ANATOMY AND PHYSIOLOGY OF THE EDENTULOUS MOUTH

UNDER THE ABLE GUIDANCE OF FACULTY MEMBERS

INTRODUCTION :
DuBrul stated that the assumption of bipedal posture had a major influence on the hominid skull and feeding mechanism. The fact that humans cannot maximally open their mouth with a pure hinge movement is one biomechanical manifestation of an upright posture,modern human dentition has ceased to be a selection factor in biologic evolution.

 So long as the vital function of respiration & digestion are subserved , the specific anatomic characteristic of the oral structures have no longer impact on survival they once had in anthropoid , prehominid and even extant primitive human societies. This factor permitted an expanding gene pool to occur resulting in enormous variability seen among human beings.Varibility in terms of tooth morphology , arch configuration and relative jaw size among patients can be appreciated by the development of clinical judgement, clinical skills & appreciation & concern for the uniqueness of each individual patient.

ORAL MUCOUS MEMBRANE:

Oral Mucous Membrane varies in structure from area to area and demonstrates adaptation to function for e.g the hard palate which has to withstand the forces developed during the mastication of rough foods the epithelium is normally keratinized, floor of the mouth which is protected from masticatory forces by the tongue the epithelium is thin & not normally keratinized.

 Oral habits as cheek biting can provoke a normally non keratinizing epithelium of the cheek to become thickened & keratinized.

 From Prosthodontists point of view it must be realized that there is a wide range in the consistency of the OMM for e.g patients with alveolar ridges covered with thick resilient mucous membrane , others have thin atrophic membranes with little subepithelial connective tissue.

 Moderate overextension of a denture flange in one patient will produce little discomfort , no ulceration & perhaps a hyperplastic response from the tissue in other patient there is early ulceration & little repair. An Overt systemic and local diseases that effect the integrity of the oral mucous membrane with advancing age the oral mucosa thins and gets easily abraded and patients may complain of dryness.

OSTEOLOGY:
The practice of Prosthodontics depends upon a precise knowledge particularly of maxilla & mandible.Living bone is a dynamic tissue in terms of internal structure as well as its external form. The concept of form & function can be understood if one considers that all bones are composite structures & each portion of them responds to somewhat different functional demands.

 The basal portion of the mandible is related to the needs of the inferior alveolar neurovascular bundle , where as the coronoid process depends upon intact and functioning temporalis muscle. The form of the mandibular angle is associated with the masseter & medial Pterygoid muscles & if these muscles continue to function normally the angular region wont appreciably change with age or following the loss of teeth.

 Occlusal & other forces on natural teeth are absorbed by hydrodynamic effect of tissue fluids, bound water & blood in the pdl Occlusal forces on natural teeth are transmitted to the alveolar bone. This mechanism helps in maintenance of the integrity of the alveolar processes. Teeth loss deprives this processes of the stimulus,under denture all loading is transmitted to the surface of the alveolar process as pressure it is believed that pressure on bone is one major factor in its resorption. Thus controlling excessive pressure on the ridges is an important consideration in complete denture construction.

 According to DuBrul the reason for the reduction in the circumference of maxillary arch is the oblique placement of the teeth in the alveolar process that is itself inclined laterally and anteriorly. On the mandible opposite situation occurs particularly in the posterior areas .thus the circumference of the lower arch tends to widen in edentulous patients.

 This difference in resorption pattern between maxilla and mandible leads to the appearance of prognathism & gross positional discrepancies between opposing residual ridges.

The Temporomandibular Joint

This joint makes up half the bilateral articulation between the mandible & cranium- The Craniomandibular joint. It may be functionally classified as a hinge joint with a sliding socket.Most of the hinge or ginglymus movement takes place between the mandibular condyle & its attached articular disc.

 The Sliding or Arthrodial movement occurs between the disc and the articular eminence of the temporal bone. The mandibular (glenoid) fossa does not normally participate in joint activities except for its anterior wall which forms the posterior slope of the Articular eminence. The functional bony elements of this joint viz. condyle and articular eminence have convex structures.

 The functional loads on the fossa are borne by the articular eminence , particularly its posterior slope. The Lateral Pterygoid muscle plays important role in determining where Condyle-disc complex is located on the eminence at any given moment. The lateral pterygoid s inferior belly influences the degree of retrusion of the condyle as it is a direct antagonist of this movement.

Role of Temporomandibular Ligament

With complete relaxation of the Lateral Pterygoid The final limitation of condylar retrusion is provided by the Temporomandibular ligament.(On lateral side of the joint). This ligament limits the ability of humans to completely depress the mandible with a pure hinge movement of the condyle.

 DuBrul implicates the Temporomandibular ligament in restraining the posterior movement of the lateral pole of the working side condyle During lateral excursion. The limiting influence of TML during lateral excursion compels a bodily shift of the mandible towards the working side as lateral excursion occurs & is called the Bennett Shift.

NEUROSENSORY AND NEUROMUSCULAR SYSTEMS

Oral and Mandibular functions are very complex & are controlled through the integration of neurosensory inputs; brain stem reflexes ; pyramidal ,extrapyramidal & cerebellar activities & the muscular and musculoskeletal response.Masticatory muscle activity is determined by rate and sequence of discharge of the alpha motor neurons located in the trigeminal motor nuclei of the brain stem.

 The firing of this final common pathway is controlled by facilitory & inhibitory influences acting on these motor neurons .When the critical firing level of nerve cell is reached depolarisation of cell membrane initiates an action potential that is propagated along the axon to the myoneural junction.When critical firing level of muscle cell membrane is reached Due to sufficiently released Ach, then depolarisation phenomenon occurs leading to contraction of the muscle cell.

