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Review of the relevant anatomy for maxillary and mandibular dentures

Razan Tanous

Khalid Al-Hamad

6-10-2013

Review of the relevant anatomy for maxillary and mandibular dentures

Mucosa: stratified squamus epithelium and connective tissue (lamina dura) Submucosa : connective tissues made of dense to loose areolar tissues - if firmly attached : withstands pressure - if loose, thin, traumatized, mobile, flabby: won't be stable to withstand pressure {not resilient} Masticatory Mucosa (keratinized) : hard palate, residual ridges, residual attached gingival Hard palate: - keratinized. - mid palatine suture : submucosa is extremely thin, requires relief! - primary support area: horizontal portion of the hard palate - secondary support area: rugae area (set at right angle to the residual ridge) The palatal gingival vestige: remnants of the lingual gingival margin, it is the remains of the palatal gingival ; after tooth extraction the position of the vestige remains relatively constant (static), the same as the incisive papilla. This can be a very helpful pointer for posterior tooth positioning during denture construction. there are some techniques that are based on these static marks, but we won't be using any of them in our fourth & fifth years! Residual Ridges: 1. Mucus membrane: it's keratinized and firmly attached the submucosa: devoid the glandular tissue. Dense collagenous fibers. It's relatively thin and not sufficient to provide support for the denture base. 2. Crest of the ridges: it is prone to resorption, and of the secondary support area! 3. Inclined facial surfaces: it loses its firm attachment, so it offers little support and cannot be used as a support area.

The Fovea Palatine: 1. Two orifices one on each side of the palatal midline. It is the coalescence of several mucous glands, and it's ALWAYS located in the soft palate! 2. They act as collecting ducts for a group of minor palatine salivary glands.

The most important thing in impressions is to get the BORDERS accurately! It's also important to get all the structures accurately; it's not an easy task to be done accurately. But it's important to know that a denture depends on the peripheral seal (for the primary impression), ok you need good adaptation, good impression, no voids here and there, the choice of the material or the technique.... but this is sort of easy; to fill between the borders! But as we can see there are many structures here at the borders that you have to get in order to have a good final impression. Knowledge of the muscles and structures that produce the borders is a prerequisite to successful impression making. Knowledge of how to activate the muscles and locate the structures is also needed.

Let's start with them one by one...

These are the labial frenum and the buccal frenum...

Then we come to the orbicularis oris, levator labii superioris, levator anguli oris, incisivus labii superioris muscles that form the anterior part of the denture (and the impression). These structures will control the depth and the length of the sulcus.

Then we go to the buccinator muscle... Forming the distal part of the denture (the impression). "the lip form the ant. Part up to the buccal frenum area"

Now the risorius muscle, controlling the width of that area.

Here you ask the patient to open wide and move the mandible to the left and to the right, to get the impression of the coronoid.

The hamular notch should be recorded here, or another name for it is the pterygomaxillary fissure.

The palatine aponeurosis which consists of different structures this area is really important to get, to complete your peripheral seal, by adapting the denture to compress that area. The structures are: tensor veli palatini, levator veli palatini, palatophartngeus, palatoglossus, musculus uvulae muscles.

And there it is all the structures are in this picture.

Let's Now Concentrate On The Posterior Palatal Seal. We have this line making the junction between the hard and soft palate it's also called Valsalva Maneuver so anterior to it is the hard palate, and posteriorly the soft palate. How do we get that line? you ask the patient to close the nostrils and blow through the nose

Now the soft palate is composed of: immovable part (just behind valsalva maneuver) and movable part The line that separates them is called the Vibrating line. Behind this line, shouldn't be covered for retention! Bcoz the area there is movable Sometimes u need to check the compressibility of the hard palate with a burnisher coz sometimes the tissues there are compressible (50% in average) so can be used for the posterior palatal seal. - measure the depth of soft tissue displacement and make a depth "not more than" 2/3rds that depth"; about one-half of the displacement! And what you do next is you carve the cast at that area "between the hard-soft palate junction & the vibrating line" (spoon shaped); the deepest part is in the middle and zero over the lines as if it flushes all the way up! That's how you make your posterior palatal seal.

We have several advantages of the posterior palatal seal: 1. To increase the maxillary complete denture retention by having the posterior aspect of the denture base slightly compress the posterior portion of the palatal soft tissue (both soft and hard palates) 2. To compensate for the polymerization shrinkage of the resin so the denture base will contact the posterior aspect of the palate and maintain the seal.

Let's start with them one by one...

These are the labial frenum and the buccal frenum.

Then the lip musculature: Depressor labii inferioris, mentalis, incisivus labii inferioris, orbicularis oris muscles. These muscles will form the anterior area of the impression controlling the sulcus depth and width.

Then the buccinator again Forming all the posterior area.

