pre-extraction record. A Boley's gauge is used to
measure the distance between the border of the maxillary and the mandibular denture
when both these dentures are in occlusion. This measurement is used to determine the vertical
dimension at occlusion.
B-PHYSI OLOGI CAL METHODS
a- Power Point: (by Boos)
;
A metal plate (central bearing plate) is attached to the maxillary record
base. Abimeter is attached to the mandibular record base. This bimeter
has a dial, which shows the amount of pressure acting on it.
The record bases are inserted into the patient's mouth and the patient is asked to bite on the
record bases at different degrees of jaw separation. The biting forces are transferred from the
central bearing point to the bimeter. The pressure reading in the bimeter is noted. The highest value
is called the Power point. The bimeter is observed when the power point is reached.
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This device registers the biting force at varying degrees of jaw separation. The theory
is that the patient registers the maximum amount of biting force when the teeth first
contact in centric occlusion. The muscles of mastication will exert their greatest
degree of force when their origin and insertion are this exact distance apart.
b- Using Wax Occlusal Rims
A tentative vertical dimension is measured with occlusal rims and the casts are
articulated in a tentative centric relation. A tracing device can be attached to the occlusal
rims for a graphic tracing. The facial expression and aesthetics are used for the final value.
Procedure
The vertical dimension at rest is established and the difference between the
reference points (between the nose and chin) is recorded.
An approximate vertical dimension at occlusion, about 2 to 5 mm less than that of
the vertical dimension at rest is considered. The facial expression can also be used as
a guide for determining this value.
The occlusal surface of the maxillary occlusal rim is coated with petrolatum and
seated in the mouth. Denture adhesive powder may be used in cases with
inadequate retention.
A thin roll of modeling wax with a triangular cross-section is
softened in a water bath at 130 F and placed over the mandibular
occlusal rim with its apex towards the maxillary rim.
The added wax is softened again with a Blowtorch and the
mandibular rim is seated into the mouth.
The patient is asked to close his mouth slowly and stop at a comfortable position
based on his tactile sensation. This gives the vertical dimension at occlusion.
The wax is allowed to cool within the patient's mouth.
It is removed and articulated in a tentative centric relation.
(Note: Do not confuse this method with the "Nick and Notch" method used in
centric relation.)
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c- Physiological rest position: (Niswonger and Thomson in 1934)
This is also called as Niswonger's method. Niswonger suggested using a 4/32-inch
interocclusal or freeway space as a guide to determining the vertical dimension of
occlusion. J Prosthodont 2003;12:30-36.
It is not considered as an accurate method because it requires patient's cooperation,
which is variable, and alterations in jaw position can occur during this procedure.
Procedure
Patient is asked to sit upright with his head unsupported and the eyes looking
straight.
Upper and lower occlusal rims which were modified according to the clinical
guidances (refer occlusal rim fabrication) are inserted and the patient is asked to
swallow and relax.
When the relaxation is obvious, the lips are carefully parted to reveal the space
present between the occlusion rims. This space is called the free-way space.
The space between the occlusal rims should be about 2-4 mm. The formula "VD at rest
=VD at occlusion + Free-way space" can be used to evaluate the vertical dimension at
occlusion. If the free-way space is more than 4 mm, the vertical dimension at occlusion is
considered to be small and if the space is less than 2 mm, the vertical dimension at
occlusion may be too great.
In the following 2 instances, dont try to get proper VDO by subtracting 3 mm from
rest position
- The patient accustomed to occluding in a very over-closed relationship for a long
period of time (not a good idea to open a patient 10 12 mm all in one operation
important to rely on patient judgement, too)
- The mouth breather lower jaw has been in an opened relationship for a long
period of time (a tactile closure into soft wax is a good way to determine the
vertical dimension in this case)
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d- Phonetics
This involves observing the movements of the oral tissues during speech and more
importantly listening and analyzing the speech of the patient. There are two common
methods in which phonetics is used to determine jaw relation. They are:
Silverman's closest speaking space.
The "F" or "V" and "S" speaking anterior tooth relation.
Silverman's Closest Speaking Space
It was first described by Silverman.
When sounds like ch, s, j are pronounced, the upper and lower teeth reach their
closest relation without contact. This minimal amount of space between the upper
and lower teeth in this position is called the Silverman's closest speaking space
This space indicates the vertical dimension of the patient. In an ideal case, the
lower incisor should almost touch the palatal surface of the upper incisor.
According to him the closest speaking space measures the vertical dimension when
the mandible is in function.
Before the remaining teeth are extracted, a line is scribed on the anterior
mandibular teeth reflecting the position of the maxillary anterior teeth while the patient
is in maximum intercuspation; this is called the centric occlusion line.
Then the closest speaking line is drawn on the same anterior teeth, reflecting the
position of the maxillary teeth when the patient pronounces the sibilant sound, s, as in
the words yes and Mississippi.
Silverman believed that the closest speaking space, or the difference between the
centric occlusion line and the closest speaking line, should be 0 to 10 mm
J Prosthodont 2003;12:30-36.
Silverman's closest speaking space
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Increase in the free-way space between the upper and lower incisors indicates an
inadequate vertical dimension at occlusion.
A decrease in the closest speaking space will indicate an excessive vertical dimension at
occlusion. Contact of the incisal edges during speech also indicates an excessive
vertical dimension at occlusion.
This differs from the Niswonger's and Thomson's method in that the Niswonger's method
measures the vertical dimension when the muscles controlling the mandible are at rest
or physiological tonus where as in this method the muscles are active.
The "For "V' and "S" Speaking Anterior Tooth Relation: (Pound and Murrel)
In this method, the incisal guidance is established by arranging the anterior teeth on the
occlusal rim before recording the vertical dimension at occlusion.
The anterior teeth are arranged on the occlusal rim and modified in the patient's mouth
based on the pronunciation of certain alphabets.
The position of the anterior teeth is determined by the position of the maxillae when the
patient pronounces words beginning with "F" or "V".
The position of the lower anterior teeth is determined by the position of the mandible
when the patient pronounces words beginning with the letter "S".
Procedure
An occlusal rim is fabricated over the maxillary record base. The maxillary occlusal
rim is inserted into the patient's mouth.
The base plate wax in the maxillary occlusal rim is adjusted using a fox plane and
made parallel to the Camper's line.
The patient is asked to repeatedly pronounce the words "fist" and "van". When the
patient says these words his upper lip should provide a facial seal. The maxillary
occlusal rim should be contoured to obtain the seal. The midline is marked on the
occlusal rim.
The upper central incisors are set in their position and checked in the patient's
mouth. The record base is removed from the patient's mouth and the anterior teeth
are set. The maxillary record base with the anterior teeth is inserted and corrected.
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3/4 inch of speaking wax (Beeswax) is added over the occlusal plane of the
mandibular occlusal rim. Both record bases are inserted into the patient's mouth.
The mandibular occlusal rim with the speaking wax is inserted and the patient is
asked to pronounce the words "sixty" and "sixty-five". The midline is marked and
the record base is removed from the patient's mouth.
The speaking wax is removed to set the artificial teeth. The mandibular record base
is inserted and the setting is verified.
After verifying the anterior teeth arrangement, soft wax or zinc oxide eugenol
(ZnOE) impression paste or impression compound or dental plaster is added as an
inter-occlusal record on the posterior part of the occlusal surface of the mandibular
occlusal rim.
The upper and lower record bases are inserted and the patient is asked to close the
mouth till the anterior teeth occlude to their proper position. This procedure is
repeated to check for errors. The inter-occlusal material placed on the mandibular
occlusal rim records the vertical dimension at occlusion.
Pound and Murrel's method
e- Aesthetics
Facial esthetics An experienced dentist evaluates facial expression. In the normal
relaxed position, the lips are even anteroposteriorly and in slight contact. The nares
and the skin around the eyes and chin are relaxed. If the face appears strained, the
vertical height may be too much. If the corners of the mouth droop, making the chin
appear too close to the nose, then vertical dimension may be too less.
Skin If the vertical dimension is too high the skin of the cheeks will
appear very stretched and the nasolabial fold will be obliterated, the
nasolabial angle will be increased. The skin on the perioral areas can be
compared with skin over other areas of the face for reference. It should
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also be remembered that there are other factors like the age of the
patient, which can influence the appearance of the skin.
Lips The contour and fullness of the lip is affected by the thickness of the
labial flange. The occlusal rims should be contoured to aid in lip
support. A flattened appearance of the lip indicates lack of lip support.
In such cases vertical dimension should not be increased to provide
lip support, as it would lead to failure of the denture.
Willis method (Facial proportions) Theoretically, the distance between the outer
canthus of the eye and the corner of the mouth should be equal to the distance
between the lower border of the septum of the nose and the lower border of the chin
f- Swallowing Threshold
It is considered that at the beginning of swallowing, the teeth of the upper and lower
jaws almost come in contact. This factor can be used as a guide to determine vertical
dimension at occlusion.
A conical occlusal rim made of soft wax is fabricated on the mandibular record
base. The upper and lower record bases are inserted in the patient's mouth.
Salivation is stimulated and the patient is asked to swallow. The height of the
conical wax rim is reduced due to the pressure developed while closing the
mandible during swallowing. The conical wax rim may also be softened to
reduce the resistance to closing.
