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Anatomy of edentulous maxilla and mandible

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First of all I want to tell you that this lecture is very interesting lecture and as DR said it is very important to understand this lecture very well . only study it well .

Denture- bearing Area ( DBA) : We will discuss the anatomy of supporting areas of complete denture

In the maxilla we call denture bearing area Denture foundation but in the mandible we call it Denture Basal Seat .

- In any denture we have two types of area :

1.

Stress bearing areas or supporting areas (provide support to denture ) Peripheral or limiting areas (determine the periphery of the denture )

2.

- Maxillary denture foundation :

1.

It is made up of bone of hard palate and RAR (residual alveolar ridge) covered by mucus membrane .

2. The denture base must extend as far as possible without interfering with health and function of tissues so extension of the denture is limited by tissues.

For example if we over-extended the denture labially we interfere with orbicularis oris muscle.

The denture base rests on mucus membrane which acts as a cushion between the base and supporting bone ( this info from the book ).
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- Anatomy of supporting structures:

Mucus membrane : it is composed of mucosa and submucosa .

1.

Mucosa : it is stratified sqamous epithelium often keratinized underlying layer of thin connective tissue ( lamina propria) joining with submucosa.

2.Submucosa: - connective tissue varies from dense to loose areolar tissue and varies in thickness .

may contain glands , fat , mucle fibers.

- It transmit blood and nerve supply to the mucosa. - It attached to bone by periosteum

- Very important notes :

1.

The support of complete denture relies on two things :

- type of bone of denture-bearing area. - the thikness and consistency of submucosa :

1.

if submucosa is firmly attached to bone so it can withstand the pressure of denture -------good for support if submucosa is thin and loosely attached to bone so soft tissue will non-resilent , and mucus membrane will be easily traumazied ----- poor support.

2.

2. soft tissue is very important for support of complete denture . so the arragment finally is : mucosa----- lamina propria ----- submucosa---periosteum ----- bone

- Hard palate : 1. It is formed by the palatine processes of the two maxillae and palatine bone . 2. It covers with soft tissues varying in thickness.

Median sagittal suture : 1. It is the junction between two maxillae.

2.

We consider it relief area because soft tissue that cover it is thin although madian sagittal suture is on the palate but we consider it as Relief area .

3.

Relief area : it means that fitting surface of denture or the base of the denture doesnt have intimate contact with this area so we provide a little space for relief .

- Posterior palate : We cosider it primary stress-bearing area ( it means it provides the main support to complete denture during function )for two reasons: 1. The submucosa of soft tissue is firmly attached to bone . 2. Posteriotr palate is perpendicular to vertical forces and it is resistant to resorption. The submucosa of posterior palate is mainly contain minor salivary glands. - Anterior palate (rauge ) : It is mainly composed of fat tissues so this increase the displace ability .

We consider it as secondry stress bearing area for two reasons 1. Soft tissue is more displaceable
3.

Rugae is inclined so inclinations of this rugae are not perpendicular to vertical forces.

- Residual alveolar ridge (RAR) :

1.

Shape and size change after tooth extraction due to resorption if the patient wear denture or not .

2.

The resorption is a physiological not pathological process .

3.

The rate of resorption : it continues forever from time of extraction until patients death (allah yrhamo )

4.

The rate of resorption in the mandible is 3-4 times higher than in the maxilla and this is the reason why in most cases we suffer from supporting problems in maxillary arch .

5.

Most of resorption happen in the first three months of extraction after that the rate of resorption declined but it continues of significant amount until first year after that resorption happens with lesser rate .

6.

Direction of resorption in maxilla it happens upward , backward , inward because there is a palate which is resistant to resorption so most of resorption happened facially so

- the labial wall of the ridge goes backward - the lateral wall of the ridge goes inward - the vertical height shorten

the net result of that resorption is : 1. smaller maxilla

2.

lack of cortical bone so we will have spaces in the bone we call this type of bone cancellous bone (trabecular, spongy )

soft tissue is firmly attached to bone and it is perpendicular to vertical forces but we consider crest of RAR secondary stress- bearing area because the lack of cortical bones .
7.

slopes of RAR provide little support because they arent perpendicular to vertical forces (inclination ) and we have what we call it mucogingival folds ( junction between keratinized and non-keratinized mucosa )
8.

The arrow indicate to Muco-buccal fold or

Note: sometimes in tuberosity area we can find cortical bones this is why in some textbooks they consider tuberosity as primary stress- bearing area.