Here is the masseter muscle. it compresses the buccinator muscle forming the masseteric notch. *These structures should not be always present, what u do is that u try to manipulate the muscles and try to see the maximum action of the muscle on the impression material, but if you don't see these things, this doesn't mean your impression is not good!

The temporalis muscle.

And also we have two important structures forming the gap ligually; the superior constrictor muscle and the palatoglossus muscle. You get these impressions by putting your finger on the tip of the tongue and ask the patient to push forward, and you resist this push.

most of the common mistakes in the lower impression is this area it's usually short! So we have to go deep and maximize the stability and retention of the lower denture.

And we have the mylohyoid muscle forming all the lingual portion of your impression.

These are all the structures of the mandibular impression

The buccal shelf area is important for support and also the marginal ridge and all the other structures.

Crest Of The Residual Ridge: 1. Ridge is smaller comparing to that of the upper in a healthy mouth. 2. Attachment varies considerably. In some people the submucosa is loosely attached to the underlying bone. 3. When securely attached to the bone, the mucous membrane is capable of providing support for the denture. However, because the underlying bone is cancellous, the crest of the residual ridge may not be favorable as a primary stress bearing area for the lower denture.

The buccinator muscle, the mandibular raphe, the superior constrictor, masseteric muscle, medial pterygoid .these are the structures that have many things to do with the placement and the relations of the denture in the jaw. - For the buccal shelf area: The mucus membrane is more loosely attached and less keratinized than that covering the residual ridge. Although the mucous membrane may not be as suitable histological to provide support for the denture, the bone of the buccal shelf area is covered by a layer of cortical bone. This, plus the fact that the shelf lies at right angle to the vertical occlusal force, makes it the most suitable primary stress bearing area for the lower denture. - The external oblique ridge does not govern the extension of the buccal flange because the resistance or the lack of it varies widely. The buccal flange may extend to the external oblique ridge, up onto it, or even over it depending on the location of the mucobuccal fold. - The bearing of the denture on the muscle fibers of the buccinator wouldn't be possible except for the fact that the fibers run parallel to the border and not at right angle. - The distobuccal border must converge rapidly to avoid the action of the masseter which pushes inward the buccinator. - The distal extension is limited by: * The ramus * The buccinator * The pterygo-mandibular raphe * Superior constrictor muscle * The sharpness of the boundaries of the retro-molar fossa. ( the denture should extend slightly to the lingual into the pearl shaped retro-molar pad). - The retro-molar pad is a triangular soft pad of tissue. It's mucosa is composed of thin, non-keratinized epithelium. Its submucosa contains: * Glandular tissue.

* Fibers of the buccinator and superior constrictor. * Pterygo-mandibular raphe. * Fibers of the temporalis. Because of these structures the denture base should only extend to one half to two thirds of the retro-molar pad.

The Retro-molar Pad: It is split into two sections. The anterior section is usually firm and fibrous, it's important for denture support and preventing distal displacement.

The Mylohyoid Ridge: It becomes more prominent following the extraction of natural teeth and subsequent resorption. This can result in mucosal soreness beneath the denture bearing area over the mylohyoid ridge.

When we talk about the mylohyoid muscle why do we look for the S shape? Because of the way the mylohyoid muscle is attached to the bone; The retro-molar pad area is deep, so the denture can go slightly in, and so will be close to the bone. (The sulcus is close to the bone). While here the mylohyoid attachment is quite high, so the denture will be away from the bone (closer to the tongue). So close to the bone posteriorly, then away (towards the tongue), then down closer to the bone (because the muscle attachment is low there). (IN , OUT , IN) This is the nice S shape u get on your lower impression.

You get that S shape by properly manipulating the tongue, but you don't always get it, not because your technique is wrong, but because sometimes the anatomy is not clear (the place of the attachment, the resorption of the ridges). But we are talking about the ideal situation. "The doctor skipped many slides, but I wrote everyth. here, so u don't have to go back to the slides"

Notes about: The Mylohyoid Muscle: 1. It is a thin sheet of fibers and in a relaxed state will not resist the impression material. 2. Carrying the border under the mylohyoid cannot be tolerated. The contraction of this muscle will displace the denture. 3. Fortunately, the denture in the posterior area of the mylohyoid can beyond its attachment because the fold isn't in this area. 4. In the retro-mylohyoid fossa the border of the denture can move back toward the body of the mandible producing the S curve of the lingual flange. 5. In the anterior region, a depression (the pre-mylohyoid fossa) can be palpated, and a corresponding prominence (the per-mylohyoid eminence) is seen on the impression. The doctor played some videos about how to activate the muscles during impression making? But he refused to give them to us. Sorry about this Here are two videos that cover most of the information needed
http://www.youtube.com/watch?v=W87YVwMy4fo http://www.youtube.com/watch?v=Z3Um3z4Zo88