Laird reported that with dentures at the accepted vertical dimension the patients
swallowed with the denture teeth in occlusion. This suggests that patients who
swallow without denture tooth contact may be functioning at a reduced vertical
dimension. J Prosthodont 2003;12:30-36
g- Tactile Sense or Neuromuscular Perception (Lytle's method)
The patient's tactile sense or sense for comfort is used to asses the vertical
dimension at occlusion.
In this method a central bearing screw/ central bearing
plate apparatus is used. The central bearing screw fits
into the depression of the central bearing plate. The
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central bearing plate is attached to the maxillary occlusal rim
and the central bearing screw is fixed to the mandibular
occlusal rim.
Procedure
The occlusal rims with the central bearing screw and plate are inserted into the patient's
mouth.
The central bearing screw is progressively tightened. This
tightening will bring both the occlusal rims towards each other.
After a certain limit the patient will feel discomfort in his jaws due
to over-tightening. This point is recorded.
The same procedure is repeated with the central bearing plate in the mandibular rim and
the central bearing screw in the maxillary rim.
The central-bearing point is slowly reduced till the patient indicates a comfortable jaw
relationship.
The procedure is repeated to avoid errors. Disadvantages include foreign body
obstruction,etc.
h- Patient's Perception of Comfort
It is a very simple and easy method of determining the vertical relation. Here, the
record bases with excessively tall occlusal rims are inserted in to the patient's
mouth and the excess base plate wax is removed stepwise till the patient perceives
the occlusal height as comfortable.
The disadvantage of this technique is that it depends on the patient's co-operation
for accurate readings.
i- Electromyography
By recording the minimal activity of masticatory muscles
postural position or rest position can be determined by means of
electromyography which would record minimal activities of muscles as all
muscles showed greater activities (in other position) than when the jaw is at rest".
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j- open rest method
Douglas and Maritato evaluated patients at an open rest position and
suggested that the occlusal plane should be established in terms of its
relationship to the commisures of the lip, with the maxillary occlusal plane 3
mm above and the mandibular occlusal plane 2 mm below the commisures. J
Prosthodont 2003;12:30-36.
On many occasions, however, it is necessary to increase the occlusal vertical
dimension to compensate for wear of the old occlusal surfaces and resorption of the
alveolar bone.
It is necessary to have a clear idea of the magnitude of change required and to
decide whether such an increase, if added to the upper rim, will improve or detract
from the appearance of the patient or, if added to the lower rim, will so increase the
height of the occlusal plane that the stability of the lower denture will be impaired.
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Clinical Techniques to Increase Vertical Dimension
The clinician must take care to avoid creating a vertical dimension in which the patient
cannot function.
Hansen technique J Prosthodont 2003;12:30-36
Hansen described a technique using clear thermoplastic resin splint material
with tooth-colored autopolymerizing resin.
After the maxillary and mandibular denture are mounted, the
autopolymerizing resin is added until the predetermined appropriate vertical
dimension is obtained on the articulator.
The mandibular denture is used to restore vertical dimension, because
mandibular alveolar bone resorbs more quickly than maxillary bone.
The final occlusal adjustment is made intraorally. The diagnostic splint is
then placed over the existing andibular denture to diagnostically restore the
vertical dimension.
Mays technique J Prosthodont 2003;12:30-36
A new set of dentures was used as a diagnostic treatment prosthesis to
gradually evaluate patient ability to adapt .
The dentures were relined with a
tissue conditioner, and methyl
methacrylate resin was applied in
small increments to the occlusal
surfaces of the mandibular denture
teeth over a 60-day period to
establish a vertical dimension 5 mm greater than the vertical dimension of his
original dentures.
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The tissue conditioner was changed
approximately every 3 weeks throughout
the treatment. The patient wore the
treatment occlusal prosthesis for 3 weeks
with an increase of 2 mm; it was then
increased to 5 mm for a total treatment time
of 2 months.
During this time, the patients TMD pain resolved and crepitus and clicking
decreased.
Occlusal device for diagnostic evaluation of maxillomandibular
relationships JPD 2004;91:586-90.
Diagnostic modification of OVD prior to complete denture therapy is often
indicated for patients who have worn existing prostheses for many years.
For these patients, clinical examination may reveal the following conditions:
severe decrease in lower face height yielding poor facial esthetics, inadequate fit of
complete dentures, worn denture teeth, clinically discernible deficiency in OVD,
acquired protrusive maxillomandibular relationship,angular cheilitis, or
temporomandibular joint sounds on auscultation.
The procedure involves modification of existing or duplicate complete dentures
to evaluate proposed alterations of the existing OVD. The primary advantage of this
procedure is that functional surfaces of the occlusal device are intraorally generated by
patient-induced mandibular movements limited by a central bearing device.
TECHNIQUE
1- Modifications may be done on duplicate complete dentures.
2- When indicated, condition the denture-supporting soft
tissues prior to diagnostic modification of the complete
dentures. Provide adequate and even reduction of the
intaglio surfaces of the dentures before applying tissue-
conditioning material. even denture base reduction by
painting the intaglio surfaces with disclosing ink.
3- Subject the prostheses to definitive laboratory reline or rebase procedures.
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4- The rest vertical dimension (RVD) is recorded,. Use a Boley gauge to record the
distance between the marks on the nose and chin. subtract approximately 4 mm,
accounting for the necessary interocclusal distance, to arrive at the diagnostic
OVD.
5- Use a central bearing device to stabilize the
mandibular denture during jaw movements and
maintain the desired OVD during diagnostic
denture modifications.
6- Apply a doughy mass of autopolymerizing, tooth
colored, acrylic resin to the posterior occlusal
surfaces of the mandibular complete denture.
lubricate the occlusal surfaces of the maxillary
denture teeth with a suitable lubricant.
7- Instruct the patient to close to the predetermined
OVD, bringing the central bearing point into
contact with the bearing plate. Direct the patient to
perform mandibular movements through all
eccentric jaw positions while maintaining contact
between the central bearing point and the bearing
plate.
8- Remove the prostheses from the patients mouth. Following complete
polymerization, trim excess acrylic resin.
9- Assure that the functional occlusal objectives of this diagnostic therapy are met,
including: (1) multiple, even occlusal, contacts coincident with CR at the
established OVD, and (2) bilaterally balanced occlusion, if desired. Instruct the
patient to wear the occlusal device throughout the diagnostic phase of therapy
and report complications.
10- Inform the patient that use of the occlusal device will be continued until stable
and comfortable maxillomandibular relationships are achieved
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HORIZONTAL JAW RELATION
It is the relationship of the mandible to the maxilla in a horizontal plane. It can
also be described as the relationship of the mandible to the maxilla in the anteroposterior
direction.
Horizontal jaw relation can be of two types namely centric and eccentric jaw
relations.
Centric relation denotes the relationship of the mandible to the maxilla when the
mandible is at its posterior most position.
Eccentric relation denotes the relationship of the mandible to the maxilla when
the mandible is at any position other than the centric relation position.
Centric Relation
The glossary of prosthodontic terms (GPT) enumerates seven different definitions for
centric relation. They are:
1. "The maxillomandibular relationship in which the
condyles articulate with the thinnest avascular portion
of their respective discs with the complex in the
anterior-superior position against the slopes of the
articular eminences. This position is independent of
tooth contact. This position is clinically discernible
when the mandible is directed superior and anteriorly.
It is restricted to a purely rotary movement about the transverse horizontal axis"
(GPT-5) (most accepted definition).
2. "The most retruded physiologic relation of the mandible to the maxilla to and from
which the individual can make lateral movements. It is a
condition that can exist at various degrees of jaw separation. It occurs around
the terminal hinge axis" (GPT-3)
3. "The most retruded relation of the mandible to the maxilla when the condyles
are in the most posterior unstrained position in the glenoid fossa from which
lateral movements can be made, at any given degree of jaw separation" (GPT-l)
4. "The most posterior relation of the lower to the upper jaw from which lateral
movements can be made at a given vertical dimension" (Boucher)
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5. "A maxilla to mandible relationship in which the condyles and discs are thought
to be in the midmost, uppermost position. The position has been difficult to
define anatomically but is determined clinically by assessing when the jaw can
hinge on a fixed terminal axis (up to 25 mm). It is a clinically determined
relationship of the mandible to the maxilla when the condyle disc assemblies
are positioned in their most superior position in the mandibular fossa and
against the distal slope of the articular eminence" (Ash)
6. "The relation of the mandible to the maxilla when the condyles are in the
uppermost and rearmost position in the glenoid fossae. This position may not be
able to be recorded in the presence of dysfunction of the masticatory system"
(Ach 1993 , Lang)
7. "A clinically-determined position of the mandible placing both condyles into
their anterior uppermost position. This can be determined in patients without
pain or derangement in the TMJ" (Ramsfjord l993).
GPT-5 definition is commonly used and accepted. Generally speaking, centric
relation can be described as the most posterior relation of mandible to the maxilla
at the established vertical dimension from which lateral movements could be
made. Any position of the mandible other than that of the centric relation is called
an eccentric position.
Note: Centric relation is the most posterior relation of the mandible to the maxilla
and the antero-superior relation of condyle to the glenoid fossa.