- Types of RAR and palate : Please refer to the pic on the slides from left to right i will explain the pictures.

1. The first picture on the left : This is the most favourable types of palate(horizontal palate) because it provides good support, stability , retention. We can see well-developed ridges .

2. The one on the right : v-shaped palate it is good for stability (can resist displacement during function ) but adhesion and cohesion are reduced so (good stability , reduced retention)

3. The second one in the left corner : We can see resorped ridges and more displacable soft tissue Poor retention because reduced surface area Poor stability because no resistant to retentional forces Poor support because most of the bones are lost

4. The last one : We can see developed ridges but we have undercuts , if we have undercuts we have the following : If undercuts are mild ---- good for retention If undercuts are moderate to severe specially if bilateral ----not good for retention either we need to do relief of the denture or surgical reduction of the ridges to avoid trauma and loss of peripheral retention.

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- Incisive papilla : 1. It covers incisive foramen or canal . 2. Indicator of amount of resorption If incisive papilla is closed to the crest of the ridge this indicate that significant amount of resorption happened

If incisive papilla is still higher than crest of RAR this indicate that the ridges are still good (little resorption)

3. It is considered as relief area 4. It is helpful in setting of teeth

The arrow indicate to : Incisive papilla Not incisive foramen why??? Because foamen in the bone only

Maxillary tuberosity (area posterior to third molar) : 1. Supportive area

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2.

May hang down and need surgical removal

3. Could be fibrous or bony enlargement

- Other relief areas: 1. Sharp spiny processes (it happens because of the resorption of the bone and we should relief the denture beneath it )

2. Torus palatinus : it just bony enlargement , and the soft tissue that cover it is thin so we consider it as relief area.
This is picture of torus palatinus be careful this is not osteosarcoma this is just benign bony growth or enlargement It is not uncommon thats mean it is common ( less than common) If it is too big like this picture we prefer surgical reduction not necessarily completetly removal .

- Anatomy of peripheral structures :

1.Labial sulcus or vestibule : From one buccal frenum to the other .

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The labial vestibule divided to right and left labial vestibule by the labial frenum .

2.

Labial frenum : fold of mucous membrane with no muscular attachment , because of this we need relief in the denture flange we call it labila notch and this notch shouldnt be wide from latral side to the other because we dont have muscular attachment in this region and for our luck as dentists (hahah) orbicularis oris muscle its fibers are run horizontal so whe this muscle contracts it doesnt dislodge the denture. As we know from anatomy we know what modiouls means Modiouls : it is the junction between the fibers of orbicularis oris muscle and buccinator muscle .

3.Buccal frenum : - Divides labial and buccal vistibues

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It could be single or double folds ( note that labial frenum is always single fold)

- Buccal frenum should have wide notch than on denture than labial frenum because of more movements

- Buccal frenum moves :

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1.

Up and down by levator anguli muscle

2. Posteriorly by buccinators muscle 3. Anteriorly by orbicularis oris muscle

If we dont provide sufficient room or space for this range of movement in the buccal frenum we will end up with frenum ulceration .

4.Buccal sulcus or vestibule : - From buccal frenum to hamular notch - Its size varies depend on : 1. Amount of resorption 2. Buccinator contraction 3. Masseter contraction 4. Coronoid process of mandible

- Usually this vestibule has the longest and highest space in the upper complete denture.
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Distal to it there is root of zygoma (soft tissue that cover it is thin so we need relief the denture ) how??? During border molding we ask the patient to open widely and move from side to side because if buccal flange of denture was thick , opening will be limited , trauma could happen , dislodgment of

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denture could also happen because of the thickness of the flange .

5.Hamular notch : 1. It is the area between tuberosity and hamulus of medial pterygoid plate .
2.

It composed of thick submucosa so it is compressible and this help in achieve posterior palatal seal (peripheral seal of upper complete denture)

3. The posterior extension of upper complete denture is hamular notch.

6.The vibrating line (ah line ): - It is an imaginary line from one hamular notch to the other - It is 2mm away from fovea palatinae
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Fovea palatinae : small identations in the anterior part of the soft palate formed by coalescence of gland ducts( arrow in pic)

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Denture extends to vibrating line or 1-2 mm posterior to it and extends into hamular notch
7.

Perygomandibular raphe:

It extends from hamulus to the top of disto-medial corner of retromolar pad area in the mandible ( buccinator musle when it turns medially behind retro-molar pad area it will merge with superior constrictor muscle of the pharynx in this raphe .

- It is very important in ID block.