ELECTROMYOGRAPHY
( Dr Robert Moyers, 1949 used it in dentistry for the first time. The sum total of electrical events produced by contraction of the motor units can be recorded by the use of Electromyography.

 Electromyography has demonstrated that mandibular elevation is produced by Temporalis, Masseter & Medial pterygoid & depression by the inferior belly of lateral pterygoids. & the digastrics. Lateral movements are performed by the ipsilateral temporalis & Masseter & contralateral medial & lateral pterygoids. Protrusion is effected by medial & lateral pterygoid.Retrusion is effected by Temporalis (posterior fibers),the digastrics & the deep part of the Masseter.

 It has demonstrated that mandibular elevator muscles show strong activity during swallowing, mainly in adult or somatic swallow (Occlusal contact normally occurs) After complete loss of teeth the infantile pattern of deglutition( Tongue is used to brace the mandible instead of dentition) is seen .The insertion of denture permits the patient to once again utilise the more normal adult swallowing pattern.

 Electromyography is also used to study Mandibular Reflexes. Masseteric silent Period-.Can be elicited by a tap to the chin while a subject clenches the teeth in centric occlusion. The short transient period of inhibition during the otherwise sustained contraction of the masseter muscles is termed Silent Period.The duration of this silent Period has been shown to be longer in groups of Pain-Dysfunction Patients.

 reflex a reflected action or movement; the sum total of any particular automatic response mediated by the nervous system. A reflex is built into the nervous system and does not need the intervention of conscious thought to take effect.

Jaw reflex

A spasmodic contraction of the temporal muscles following a downward tap on the loosely hanging mandible and seen in lesions of the corticospinal tract.

JAW OPENING REFLEX:

The Nociceptive Trigeminal Inhibition Tension Suppression System (NTI-tss) takes advantage of a protective reflex which suppresses the temporalis muscles from contracting with their fullest intensity. . Whenever the lower incisors are put under moderate to severe pressure, they signal the temporalis muscles to relax before pain and damage can happen to them. This is called the jaw-opening-reflex.

 It is designed to prevent us from putting something too hard into our mouth that may be damaging to our back molar teeth. The back molars, on the other hand, do practically the opposite. Whenever something comes in contact with them (like frozen-solid Snickers Bars, a piece of bone, or TMJ splints), the back molars signal the jaw-closing muscles to bite down hard (because they figure, since there's something between them; it must be time to chew!)

APPLICATION OF JAW OPENING REFLEX

Protects dentition & other intra oral structures from undue stress & injury During jaw closure. Involved in learning process in dentulous patient that permits the mandible to close in to a precise occlusal relationship when the head is upright.

 The jaw jerk reflex or the masseter reflex is a reflex used to test the status of a patient's trigeminal nerve (CN V). The mandible or lower jaw is tapped at a downward angle just below the lips at the chin while the mouth is held slightly open. In response, the masseter muscles will jerk the mandible upwards. Normally this reflex is absent or very slight. However in individuals with upper motor neuron lesions the jaw jerk reflex can be quite pronounced.

APPLICATION OF JAW JERK REFLEX

This reflex is used to judge the integrity of the upper motor neurons projecting to the trigeminal motor nucleus. Both the sensory and motor aspects of this reflex are through CN V. It is not part of a standard neurological examination. It is performed when there are other signs of damage to the trigeminal nerve.

Postural rest Position

The neuromuscular paradigm of finding the mandibular position of optimal physiologic rest is based on muscle physiologic laws that muscle efficiency is generated at a length that corresponds to a maximal overlap of actin and myosin filaments, which represents an optimal crossing bridging effect. Physiologic rest of the mandible is where the muscle fibers are normally near a passive resting length fulfilling the laws of muscle physiology and posture.

 Physiologic rest position can be defined as: The mandibular position vertically anterior-posteriorly and laterally when the head is in an upright postural position and the involved muscles, particularly the elevator and depressor muscles, are in equilibrium in tonic contraction. It is that position in space where minimal expenditure of muscle energy is needed along an isotonic path of mandibular closure that begins from the rest position of the mandible. This means that the extensor and depressor muscles that move the mandible are postured at a position that exert minimal electrical activity during resting modes. It is the reference position of the mandible from which diagnostic and therapeutic decisions are made.

 With the Mandible in postural Rest Position and with the head upright ( & looking straight ahead) an interocclucal distance or free way space of 2.5-3mm usually exists between the opposing teeth in the premolar area.

Application of PRP
Yemm reported that emotional stress or psychic tension increases muscle tone, an increase in the tone of mandibular elevators will decrease rest vertical dimension & consequently reduce inter occlusal distance. Thus psychological status of patient is important consideration in all stages of complete denture construction in which PRP is used as a reference position.

Cyclic Jaw Movement or Occlusal Gait

Cyclic jaw movement involves the sequential rhythmic depression & elevation of the mandible as occurs during mastication. Each person has an individualised pattern of cyclic movement. Cyclic jaw movement is controlled & coordinated by a CPG( central pattern generator) or chewing center in the brain stem.

 The dentulous person demonstrates smooth jaw motion during mastcation. Shape- Tear drop when viewed in frontal plain. Edentulous patient will have a distortion of this movement with the process becoming more random & indiscriminate. During closing path of cycle Dentulous subject will decelerate the movement just before tooth contact to dampen the effect of closure on the dentition.

 Edentulous patient will seem to elevate the jaw at a constant velocity with no deceleration near the end of closure. Edentulous patient wont develop the same isometric tension on dentures,that is attained by people with dentition a reduction of atleast 75% is reported.

REFERENCES
ESSENTIALS OF COMPLETE DENTURE PROSTHODONTICS- Sheldon Winkler.