These definitions are somewhat different; they all agree that the CR is determined by
the TMJ structure and not by the dentition. Most of them relate to the THA, some of
them mentioned the retruded or posterior position, and other emphasis the uppermost
position of the condyles .

HARMONY BETWEEN CR AND CO
o Intercuspal Position: is the position of the mandible when the teeth are in
intercuspal occlusion.
o Centric occlusion: The occlusion of opposing teeth when the mandible is in
centric relation. Formerly Maximum Intercuspation
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o In 90% of people the CR is not coincide with CO. In the natural dentition CO
is usually located anterior to CR, the average distance being 0.5to 1 mm. In
the young age and complete denture the CR and CO are coincide to each
other.
o The confusion in terminology has been aggravated by controversy over the
correlation between the CR and centric occlusion CO i.e., the intercuspal or
maximum intercuspation position. The current definition of CO is the
occlusion of opposing teeth when the mandible is in CR. this may or may not
coincide with maximum intercuspation.
o Another argument for this concept the distance between the maximum
intercuspation position and the CR are increase in long-term CD wearers,
even if they coincide when constructed.
CENTRIC OCCLUDING RELATION
This exists when the jaws are in centric relation and the teeth
(0cclusal surface ) are in centric occlusion. It is the most important
basic relationship of the body of the mandible to the maxillae.
Coincidence of C.R. and C.O. (Centric occluding relation):
Complete denture prosthodontists have established that slower ridge
resorption occurs, greater chewing efficiency results and greater stability
of the denture bases exist, when denture patients are provided with
coincidence of C.O. (centric occlusion) and C.R. (centric relation).
Periodontists have established that greater potential for preservation of
supporting structures results and more rapid healing of diseased tissues
occurs when coincidence of C.O. and C.R. exists.
Detrimental effects may occur when these positions do not harmonize.
1. masticatory efficiency is reduced: Maximum muscle load is required to
produce minimum work i.e.
2. deflective malocclusion :Slide frequently exists between C.R. and C.O.. The
slide introduces adverse forces not in line with long axis of teeth. These adverse
forces tend to accentuate periodontal problems. The resultant deflection can
produce wear and instability of the teeth in the dental arch This deflection also
tends to predispose to muscle tension and spasm or other complaints associated
with TMJ. problems.
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3. Two arcs of closure coupled with emotional stress appear conductive to
bruxism or clenching habits.
4. Two arcs of closure produce two different vertical dimensions of occlusion,
which in turn may produce muscle inefficiency.
5. If C.R. and C.O. are not made to coincide, all lateral eccentric excursions are
apt to be in conflict with TMJ. guidance.
6. Because C.R. is the only maxillo-mandibular relationship that can be routinely
repeated, so it is logical to have C.O. coincide with it to maintain a more constant
anatomical relationship between the jaws and consequently between the teeth in
occlusion.
THE CENTRIC AND VERTICAL RELATIONS
Many vertical relations (VR) are possible between the mandible and the
maxillae. However, there is a most retruded position of the mandible for
each VR and there is a change in CR for each change in the vertical
dimension .
The CR record must be made at the established vertical dimension of
occlusion when an arbitrary face-bow transfer is used to orient the cast to
the opening axis of the articulator. While, when the cast are mounted with
the correctly located T H A, the operator can change the VD without change
in the CR.
Importance of Centric Relation (Significance)
1- The centric relation position acts as a proprioceptive centre to guide the
mandibular movements. The proprioceptive impulses (impulses of three-dimensional
spatial orientation) guide the mandibular movements.
In dentulous patients the proprioceptive impulses are obtained from the periodontal
ligament. Edentulous patients do not have any proprioceptive guidance from their teeth
to guide their mandibular movements. The source of the proprioceptive impulses for an
edentulous patient is transferred to the temporomandibular joint.
2- The centric relation has the following salient features:
It is learnable, repeatable and recordable position which remains
constant throughout life.
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It is a definite learned position from which the mandible can move to
any eccentric position and return back involuntarily. It acts as a centre
from which all movements can be made.
If the mandible has to move from one eccentric position to another it
should go to the centric relation before advancing to the target eccentric
position.
Functional movements like chewing and swallowing are performed in
this position, because it is the most unstrained position.
The muscles that act on the temporomandibular joint are arranged in
such a way that it is easy to move the mandible to the centric position from
where all movements can be made.
3- The casts should be mounted in centric relation because it is the point from
which all the movements can be made or simulated in the articulator.
The accurate CR record will orient the lower cast to the opening axis of the
articulator and the mandible.
It is helpful in adjusting condylar guidance in an articulator to produce
balanced occlusion.
It is a definite entity so it is used as a reference point in establishing centric
occlusion.
Centric relation is a learned position (not a default position) and the dentist
should teach the patient with patience to move his mandible from the centric relation
position.
4- The irregular loss of teeth often creates deflective occlusal contacts that guide the
mandible into slightly protrusive or lateral positions, or both. The muscles, bone,
ligaments, teeth, and all related structures grow into coordinated center for
muscular activity. To change this center for muscular activity is to imperil the
stability of denture .
5- If the CR is not recorded, premature contact will be built in the denture particularly
when the mandible moves backward to the CR.
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Retruding the Mandible
The mandible should be in its most posterior position while recording
centric relation. Some patients may show difficulties in retruding the mandible due to
certain systemic conditions. These difficulties can be overcome by conditioning the
patient psychologically using special jaw relating apparatus, etc.
Method of Retruding the Mandible
Relaxing the patient. Making him feels comfortable.
Massaging or palpation of the temporalis and masseter muscles to relax them. In
the terminal hinge position, closing the mandible then the
temporalis muscle can be felt by the dentist.
Roll the tongue backwards .The patient should be instructed
to touch the posterior border of the upper record base with his
tongue. Knob for tongue retrusion
Protrude and retrude the mandible repeatedly, while patient
hold finger lightly against the chin.
Tilting the head backwards tends to pull the mandible backward because of
tension on the infrahyoid muscles.
Swallow and close. The disadvantage is that a patient can swallow: slight
eccentric positions also.
The mandibular occlusal rim should be tapped gently with a finger. This would
automatically make the patient to retrude his mandible.
The patient is asked to try to bring his upper jaw forward.
Push the upper jaw out and close on the back teeth.
Boos stretch-relax exercises Open wide and relax, move the jaws the left and
relax, right and relax, forward and relax. This helps the patient to coordinate
movements and follow the dentist's instruct
Tapping rims together rapidly and repeatedly.
The patient may be further encouraged at this stage to make contact in the
retruded position by reducing the height of the lower rim anteriorly by about
1 mmso that the rims occlude only in the premolar and molar regions.
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Difficulties in Retruding Mandible
Difficulties in retruding the mandible can be classified as
Biological
Physiological
Mechanical.
Biological causes
Lack of co-ordination between groups of opposing muscles when the patient is
requested to close the mouth in the retruded position.
Habitual eccentric jaw relation.
Physiological causes
Inability of the patient to follow the dentist's instructions is one of the major
psychophysiological factors, which produce difficulty in retruding the mandible.
This is overcome by instituting stretch relax exercises, training the patient to open
and close his mouth, etc. Central bearing devices can also be used to retrude the
mandible in these patients.
Mechanical causes
Poorly fitting base plates produce difficulty in retruding the mandible. The base
plates should be checked using a mouth mirror for proper adaptation.
Amount of pressure that the patient exerts at the time of CR registration.
Muscles involvement in CR
Centric relation is not a resting or postural position of the mandible. Contraction
of muscles is necessary to move and fix the mandible in it. The posterior and
middle parts of the temporal and the suprahyoid muscles are move and fix the
mandible in its most retruded position relative to maxillae. The temporal,
masseter, and medial pterygoid muscles elevate the mandible to a particular
vertical relation with the maxillae. The lateral pterygoids show little activity
when the mandible is in CR.
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Recording centric relation Synonyms Bite registration
There are two schools regarding pressure used while recording centric relation.
A. Minimal closing pressure
A minimal pressure is advocated so that tissues are not displaced. Thus, the
opposing denture teeth will touch uniformly and simultaneously at first contact.
B. Heavy closing pressure
to produce same displacement of soft tissues that occurs during function.
Advantage : Occlusal forces are evenly distributed over the residual ridge under
heavy loads.
Disadvantage
1. If soft tissues have uneven thickness, the teeth contact uneven at first contact.
2. Uneven contacts may cause clenching in nervous patients
Methods of recording CR
A- STATIC RECORDING
Interocclusal registration (check-bite interocclusal registrations, Wax wafer method)
B- DYNAMIC RECORDING
I-Functional recordings (physiologic techniques)
a- Excursive functional recording (chew-in):
1- Pumice and plaster occlusal rims (Patterson)
2- Needles and needles house techniques
3- Functional movement of soft wax occlusion rims covered by tin
foil (Meyer)
4- Occlusal pathway in single dentures: Chew in or functional
record method, Functional generating path.
5- Stereograph.
b-Non-excursive function recordings : Swallowing (physiologic or
deglutition) techniques.