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If denture manily lower is over-extended posteriorly trauma to the raphe could happen .

- Please look at these pictures they are useful

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This picture sammarizes every things:

1- Labial frenum 2- Labial vestibule 3- Buccal frenum 4- Buccal vestibule 5- Coronoid bulge 6- Residual alveolar ridge 7- Maxillary tuberosity 8- Hamular notch

Oh 25eeeran 5alsna anatomy of maxilla we will move to anatomy of mandible (eshrabo fnjan 2hweh w rja3o 3la tafree3) .

Anatomy of supporting structures :

Mandibular DBA ( denture-bearing area) = 14 cm square Maxillary DBA =24 cm square

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We notice that mandibular DBA is about half surface area of maxillary arch so this is why maxillary dentures are more successful than more mandibular dentures ( increase surface area ------ better retention ).
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Crest of RAR : keratinized mucosa and variable submucosa attachment it could be firm or loose , it contains cancellous bone so we consider it secondary stress bearing area .

RAR:

1. Shape and size change after teeth extraction due to resorption 2. Rate of resorption : it is 4 times faster than maxilla and as we know most of resorption happened after 3 months of extraction so we ask the patient to visit us after 3 months to be sure that we dont need to do relining to the denture .

3.
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Direction :

In the mandible the alveolar ridge and the base are not on the same level so after extraction the resorption takes place in the alveolar bone not the base .

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In anterior area : there is no palate to resist resorption as maxilla so ---- labial wall of ridge resorption happened backward
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Lingual wall of ridge it goes forward Net result is RAR becomes more forward

In premolar area : labial wall ---- goes lingually

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Lingual wall --- goes labially

But the crest of RAR stays static (in the same place )

- In the molar region : you dont have resorption from labial wall resorption from lingual wall ----- labially the net result : larger mandible ,smaller maxilla ( class III ) prognathic .

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In this pic we can see resorption that take place anteriorly

In this picture we see resorption that take place posteriorly

In this picture we can see the progressive resorption of maxillary and mandibular ridges makes the maxilla narrower and mandible wider. A and B represent the centers of the ridges notice that distance become greater as maxilla and mandible resorb.
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We know that after resorption we will end with sharp spines . Sometimes when the resorption is of significant amount the lingual fold ( soft tissue of

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floor of the mouth and submandibular gland duct underneath it ) , so when it becomes higher than the ridges it self it complicate the construction of lower complete denture .

Retro-molar fossa : it is the space between the external and internal oblique ridges.
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- The anatom of supporting structures :

1.

Buccal shelf (buccal flange area ):

- Boundaries : Medially ----- crest of RAR Laterally ----- external oblique ridge Anteriorly ---- buccal frenum Posteriorly---- retromolar pad
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The mucus membrane is loosely attached and less keratinized but because there are high amount of cortical bone and perpendicular to vertical forces we consider it primary stress bearing area

- Buccinators muscle fibers are horizontal so it doesnt dislodge the denture.

Note very important :

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In lower complete denture :

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The primary stress bearing area is buccal shelf area but The secondary stress- bearing area is crest of RAR

Left picture : the arrow indicate buccal shelf area Right picture : the dotted area is the buccal shelf area that extend from buccal frenum (A) to retromolar pad area (B) and from external oblique ridge to the crest of the residual alveolar ridge (C)

2. Mylohyoid ridge : - Obligue - It is close to inferior border of the mandible anteriorly

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- It is close to superior border of mandible posteriorly

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The mucus membrane over a sharp mylohyoid ridge will be easily traumatized by denture base .so we need to do relief to the denture base.

3.Mental foramen : - Indicator of the amount of resorption if it is very close to the crest of RAR this indication of severe resorption. - The mental nerve and blood vessels could be compressed by denture base unless relief is provided .

In the picture : A- Canine region B- Premolar region C- First molar D- Third molar In anterior area we see that mylohyoid muscle is close to the base of the mandible but in

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In some patients with severe resorption mylohyoid muscle becomes sometimes above the crest of the ridge

4.Genial tubercules :
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With resorption it become prominent so we need t do relief .

5.Torus mandibularis : - It is bony prominence - It found bilaterally and lingually near the first and second premolars.
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It covers with thin layer of mucus membrane so we need to do surgical removal of these tori because trauma could happen to the mucosa and peripheral seal affected also .