II- Graphic recording : - Gothic arch tracing - Pantograph - Minigraph
III- Terminal hinge axis recording
IV- Radiographical methods : - Cephalometric - Transcranial - C T scan
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A-STATIC RECORDING
(Interocclusal registration of CR)
Interocclusal records are made with a recording medium between the occlusal rims, the
trial denture bases. The patient close into the recording medium with the lower jaw is in the
most retruded position and stops the closure at the predetermined vertical relation
The common materials for the interocclusal records in order of accuracy are as the
follows: polyether, zinc oxide and eugenol past, plaster, autopolymerizing acrylic resin,
condensation type silicones, and wax. Recently, addition type silicones have been proposed
as registration material to improve the accuracy of condensation type silicones.
Requirement of the ideal interocclusal recording material:
1- Low viscosity, 2- Low resistance to closing of the jaws,
3- Precision in detail, 4- Dimensional stability,
5- Plasticity, 6- Elasticity,
7- Ease of use; adequate working time, rapid hardening, simple operation, and
8- Acceptability by the patient.
Technique
a- Three check lines are drawn with a wax knife from one rim to
the other, one in the midline and one either side in the premolar
regions. These lines
Enable the blocks to be located outside the mouth to establish whether there is any
premature contact on the posterior aspects of the rims or bases.
In addition, the check lines allow the clinician to judge whether the patient continues
to close in a consistent manner.
b- Two millimeters of wax was removed from the mandibular occlusal rim. Two V-shaped
notches were cut in the occlusal surface of the lower rim. Depth 1-2 mm
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1- Remove 3 mm of the mandibular rim from the mandibular first premolar area distally
to the end of wax rim on both sides. On the maxillary rim in the corresponding areas cut two
or three notches. If desired, the record medium can be placed on the maxillary recording base
and grooved placed in the mandibular wax occlusion rim serves as index. (Winkler 1988)
2- Place the index on the occlusal surface in the regions of upper first molars. Make the
index by placing transversely a step that is approximately 2 mm deep anteriorly, tapering
distally to nothing. (Syllabus 1980)
3- Other placed the index in the areas of upper premolar in form of buccolingual H shape,
and the wax interocclusal record confined to the second bicuspid molar area of lower
occlusion rim. (Cairo 73).
c- The occlusal surfaces of the upper and lower wax rim were smeared with a thin film of
Vaseline.
d- Four mm of softened base palate wax was attached to the occlusal surface of the
mandibular rim.
e- The blocks were placed into the mouth. Then the patient was guided to close in centric
relation by asking him or her to place the tip of the tongue as a back on the palate as
possible, keep it there and close the record blocks together until they were met at the
predetermined vertical relation.
f- The record blocks were removed from the mouth, and
chilled with cold tap water. Then the interocclusal wax
record was separated from the wax rims and kept in cold
water.
g- The record blocks can be sealed by using sablets
Indications
1- In situations of abnormal related jaws.
2- Excessively displaceable supporting tissues.
3- Large awkward tongue.
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4- Uncontrollable or abnormal mandibular movements.
5- To check teeth those have been arranged in trial dentures.
6- To check the occlusion of the teeth in the existing dentures.
7- For clinical remounting of complete dentures.
8- In almost all case of complete dentures.
Other material used
Alluwax
Must be dead soft
Zinc-oxide paste is used as interocclusal material
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DYNAMIC RECORDING
I-Functional recording
a-Excursive functional recordings
1-Pumice and plaster occlusion rims or plaster and carborundum (Patterson).
In this method the record block made from wax occlusal rim. Correct VD and CR are
determined (as discussed in interocclusal record method).
The record blocks are mounted on the articulator, the incisal post is open by about 4
mm.
A trench is made in each occlusal rim, and mixture of plaster and pumice or
carborundum is placed in the trench.
The plaster mixture should be allowed to set for at least 24 hours before begin used.
The patient instructed to grind the blocks together in both lateral and protrusive
movements. But only to use the minimum pressure necessary to keep the block in
contact. The grinding should be continued until the correct VD is obtained.
Then the patient instructed to retruded the mandible and the occlusal rims are joined
together with metal staples.
The main object of this technique is to obtain the degree of curvature of the compensative
curve. The record is also used as the CR record.
Stability of record block is essential for accuracy since there will be a considerable lateral
and protrusive drag, owing to friction, during the process of grinding, and therefore, the base
should be made of acrylic resin.
2- Needles and Needles-House technique
Needles 1923 used compound occlusal rims with three studs on maxillary rim. When
the mandible moves, the studs are cut arrow tracing into mandibular rim. After removal from
mouth, the rims are assembled with the functional grooves.
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While the Needles-House, used four styli instead of three studs in the maxillary rim.
When the mandible moves, the styli are cut four diamonds shaped tracings. The tracing
incorporated the movement in three planes, and the records are placed on a suitable
articulator to receive and duplicate the record. The record can also be used as the CR record
on the other types of articulators.
3. Functional movement of soft wax occlusion rims covered by tin foil.
Meyer (1934) used soft wax occlusion rims. Tin foil was placed over the wax and
lubricated. The patient performed the function movements to produce the wax path. A plaster
index was made of the wax and the teeth were set to the plaster index.
4- Occlusal pathway in single complete dentures
functionally generated chew-in techniques (FGPT):
This technique provide the most accurate method of recording occlusal patterns.
Requirement of FGPT:
The record base should be stable and retentive
The patient must have the neuromuscular control to perform the desired jaw
movements and the mental competence effectively cooperate.)
Functional Chew-In Techniques
In (1928) Stansbury described the first functional chew in technique for an upper
complete denture opposing lower natural teeth. By using a compound maxillary rim
trimmed buccally and lingually so that the occlusion free in lateral excursions.
Carding wax is added to the compound rim, and the patient instructed to perform,
eccentric chewing movements. The carding wax is slowly molded to the functional
movements, while the compound in the central fossa acts as a guide to preserve the
vertical dimension. The generated occlusion rim is now removed from the mouth,
and stone is vibrated into the wax paths of the cusps. The upper cast is again
fastened to the articulator with the generated occlusion rim and the stone cusp path
record. The stone cusp path record is secured to the lower member of the articulator
with plaster. We now have the upper cast mounted on the articulator and two lower
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casts. One is a duplicate of the lower teeth and the other is a replica of the generated
path. The denture teeth are first set to the lower cast of the patient's teeth. After the
esthetics have been approved at the try-in, the lower cast is removed and the lower
chew-in cast record is then secured to the articulator. All interfering spots are
carefully ground until the incisal guide pin prevents further closure. Thus. in centric
and in eccentric movements maximum bilateral balanced occlusion will have been
established.
In1964 Vig described a similar technique, by using of a fin of resin placed into the
central grooves of the lower posterior teeth, instead of using compound as
mentioned by Stansbury. The resin fin maintains the vertical dimension and also
helps to diagnostically locate the interfering lower cusp in eccentric movements the
lower cusp tips are ground until equal contact occurs between the teeth and resin.
The fin is then built up using a soft wax, and a functional path is recorded.
In 1968 Sharry mentions a simple technique of using a maxillary rim of softened
wax. Lateral and protrusive chewing movements are made so that the wax is
abraded, generating the functional paths of the lower cusps. This is continued until
the correct vertical dimension has been established.
In 1973 Rudd used a compound maxillary rim as the same way. A thickness of
recording matrix, made up of three sheets of medium-hard pink baseplate wax and
two sheets of red counter wax, is added to the buccal and lingual surfaces of the
compound rim. He also using two maxillary bases, one for recording the generated
path and the other for setting the teeth. The advantage of this is to reduce the
number of appointments necessary for the construction of the upper denture.
5- Stereograph
All border movements can be accurately recorded in three diminutions by means of
simple intraoral clutches that are stabilized by a central bearing point.
The TMJ instrument designed by Kenneth Swanson in 1965 is representative of this
class.
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An intraoral registration is generated by studs in autopolymerizing resin similar to the
technique utilized with the House articulator. The stereographic recording is then
placed on the articulator and used to mold fossae in autopolymerizing resin.
It is claimed that these fossae produce an accurate analog of the patient's
temporomandibular joint function.
b- Non-excursive function recordings (Swallowing, physiologic or deglutition
technique)
Soft cones of wax are placed on the lower trial denture base. The wax cones contact
the occlusal surface of the upper occlusion rim when the patient swallows.
This provides a record of the horizontal relation of the mandible to the maxillae.
Unfortunately, the mandibular position recorded by this method is not necessarily
consistent with CR and is not repeatable.
II- Graphic recording
1- Gothic arch tracing (arrow point tracing, central bearing point):-
I. Intra-oral tracings;
The intraoral device consists of
a) A carrier through the centre of which is threaded a pointed
stylus (tracing point controlled by a locking nut
b) A locking disc and
c) A tracing plate
After the correct vertical height has been obtained, the
carrier is fitted to the lower rim so that the tracing point is
placed centrally across a line joining the premolars. The
tracing point serves, also, as a central bearing point.
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The tracing plate is inserted parallel to and just below, the occlusal surface of the
upper rim.
Place the blocks in the mouth with the stylus adjusted to hold the rims slightly apart.
The patient now performs lateral jaw movements, keeping the tracing point in contact
with the plate the whole time.
When the operator is satisfied that the patient can perform these movements
correctly, the upper blocks is removed and after the tracing plate has been filmed with
blue inlay wax the blocks are replaced in the mouth.
Lateral and protrusive movements are made, the tracings
examined, and if clearly defined arrow has been recorded the
retruded position has been obtained.
The locking disc is a transparent plastic disc having a hole in the
centre and which can be secured to the tracing plate in any
desired position. The disc is placed over the tracing plate and its
hole is adjusted to the apex of the Gothic arch. The disc is then secured to the
underlying plate.
The tracing point is then readjusted just to make the rims in contact. The blocks are
returned to the mouth and the patient is asked to move the mandible until the stylus
slips into the hole of the disc.
The blocks should now be in even contact and no longer held apart by the screw. The
blocks are united in the mouth with hot wire staples or a mix of plaster.
II- extraoral tracing:-
The extra tracing apparatus is similar to the
intraoral except that the stylus and tracing plate are
outside the mouth, being attached to the record blocks
by rods which pass between the lips. The tracing plate
is attached to the lower rim.
No locking discs or plate are required to ensure that
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the mandible is in most retruded position. This is can be known from the tracer out side the
mouth.
A double needle-point tracing, one anterior to the other, also can be made by increasing or
decreasing the V D at which the tracing is scribed. This to tracings afford an excellent
illustration of how to the centric position varies at different levels of the V D.
Many needle-point tracing are not indicative of an exact C R because of the roundness of
the apex. The lateral movement should be made until the apex is sharp to indicate the true
retruded position of mandible. The dull or rounded apex on a tracing may be caused when
the condyles do not reach their most posterior positioning the TMJ, or when the recording
bases move on their basal set.
Errors may be introduced in the graphic tracing procedure:
When central bearing point is not mounted in the center of the lower basal seat
area.
When central bearing plates are not positioned parallel to each other and to
ridges.
When patient closes too hard causing unequal tissue displacement under the
bases.
When the tissue conditions are unfavorable as in conditions of hypertrophy
which could cause shifting of the bases.
When the arch relationships are unfavorable, as in severe angle class II or III,
which can result in a tipping of the upper base even when the central bearing
point is adjusted to be in the center of the lower arch.
Further, when central bearing plates are used the operator must be certain that
there is no interference in the occlusion rims in the posterior regions during
movement of the mandible.
Limitation of excursive recordings
The trial denture bases should remain seated during recording of the gothic arch
tracing. In Angles class II&III, it is impossible to centralize the biting load on the
trial denture bases by the use of a central bearing device. This is due to the
anatomical variation in size of the upper and lower jaws.
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Excursive recordings are more suitable in angle class I cases. In the presence of
flat of flabby ridges it is difficult to stabilize the trial denture bases. Often the
inability to obtain a precise apex in the tracing is due to shifting of the base.
In an attempt to stabilize the bases and obtain a three-dimensional tracings. House
used sharp studs set in the upper rim. These studs cut the movement path into a
compound rim on the lower trial denture base. This technique is suitable for
patients with good ridges.
2- Pantograph:- see mandibular movement
3- Minigraph:- see mandibular movement
III- Terminal hinge axis recording:-
When a record centric relation is made, it can be assumed that the anteroposterior
relation of the mandible to maxillae at the terminal hinge position is the same as centric
relation.
Techniques for recording the hinge axis location:-
The kinematic face bow is first-fastened to the mandibular rim and kept in close
adaptation to the lower ridge by a clamp under the chin that hold the mandibular
block in place.
The patient is put through simple opening and closing movements 20 mm. This
movement of the mandible shows whether the condyle rods are on the rotational
centre. If they are not, concentric circular movements of the condyle rod points will
be made. These points are adjusted during the opening movements until they rotate
without any concentric arcing.
When the hinge axis centre is determined, it is marked with indelible pencil. The
condyle rods are provided by adjustment screws that allow the rods to move in
various directions to enable the operator to ascertain the hinge axis without altering
the "fork to rim" relation
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Using the Palate for the Interocclusal RecordJ of Prosthodontics 19 (2010) 245246
o This technique may be used in full-arch rehabilitations involving either natural
teeth or osseointegrated implants.
o Obtaining the interocclusal record using the palate as an area of registration takes
advantage of the limited tissue mobility of the region, and does not require
segmentation of interim prostheses at the midline. Moreover, it maintains the
previously established OVD, allowing the casts to be mounted in the articulator for
the fabrication of the framework.
Technique
1. Manipulate the silicone putty elastomer (Zetaplus, Zhermack,
Badia Polsine, Italy) and place it over the hard palate and occlusal
surfaces of the interim prostheses on the maxillary arch (covering
the incisal/occlusal third of the teeth).
2. Ask the patient to close his/her mouth into maximum
intercuspation.
3. Trim the excess registration material, covering the cast with a
scalpel blade.
4. Mount the maxillary cast in the articulator with a facebow
transfer. Fix the cast to the platform with stone (Vel-Mix,Kerr,
Romulus, MI).
5. Verify that the interocclusal record is seated correctly over the
mandibular cast.
6. The silicone must be in intimate contact with the hard palate in
the maxillary cast and with the occlusal and incisal surfaces in the
mandibular cast.
7. Fix the mandibular cast to the platform with stone.
8. The casts on the articulator are now ready for laboratory procedures. An additional
advantage of this technique is that the record of the incisal edge position of the interim
prosthesis may function as a guide for the production of the framework of the prosthesis
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Eccentric Jaw Relationships
Any jaw relation other than centric relation
Protrusive Record
Right Lateral Record
Left Lateral Record
Methods of Registration
Wax registration method.
Graphic tracing method.
Chew in or Functional method as by Needle House and Patterson
techniques
1- Wax wafer Method:
It is based on Christensen phenomenon:
a) Protrusive record:
The wax wafer used in recording centric relation is removed
carefully and replaced by another softened wax wafer of 4 mm
thickness which is placed on the lower occlusion block. The
upper and lower blocks are inserted in the patients mouth and
the patient is instructed to close in protrusion about 46 mm.
This record is needed in case of using semi-adjustable condylar
path articulator to adjust to horizontal condylar path, while the lateral
condylar path will be calculated indirectly by the formula.
This protrusive record is subsequently used to adjust the angle of the
condylar track to the horizontal plane. It is placed on the lower record rim
on the articulator and then, as the upper rim is seated in the record, the
condylar track is caused to rotate. The resulting condylar angle can be read
from the scale on the side of the joint assembly.
b) Lateral records:
Two softened wax wafers of 4 mm thickness are needed. When one wafer
is inserted the patient is instructed to close on one side (e.g. right side).
This record will help to adjust the condylar inclination of the left side.
Whereas the other wax wafer is used and the patient is instructed to close
on the left side to adjust the condylar path inclination of the right side.
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These right and left lateral records are used for the fully adjustable
condylar path articulators. Where both horizontal and lateral condylar
path inclinations are adjusted according to the patients records.
2- Graphic Tracing Method:
When the stylus is in the desired eccentric position (either protrusive or lateral
position), the upper and lower occlusion blocks are locked together with plaster
and then transferred to the articulator to adjust the condylar guidance of the
articulator.
(a) The condylar angle the angle of the condylar track to the horizontal plane. (b) The
Bennett angle the angle of the condylar track to the sagittal plane.
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Obtaining balanced occlusal contact
Balanced occlusion: Balanced occlusion is present when there are simultaneous contacts
between opposing artifi cial teeth on both sides of the dental arches. This term describes a
static situation and applies when upper and lower dentures meet in any position.
Balanced articulation: Balanced articulation is a dynamic situation in which there are
bilateral, simultaneous, contacts of opposing teeth in central and eccentric positions as the
mandible moves into and away from the intercuspal position.
Working and non-working sides: The working side is that to which the mandible moves, for
example, in order to break up a bolus of food. The opposite side of the arch is termed the
non-working, or balancing side.
Condylar path : The condylar path is the route taken by the mandibular condyle as it moves
forwards and downwards from the glenoid fossa to the articular eminence.
Condylar angle : the angle between the condylar path and the Frankfort plane.
Condylar axis: The condylar axis is a line between the mandibular condyles close to a hinge
axis around which the mandible can rotate without translatory movement.
Advantages of occlusal balance
Masticatory forces are transmitted as widely as possible over denture-bearing tissues.
the even contact positively assists in retaining the dentures
Balanced occlusion and articulation are only relevant when the teeth make contact.
This situation occurs during the so-called empty mouth contacts while swallowing saliva,
clenching or grinding the teeth.
During mastication, in the early stages, the bolus is generally too large or too firm for the
teeth to penetrate fully and to come into contact. Thus, occlusal balance does not operate at
this stage, a situation reflected in the old adage, Enter food, exit balance.
It is only in the later stages of comminuting of the bolus that the food is broken down and
softened enough for the teeth to contact and for occlusal balance to come into play.
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Relating the maxilla to the hinge axis by face bow
Hinge axis [posterior reference point]
(Transverse horizontal mandibular axis, terminal hinge axis, kinematic axis)
The hinge axis, or transverse horizontal axis, is an imaginary line around which the
mandible may rotate within the sagittal plane. This rotation averages about 12
o
or 18-25mm
of incisal opening, and occurs during centric relation.
This movement is most likely performed in the lower part of the temporomandibular
joint between the surfaces of the condyle and the articular disc.