This is a picture of torus mandibularis as we said if too large like this we should do surgical removal

- Anatomy of limiting strctures : 1.Labial vestibule :

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From labial frenum to buccal frenum

- Length and thickness of labial flange vary

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Labial frenum : it contains band of fibrous connective tissue that helps attach the orbicularis oris muscle so labilal frenum is quiet sensitive and active .

2.Buccal vestibule : - From buccal frenum to retromolar pad. - The extent of buccal vestibule is influenced by the buccinator muscle .

The buccal flange may extend to the external oblique ridge up onto it or over it depending on the location of muco-buccal fold and sharpness of external oblique ridge.

Posteriorly the buccal vestibule must converge to avoid displacement by the contraction of masseter muscle ( anterior fibers of this muscle run outside and behind the buccinators muscle ) so we need to do relief .

Distal extension :

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1.

Retromolar fossa : it is the area between external and internal oblique ridges If the impression is overextend it can cause soreness and displacement of denture because pterygomandibular raphe during movement it will dislodge the denture anteriorly

2.Retromolar pad : - It is pear shaped soft tissue pad located at distal end of RAR - It contains thin non-keratinized mucosa - Submucosa contain glandular tissue and muscle fibers (pterygomandibular raphe and tendon of temporalis )

- The denture should cover to 2/3 over the retromolar pad .

The arrow indicate to retromolar pad area and pterygomandibular raphe.

Notice when buccal shelf turns to cover retromolar pad area (in that area we have only buccinators muscle) behind buccinators there is masseter muscle so when the

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patient bites masseter muscle contracts and become wider , it pushes buccinators muscle . so in some patient we need to do relief to flange of denture and we do this during border molding we press on tray and ask the patient to bite aganist our fingers so masseter muscle contarcts and we call this ( masseteric notch )

- In other patient we have tense mentalis muscle so we cant provide thick flange in this area it will dislodge so the flange of denture should extend to muco-buccal fold and some fibers of buccinators muscle will be under the denture.

3. Lingual border :
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The lingual tissues under the tounge are less resistance than labial and buccal and ar easily distorted.

Mylohyoid muscle :

1. It forms the floor of the mouth 2. It originates from mylohyoid ridge and inserted to hyoid bone 3. The ridge more prominent posteriorly so denture flange must parallel to mylohyoid muscle to avoid sorness (pain) , peripheral seal and tounge rests on the flange

4. Retromylohyoid fossa :

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It located posterior to mylohyoid muscle and it is bounded with Retromylohyoid curtain

The denture must extend to this fossa ( S-curve configuration )

5.Retromylohyoid curtain boundaries: - Posteriolaterally : superior constrictor - Posteriomedially : palatoglossus muscle - Inferior wall : overlies submandibular gland
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Medial pterygoid muscle can cause bulge in the wall of the curtain as masseter dose with buccinators

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In this picture sorry the letters are inverted B : buccinator muscle M: masseter muscle MP: medial ptyregoid PR: pterygomandibular raphe RM: ramus of the mandible SC: superior constrictor muscle RMC : posteriolateral portion of retromylohyoid curtain formed by the mucus membrane covering SC. If pic is not clear please refer to the book page 242 figure 14-

- The following picture may help you in understanding :

- Finally i advice you to refer to my tafree3on mytoothy because there are alot of pictures

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- Big greeting to my lovely dad ( miss you too much )

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This lecture is dedicated to my mother ( mam ,ground

me for the day of judgment , love you )

To my lovely niece muna ( your album manosh in Jordan is ready i am waiting you to grow uo to see it ) And to my lovely nephew (mahmood ( )allah y3enek hal fatrah btale3 asnan hahha )

- Big thank to our CR Bader Ali ( allah y3teek al3afyeh)

Deena (5arej altagteyeh) , haneen mind (sho mshan sho jab l jab 2affa 3leke hek bde eyake ) , haneen mohsen (welcome back nawarteena wallah ) , 7anan kateeb (thanks for everything)

My lovely friend ( Maram jaradat ) love you , ( 2thorah , nur ----always well ) , aya (allh y5alsek mn lsanek haha) , my partener in labs (nor t3ani love your smile , allah y3enek 3lye ) .

Special thanks to pharmacist 3yoosh (ra7 3leke el- film hah )

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Finally i wish that i explain lecture in understanding way .

This words make me stronger when i read it :

Never take some one for granted ,Hold every person Close to your Heart because you might wake up one day and realise that you have lost a diamond while you were too busy collecting stones." Remember this . always in life

- Wish you all the best in the your third year in dentistry here in just .

your collegue : Abeer Talal al-hamarneh