Many hinge-axes exist; there are at least twelve hinge-axes in every head; three in
each temporomandibular joint and three in each mandibular angle. Only the three in each
joint require consideration:
(1) The transverse hinge-axes that govern jaw rotation in the sagittal plane (opening and
closing),
(2) The vertical hinge-axes that govern jaw rotation in the horizontal plane (side-to-side),
(3) The sagittal hinge-axes that govern jaw rotation in the transverse plane.
Importance of the hinge axis:
1. Accurate location of the hinge axis is of clinical importance for the orientation of the
maxillary cast on the articulator and the subsequent mounting of the mandibular cast with
the centric relation record.
2. If the casts are not mounted on the hinge axis, then, an articulator cannot be adjusted to
reproduce jaw movements accurately.
3. Alteration of occlusal vertical dimension on the articulator is possible with hinge axis
mountings.
4. With the use of hinge axis transfers, a cusp form (anatomic) posterior teeth are indicated
with minimal adjustment.
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5. The use of hinge axis transfers develops an occlusion, which would preserve and restore
oral functions, with minimal remounting procedures to perfect the occlusal scheme.
6- Without the hinge axis for the transfer of casts to an articulator, it is impossible to
diagnose an occlusal problem because the teeth on the model would not meet in the same
way as they would in the mouth.
1- If the location of the hinge axis of a patient is precise, centric relation registrations
can be made at an increased vertical dimension of occlusion and transferred to an
articulator. On removal of the interocclusal record, the casts can be brought together in an
occlusal relation that is the same as that of the patient. This is an essential step to consider
when the vertical dimension of occlusion needs to be altered
Existence of hinge axis:
There are four main schools of thought regarding hinge axis theory.
Group 1. Nonbelievers of the transverse axis theory. They believe the hinge axis is
theoretical, but not practical.
Group 2. Absolute location of the hinge axis. These people believe the hinge axis is a
component of every masticatory movement of the mandible and cannot be
disregarded.
Group 3. Arbitrary location of the axis. These people believe the hinge axis is of some
value, but not worth the effort to locate it truly.
Group 4. Split-axis rotation. They believe in the transograph theory. That each
condyle has its own center of rotation.
Presence of hinge axis
Ferrario said a pure rotation did not occur around the intercondylar axis and that the
centre of rotation is movable during every phase of the physiologic (habitual) jaw
movements. Page said a condyle rotates; therefore, any argument against its doing so around
rotational centers or a hinge axes is an argument against the truth.
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One or multiple hinge-axis controversy:
Trapozzano reported that there are multiple hinge axis points along the path of the
translatory movement of the condyle so more than one terminal hinge-axis exists
Preston, suggested that a single transverse horizontal axis exists as a fact in
articulating instruments and as a theory in the human craniomandibular complex
Instantaneous center of rotation theory
The instantaneous center of rotation (ICR) is a variable that
describes the position of the center of rotation at any instant of time
during the simultaneous rotatory and translational movement of the
mandible. Such motion differs from hinged axial rotation by having
the center of rotation shifting along a path. According to this theory, the mandible
undergoes both translation and rotation in varying degrees from the initiation of jaw
opening. The center continues to move as the jaw opens.
Relation of hinge axis to condyle controversy
The axis of rotation appears to lie in anatomic center of condyle , anatomical
characteristics of TMJ structures, such as the ligaments, the capsule, the configuration
of condylar surface, influence the hinge movement and hence, location of hinge axis.
Beyron found that the axis point of each condyle was located within the outline of
condyle but not in any regular relationship to any definite part of the latter.
Moss suggested that the mandible rotates about the mandibular foramen, and that
this represents an adaptation to reduce the amount of movement about this region in
order to minimize the potential for trauma of the inferior alveolar nerve. Some
investigators place the center of rotation in the neck of the condyle, at the attachment
of the temporomandibular ligament. Their rationale is that the temporomandibular
ligament is taut during function and acts as a rotational center,
The colinearity- noncolinearitv (split axis) concept:
Some authors believe in the split axis i.e. each condyle rotates independently of the
other and has its own axis of rotation (two axes). Page in his proposal of the
transographic concepts. He postulated the existence of two mutually independent,
noncolinear axes or, simply, that each condyle had its own axis of rotation.
Most authors believe in the existence of a single rotation and a single transverse
horizontal axis.
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True, arbitrary hinge-axis controversy
Several investigators recommend accurate location of the patients true transverse
horizontal axis as any deviations between a patients true transverse horizontal axis
(THA) of mandibular rotation and the location of the axle on an articulator will
produce occlusal error and an arbitrary face-bow transfer instrument is considered
acceptable only for patient treatment when the vertical dimension of occlusion
(VDO) will not be altered on the articulator.
some authors consider the anatomical method of locating the axis as an acceptable
technique, and an easily determined point that is consistently close to the kinematic
axis would simplify transfer of the arc of rotation from the patient to the articulator.
Methods of locating terminal hinge axis
I. True hinge axis
A) By using mandibular face bow or hinge axis locator:
In dentulous patient the device is firmly attached to the mandibular teeth
by a clutch. In edentulous case it is maintained in close adaptation to the
mandibular ridge by the use of some external attachment such as clamps
under chin that hold the mandibular occlusion block in place.
The clamp or the clutch is attached to a transverse bar. An adjustable
side armis attached to the transverse arm. In the condylar region pointed
condylar needle is attached to the side arm.
The patient is asked to move the mandible up and down in its most
posterior position and the condylar needle is noticed as it moves in arcs.
The needle is moved to the center of these arcs. The needle is further
adjusted until it rotates in a point "still point". This is the position of terminal hinge axis.
B) Axiograph
The mechanical axiograph has been used to locate the transverse
horizontal axis.
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Others prefer the computerized axiograph to document the
biomechanics of the temporomandibular joint (TMJ), analyze condylar
paths in temporomandibular disorders (TMD), or monitor function and
dysfunction before and after TMD treatment.
The Axiotron is a computerized accessory for the mechanical axiograph.
It generates digital records of condylar paths in 3 reference planes.
Electronic axiograph Cadiax Diagnostic utilizes exactly determined
hinge axis. CADIAXdiagnostic, measures translational- and rotational
mandibular movements at the exact hinge axis, using a double-stylus
system
Accuracy of hinge axis location:
Some authors believe that it is impossible to locate the transverse hinge axis kinematically
with accuracy for one or more of the following reasons:
1. The angle of opening movement is small (10-12 degree) and thus the arc of movement
of the styli is small. Also there is a difficulty in training the patient to perform opening
and closing in the terminal hinge position.
2. The edentulous ridge is relatively unstable base on which to affix a record block that
will carry the weight of the hinge axis face bow.
3. The clutches used for dentulous patients can alter the closed position of the condyles
and limit the extent of condylar movement.
4. There may be movement of the skin over the condyles during registration. This
difficulty can be eliminated by the use of flags for the recording procedures.
II. Arbitrary hinge axis :
A. Arbitrary points related to earpiece face bows, which utilize the external auditory
meatus as the posterior point of reference.
B. Arbitrary points selected by anatomical surface marking and dependent upon average
value measurements, these include:
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1. Gysi's arbitrary axis Some authors advocated the use of a point anterior to the
tragus on a line extending from the superior border of the tragus of the ear to the
outer canthus of the eye. The authors advocated the use of a point 10-13 mm
anterior to the tragus on the line.
2.The Denar face bow and articulator utilize points 12 mm anterior to posterior
border of tragus and 5 mm inferior to a line extending from the superior border
of tragus to outer canthus of eye.
3. Other authors recommended the use of a line extending from the middle and
posterior border (apex) of the tragus of the ear to the corner of the eye, as the
reference plane. The authors used points from 10-13 mm anterior to the apex of the
tragus on this reference line.
4. Other authors used an inferior reference line extending from the inferior margin
of the tragus of the ear to the outer canthus of the eye. They used 13 mm
measurement anterior to the tragus on this line.
5. Others, used measurements from the center of the external auditory meatus.
6. Bergestrom used a point 10 mm anterior from the center of the external auditory
meatus and 7mm down the Frankfort horizontal plane.
7.Lauritzen and Bodner suggested a point 12 mm anterior of and 2 mm. down from
the center of the external auditory meatus on a line extending from the superior
margin of the tragus to the outer canthus of the eye.
8. Beyron's arbitrary axis 13 mm in front of the posterior margin of the centre of the
tragus on a line extending from the tragus to the lateral angle of the eye.
C. Palpation as described by Dawson, from behind the patient the index finger is placed
over the joint area, and the patient is asked to open widely, As the condyle is translated
forward the finger tip will drop into the depression left by the protruded condyle. The patient
is asked to close and as the condyle is pulled back into centric relation, the fingertip could
locate its position. This is repeated several times to feel the center of condylar rotation.
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The arbitrary axis versus the true axis:
Unless the true hinge axis is located and transferred to the articulator, error in
occlusion will be induced when the wax interocclusal record is removed and the
articulator is closed.
The error involved is minimized by having the interocclusal record of wax in centric
relation very thin (less than 3 mm). simulates the anteroposterior error (about o.2
mm) at the second molar that occurs with an interocclusal record of 3 mm thickness
and when there is a 5 mm discrepancy between the true and arbitrary hinge axis.
Also, balancing side occlusal error results from inaccurate location of kinematic
hinge axis.
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The anterior points of reference
The selection of the anterior third point of reference determines which plane in the head
will become the plane of reference when the prosthesis is being fabricated.
Anterior points raise or lower the cast about a fixed radius and as it raises it move slightly
forward. However the angle between the face bow and occlusal plane remains constant.
The anteroposterior difference in the position of maxillary cast
appears to produce minimal occlusal error if upward/ downward
position does not exceed 16 mm.
The anterior point of reference raises or lowers the cast . Raising the
cast place it more anterior (A more anterior than B and C). While
the angle y is constant.
Many anterior points have been recommended. These points are:
1. Orbitale: is the lowest point of the infraorbital bony margin. The orbital pointer of the
face bow is adjusted to this point and transferred to the orbital plate of the articulator.
2. Orbitale minus 7mm: It was found that the mean distance of
the hinge axis points to the FHP was about 7 mm. To compensate
for this distance the anterior point of reference is marked 7 mm
below the orbitale on the patient or to position the orbital pointer
of the face bow 7 mm above the orbital indicator of the articulator.
Some articulators compensate automatically for this distance by
placing the orbital indicator 7 mm higher than the condylar horizontal
axis. The axis orbitale -7 mm plane is parallel to the FHP. The
orbital plate of articulator is higher than the condylar axis by 7 mm.
3. Nasion: The Whip-Mix face bow utilizes the nasion as the anterior
point of reference. The nasion relator is designed so that when it is
attached to the face bow and is positioned at the nasion point (bridge
of the nose), the cross bar will be in the approximate region of orbital.
By this way the Whip Mix face bow employs an approximate axis-orbital plane.
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4. The incisal pin notch of the articulator: With some
articulators it is recommended to use a notch in the incisal guide
pin of the articulator for the third point of reference. During
mounting the incisal edge of the upper anterior teeth or wax rim
is adjusted at the level of this notch. The incisal edge of wax rim
is placed in level with incisal pin notch.
5. Ala of the nose: This point can be transferred to the
articulator by marking the right or left ala on the patient,
setting the anterior reference point of the face bow to it, and
with the face bow, transferring the ala anteriorly and the hinge
points posteriorly from the patient to the articulators hinge-
orbital indicator plane.
A second method is to make the maxillary occlusion rim parallel with Camper's line and
transferring it to the articulator with a face bow. Its occlusal plane is made parallel with the
upper and lower articulator's arms.
6. A point 43 mm superior to edge of incisor. This distance
is measured above the incisal edge on the patient and its
uppermost point is marked as the anterior point of reference on
the face. This divides the space between the articulator
horizontal axis and the lower member of the articulator and
position the occlusal plane near the midhorizontal plane of the articulator e.g. Denar Mark 2
articulator.
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Face-Bows
It is a caliper like device that is used to record the relationship of the jaws to the TMJ.
or the opening axis of the jaws and to orient the cast in the same relationship to the opening
axis of the articulator.
Functions of face-bows :
1. Locate the terminal hinge axis by the use of a kinematic face bow.
2. Relate the maxillary cast to the transverse axis of the articulator in
the same relationship as e maxilla is related to mandibular hinge axis.
3-Relate the mandibular cast to the hinge axis by means of a centric
relation record
Value of the face bow:
The negligence of the use of face bow leads to:
1- Errors in centric occlusion if any change in vertical dimension on the
articulator is made.
2- Incorrect adjustment of condylar guidances of the articulator, which
leads to error on balancing side occlusal contact.
The use of face bow is essential If cusped teeth are used or interocclusal record are
made with the teeth out of contact so the vertical dimension can be changed.
The errors produced by not using the face bow are negligible If zero degree teeth are
used or interocclusal record are made with the teeth in contact . Boucher
Types of face-bows:
A. kinematic face bow (mandibular, hinge axis locator):
The face bow aids in finding the kinematic center (terminal hinge
axis) of the jaw opening as described before
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The hinge axis transfer bow: It is similar to the hinge axis
locator but it has two side arms and the clutch tray is replaced by
bite fork. It is used to transfer the relationship between the maxilla
and the predetermined hinge axis to the articulator.
Because the asymmetry of the mandibular condyles, the
kinematic face bows intercondylar distance should not be altered on the articulator. Some
articulators have extendable condylar axis to meet the condylar pointers of the hinge axis
transfer bow.
If the condyle pointers on the face- bow are extended
inward (in order to fit fixed articulator axis) the
orientation of the axis to teeth will differ between
mouth and articulator. results in altered orientation
of cast to axis on articulator. This may be a small
enough distance, but it will alter the paths of vertical
motion relative to the retruded axis when the teeth close together and the starting point of the
lateral border movement.
B- The arbitrary (maxillary) face bow):
The maxillary face bow is the one generally used in the construction
of complete dentures.
It is used to record the position of the upper jaw in relation to the
hinge axis and transferring the relation to a mounting instrument.
It consists of a U- shaped metal bow with two graduated condylar
rods, bite fork and a universal joint.
It is either fascia or ear face bow. The ear face bow is arbitrary
face bow using the external auditory meatus as the posterior reference point.
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Errors in maxillary face bow record and transfer:
1-Movement of part of the face bow caused by incomplete tightening of one of the locking
screw.
2-Inadequate stabilization of the bite fork record on the maxillary cast.
3-Poor fit of the maxillary cast into the bite fork indentation.
4- Neglect use of maxillary cast support during mounting causing distortion of the face bow
record.
T- cast support is mounted on the lower member of the articulator to support the bite fork during
mounting the maxillary cast.
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Maxillary Face Bow Record
1- Bite fork is heated and inserted into the rim midway its height and
parallel to its plane.
Both are then placed intraorally together with the lower occlusion
block.
2-The condylar axis is then determined either arbitrarly or by using
mandibular face bow record. The rods are then placed on it , so that the
bow surrounds the patients face. The stem of the bite fork is slipped
into the universal joint.
3- When the patients face is centralized in the bow, all clamps are
tightened. Notice position of the condylar rods , infraorbital pointer
& bite fork.
4- Universal joint once tightened, never opened.
Maxillary Face Bow Transfer
1- The slide bar clamp is unscrewd to remove assembly from the face.
2- Assembly is now centralized on the articulator. Again notice
position of - condylar rods -infraorbital pointer , - L shaped bitefork ,
bypassing incisal pin
3- Upper cast is mounted on the articulator.
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THE ARTICULATOR AS A PATIENT ANALOGUE
ARTICULATORS
An articulator is a mechanical device to which maxillary
and mandibular casts may be attached, representing the
temporomandibular joints and jaw members.
Articulators can simulate but they cannot duplicate the
mandibular border movements.
Articulators are used to hold casts in one or more
positions in relation to each other for the purposes of diagnosis,
arrangement of artificial teeth, and development of the occlusal
surfaces of fixed restorations.
Other functions of articulators : Mounting the casts for:
a- Diagnosis and treatment planning.
b- Representation to the patient.
c- Pre-extraction record.
d- Setting-up of teeth.
e- Fabrication of occlusal surface of the restoration.
f- Maintaining the desired centric relation and vertical dimension.
g- Determining cusp angle (true condylar guidance).
h- Selective grinding on the adjustable articulator (laboratory & clinical remounting).
i- Increase or decrease in vertical dimension by mounting with face bow.
Types of articulators
I. Simple, hinge or plane line articulators.
II. Mean value or fixed condylar path articulators.
III. Adjustable articulators.
a. Semi-adjustable condylar path articulators.
b. Fully adjustable condylar path articulators.
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(a) A simple hinge articulator; (b) an average-movement articulator; (c) a semi-adjustable articulator
(Dentatus)
I-Simple, hinge or plane line articulators
The hinge articulator consists of two metal frames, which are
held apart at a certain distance by a setscrew at the back that
can raise or lower the distance between the two frames and
permitting only the hinge like movement.
It provides only a hinge movements. thus limited to opening
and closing.
a hinge articulator is an instrument whose hinge bears no
measured or transferred relationship to the terminal hinge axis
of the mandible.
It may have a single or double hinge and casts mounted on it
will open and close on an arc, which does not copy mandibular opening or
closing arc (smaller arc).
Uses:
- Maintaining the centric occlusion relationship only.
- Setting-up of teeth.
- Representation to the patient.
The distance between the maxillary cast and the axis of rotation on the articulator is very
short from that of the patient resulting in errors in occlusion on balanced side.
Possible movements: It gives only opening and closing movements.
Records required: 1-Vertical dimension of occlusion. 2- Centric relation record.
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Disadvantages:
These articulators do not represent the temporomandibular joint and the
dynamic mandibular movements.
The major limitations of simple articulators include the contact occlusal
relationships in eccentric movements are unrelated to the patient, there is
no provision for movement in centric relation; the centric occlusion
position may not be accurately defined.
The errors which may occur as a result of the limitations of a simple
articulator include premature contacts in centric occlusion, centric
relation, balancing interferences, protrusive and working interferences.
If the casts are mounted, the intercuspal position can be copied and repeated but
not the arc of closure to it. Thus the pre-contact registration (using interocclusal record)
for mounting the casts will results in a different occlusal position than the intercuspal
position in the mouth.
This, type of articulators is of no aid to the operator in establishing occlusal
relationship other than centric occlusion.

Left; the arc of closure of the articulator is smaller than that of the patient. Right; mounting cast
using interocclusal record (A), when the record removed posterior separation occurs (B).
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II. Mean value, average or fixed condylar path articulators
In this type the two members of the articulator are joined
together by two joints, which represent the
temporomandibular joint.
In this type, the condylar path is fixed at a certain angle and
the angle is used for all patients. It is especially successful
for those patients whose condylar path approximates this
angle.
As these angles have been arrived at by taking an average over many hundreds of
patients it may be assumed that a good proportion of cases can be treated
successfully with this type of instrument.
In some fixed condylar path articulators the upper cast is
mounted on the upper member of the articulator with a face
bow transfer e.g. Hanau mate articulator where; the
horizontal condylar path is fixed to 30 degree, the lateral
condylar path to 15 degree and the incisal guide table to 10
degree.
Other articulators mounting is carried out according to the Bonwill triangle.
Bonwill mentioned that the distance between the condyles
and the distance from each condyle to the contact point of the lower
central incisors is 4 inches. Bonwill, thus, formulated the theory of
the equilateral triangle and designed an articulator to this theory.
To orient the cast in relation to Bonwill triangle ,the fixed
condylar path articulators usually have a pointer attached to incisal
pin so that it touches the midline of the occlusion rim labially to
locate the tips of central incisors, so that it touches the midline of the
occlusion rim labially and thus helps to orient cast in relation to
Bonwill triangle. and the occlusal plane is oriented parallel to the upper and lower
members of the articulator (horizontal).
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On the fixed and most adjustable condylar path articulators the upper members are
movable and the mandibular members are stationary (non-arcon or condylar
articulators) to provide a firm base and facilitate the arrangement of teeth. The fixed
condylar path articulators have their condyles on the upper member and the condylar
guides on the lower member. Therefore, the upper member moves backward and upward
in protrusion. This reverse arrangement (non-arcon) provides a firm base and facilitates
setting up of teeth.
This articulator is classified into two groups:
1- Accept face bow transfer.
2- Does not accept face bow, and transfer mounting is done by:
a- Bonwill triangle.
b- Monson spherical theory.
c- Needle house chew in technique.
Possible movements:
1- Opening and closing.
2- Protrusive movement at a fixed condylar path angle.
Records required:
1- Vertical dimension of occlusion.
2- Centric relation record.
3- Face-bow record: In some designs of these articulators, the upper cast can be
mounted by a face bow transfer.
Disadvantages:
1-Most of these articulators does not accept face-bow record.
2-The condylar path moves to a fixed angle and it is successful in-patients whose
condylar angle approximates that of the articulator.
3- No lateral movements.
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Occlusal errors with fixed condylar path articulators:
1-Without the use of face bow or an arbitrary face bow is used; the hinge axis of the
patient will not coincide with that of the articulator leads to occlusal error.
2- Arbitrary location of the anterior point of reference leads to balancing side errors.
3- This articulator may be successful for those patients whose condylar paths
approximate those fixed on the articulator. Improper condylar path angle leads to
error in protrusive and balancing contacts.
4-The condylar path on the patient is curved while on the articulator it is straight, this
leads to occlusal error in both working and balancing side.
5- There is no lateral movement in most types and those types moves laterally moves
to a fixed angle. This may gives balancing side occlusal error.
6- The incisal table is fixed which may produce error during excursions.
7-There is no immediate side shift adjustment, leads to balancing side occlusal error.
8- The intercondylar width on the patient does not coincide with that on the articulator
(non adjustable); this gives a balancing interference.
Procedures for mounting casts on a fixed condylar path articulator:
1- The upper and lower casts are prepared for laboratory remounting by cutting indices
on the undersurface of their base.
2- The upper and lower trial denture bases are sealed together and to the casts.
3- The incisal pin of the articulator is adjusted so that it's top flush with the top of the
upper member (This makes the articulators members parallel).
4- The arms of the articulator to be used are lubricated with Vaseline or oil to facilitate
cleaning of the articulator later on.
5- A piece of clay is placed on the lower member of the articulator and the casts with
attached record blocks are placed on the clay.
6- The occlusal plane of the wax rim is adjusted parallel to the orientation plane of the
articulator. To facilitate the orientation of occlusal plane, a rubber band is warped
around the articulator at level of incisal pin mark anteriorly and the two marks on the
condylar posts posteriorly (Bonwill triangle).
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7- The upper member of the articulator is opened and a mix of plaster is placed on the
top of the upper cast. The articulator is closed slowly until the incisal pin touches the
incisal table. This will attach the upper cast to the articulator.
8- After setting of plaster, clay is removed and the lower cast is attached to the
articulator by plaster. The excess plaster is removed while it is still soft and the
mounting plaster is smoothed with a sand paper.
III. Adjustable articulators
The adjustable articulator employs the face bow to transfer the arbitrary or actual
terminal hinge axis of the mandible to the articulator and posses condyle mechanisms
which can be adjusted to copy condyle positions transferred by interocclusal, protruded
and lateral records from the mouth.
A. Semi-adjustable condylar path articulators
A semi adjustable articulator is an instrument whose larger
size allows a close approximation of anatomical distance
between the axis of rotation and the teeth.
With this type of articulators it is said to be possible to
adjust the sagittal condyle path to the same inclination as those of the patient.
The lateral condyle path inclination can be obtained from the following
formula: L=H/8+12
Where L and H are the lateral and horizontal (sagittal) condyle path inclinations.
Some of the semiadjustable articulators have orbital plane guides. The orbital
plane guide allows the casts to be mounted in relation to the axis-orbital plane of
the patient and orients the casts on the articulator in the same relationship to the
bench top as the dental arches are in the patient.
Possible movements:
1-Opening and closing.
2-Protrusive movement according to the horizontal condylar path angle
determined from the patient.
3-Lateral movement to the angle estimated from the Hanau formula.
4-Some types have Bennett movement (immediate side shift).
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Records required:
1. A maxillary face bow record to mount the upper cast.
2. Centric occluding relation record (vertical dimension and centric
relation) to mount the lower cast.
3. Protrusive record to adjust the horizontal condylar path inclination of
the articulator.
Disadvantages:
1-The lateral condylar path angle is determined from the formula.
2-Most of these articulators have no Bennett movement.
Hanau semiadjustable articulator.
Arcon versus condylar articulator:
The term arcon is commonly used to indicate an instrument that has its condyles
on the lower member and the condylar guides on the upper member. Instruments that
have the condyles on the upper member and condylar guides on the lower member are
commonly referred to as condylar instrument or as non-arcon instruments.
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Left; Hanau 96H2O, non-arcon articulator. Right; Denar Mark II, arcon articulator.
In arcon articulator, the condylar guide moves with the upper member. In a non
arcon articulator, the condylar ball moves with the upper member. So that differences in
angles between arcon and condylar articulator is evident, such as differences in the
angles between the condylar guidance and the shaft housing or hinge axis of upper
member. The angles is reversed, i.e., in one instrument an angle is fixed, whereas in the
other instrument the angle changes.
Left: In condylar articulator; the angle between the condylar guidance and the shaft housing is fixed (F),
while the angle between the condylar guidance and the hinge axis of upper member is changeable (C). In
arcon articulator, the angles are reversed (Right).
In the sagittal plane, as the condylar instrument is opened, the occlusal plane change but
the condylar guidance angle remains fixed. On the arcon type instrument, the condylar
guidance angle change as the articulator is opened.
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Increasing the vertical dimension on the articulator. Left; in non arcon articulator, the occlusal plane
inclination change (cp) and the condylar guidance remains fixed, so the angle between the two is changed
(C). Right; in arcon instrument, the occlusal plane and condylar guidance angulations change, so the
angle in between remains constant (F).
The distance between the condyles and the lower teeth in protruded relation will
be the same in the mouth as on arcon articulator. On the condylar articulator, where the
condyles move backward in protrusion, the distance between the condyles and the lower
teeth will be twice the distance which the condyles travel. Since, on the condylar
articulator, the condyle moves upwards as well as backwards. The angle between the
line forming the condyle and upper incisor teeth and the horizontal plane will be steeper
than the angle made by the line joining the same two points in the arcon articulator.
Difference between angle of condyle descent between arcon (A-B) and condylar (X-B) mechanisms.
Occlusal errors with semiadjustable articulators:
1-When arbitrary face bow is used; the hinge axis of the patient does not coincide with
that of the articulator leads to occlusal error.
2- Arbitrary location of the anterior point of reference leads to balancing side
interference.
3- The condylar paths on the patient are curved while on most articulators it is straight;
this leads to occlusal error in both working and balancing side.
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4-The lateral condylar path angle (Bennett angle) is calculated from the formula and not
recorded.
5- On many instruments the Bennet movement is reproduced as a gradually deviating
straight line, although several recently introduced semi-adjustable articulators do
accommodate the "immediate side shift".
6- Intercondylar distance does not have total adjustability. They can be adjusted to
small, medium and large (e.g. Whip- Mix articulator). Restorations made on this type of
articulator will have balancing interferences and will require some intra-oral adjustment.
Lateral shift permitted in Hanau (Dentatus) articulator. G; gap. The condyle axis moves straight laterally
during balancing movement From AB to XY.
b. Fully adjus