BIOLOGICAL CONSIDERATIONS FOR

MAXILLARY IMPRESSIONS

If dentures and their supporting tissues are to coexist for

reasonable length of time, the dentist must fully understand the

macroscopic and microscopic anatomy of the supporting and limiting

structures.

A thorough understanding of their role will determine:

1) The selective placement of forces by the denture bases on the

supporting tissues

2) The form of the denture borders that will be harmonious with the

normal function of the limiting structures around them.

It is convenient to regard the impression or fitting surface of a

denture as comprising two areas: - A stress-bearing or supporting area

and a Peripheral or sealing area.

MACROSCOPIC ANATOMY OF SUPPORTING STRUCTURES

The foundation for dentures is made up of bone covered by mucous

membrane, mucosa and submucosa. In the submucosa are the vessels that

carry blood to the basal seat and the nerves that innervate it.

Each type of tissue found in the oral cavity has its own

characteristic ability to resist external forces. This is important to the

maintenance of health of the tissues of the basal seat and the stability and

support of dentures.

1) SUPPORT FOR THE MAXILLARY DENTURE:-

The ultimate support for a maxillary denture is the bone of

the two maxillae and the palatine bone. The palatine processes of the

maxillae are joined together at the midline in the median. The two

palatine processes of the maxillae and the palatine bone form the

foundation for the hard palate and provide considerable support for the

denture. More important, however, they support soft tissues that increase

the surface area of the basal seat.

The center of the palate may be very hard because of the layer of

soft tissue covering the bone in the region of the median palatal structure

is extremely thin.

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 If the hard palate is less resilient than the soft tissues covering the

residual ridges, it should be relieved to prevent a tendency of the denture

to rock or the development of soreness in this region when vertical forces

are applied to the teeth. The relief for the median palatal suture and its

overlying raphe can be developed in the impression making or denture-

processing procedure or after the denture has been completed. The

various regions in the mouth that have special responsibilities for stress

distribution

The socket surrounding the roof of each natural tooth is the alveolus,

and the bony ridge that supports the teeth is the alveolar ridge.

The bony process remaining after teeth have been lost is the residual

alveolar ridge, which also includes, the mucous membrane that covers the

bone. The nature and relative thickness of the soft tissues in different

parts of the basal seat determine the amount of support these tissues can

provide for a denture.

2) RESIDUAL RIDGE: - The shape and size of the alveolar ridges

change when the natural teeth are removed. The alveoli become mere

holes in the jaw bones and begin to fill up with new bone, but at the same

time the bone around the margins of the tooth socket begins to shrink

away. This shrinkage or resorption is rapid at first, but it continues at a

reduced rate through out life. The resorption of the alveolar process

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causes the foundation for the maxillary denture to become smaller and

otherwise change shape.

If the teeth have been out for many years, the residual ridge may

become quite small and the crest of the ridge may lack a smooth cortical

bone surface under the mucosa.

3) STRESS BEARING AREAS: -

a) RESIDUAL RIDGE

b) RUGAE

c) GLANDULAR REGION OF HARD PALATE

a) RESIDUAL RIDGE: - It is the major or primary stress bearing area

in the upper jaw. The crest of the residual alveolar ridge is covered with a

layer of fibrous connective tissue, which is most favourable for

supporting the denture because of its firmness and position. The artificial

teeth will be placed near this ridge so leverage will be minimal.

b) RUGAE: - In the anterior part of the hard palate are irregularly shaped

rolls of soft tissue that serve no function in humans.

To avoid unseating of the dentures the rugae should not be distorted

during impression technique because rebounding tissue tends to unseat

the denture.

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c) GLANDULAR REGION OF HARD PALATE: - The glandular region

on each side of the midline in the posterior part of the hard palate. To aid

in retention this area should be covered by the denture, and because of

high resiliency at this site it wont provide significant support for the

denture.

4) INCISIVE PAPILLA: - It covers the incisive foramen and is

located on the line immediately behind and between the central incisors.

Its position varies in different patients. It is located on the centre of the

ridge after resorption has occurred in mouths that have been edentulous

for a longtime. Relief for the papilla should be provided in every denture

to avoid any possible interference with the blood and nerve supply.

5) POSTERIOR PALATEL AREA: - The posterior palatine foramina

are so thickly covered by soft tissue that they do not need to be relieved

except in extreme cases of resorption. A study of the bony portions of the

palate reveals many sharp spines, which are a source of trouble in ridges

with extreme resorption. These bony spines are difficult to locate when

they are covered by soft tissues of the palate.

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6) INCISIVE FORAMEN: - It is located in the palate on the median

line at the lingual gingival of the anterior teeth; it comes nearer to the

crest of the ridge as resorption progresses. Relief should be provided in

the denture to prevent impingement on the nasopalatine nerves and blood

vessels as they pass through the foramen. The location of the incisive

papilla gives an indication as to the amount of resorption of the residual

ridge and thus is an aid in determining vertical dimension and the proper

position of the teeth.

7) ZYGOMATIC PROCESS: - It is one of the hard areas found in

mouths that have been edentulous for a long time. It is also called

maxillary process and is located opposite to the first molar region. To aid

retention and prevent soreness of the underlying tissues relief is required

for dentures in this area.

8) MAXXILARY TUBEROSITY:-The tuberosity region of the

maxilla often hangs abnormally low because, when 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-hanging tuberosity is complicated by an excess of

fibrous connective tissue. This excess soft tissue can prevent proper

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location of the occlusal plane if it is not removed. In addition, rough

rough and irregular bone can be irritated by the denture base.

9) TORUS PALATINUS: - It is a hard bony enlargement that occurs

in the midline of the roof of the mouth. It occurs in about 20% of

population. Different types are:-

a) Soft tissue, loose and flabby

b) This layer of mucosal tissue covering the bone.

The extent of the forms can be determined by palpation and an arbitrary

relief shape that disregards the extent of this hard area should not be used.

Such a relief shape may rub the denture of part of its support area.

MACROSCOPIC ANATOMY OF LIMITING

STRUCTURES (peripheral or sealing area of a denture):-

The denture base should include the maximum surface possible

within the limits of the health and function of the tissues it covers and

contacts. This means that a denture should be made in such a way that

covers all the available basal seat tissues without causing soreness at the

denture borders and without interfering in the action of any of the

structures that contact or surround it.

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 The limiting structures of the maxillary basal seat can be analyzed

in different regions. The anterior region extends from buccal frenum to

the other on the labial side of the maxillary ridge and is called the labial

vestibular space. In this region three objective are apparent.

First The impression must supply sufficient support to the upper lip to

restore the relaxed contour of the lip.

Second- The labial flange of the impression must have sufficient height to

reach to the reflecting mucous membrane of the labial vestibular space

without distributing.

Third There must be no interference of the labial flange with the action

of the lip in function.

1) LABIAL FRENUM:- The maxillary labial frenum is a fold of

mucous membrane at the median line. It contains no muscle and has no

action of its own. This band of tissue starts to superiorly in a fan shape

and converges as it descends to its terminal attachment on the labial side

of the ridge. the labial notch in the labial flange of the denture must be

just wide enough and just deep enough to allow the frenum to pass

through it without manipulation of the lip. This fact should be taken into

consideration in the relief for this attachment. The denture borders should

not only be cut lower but also have less thickness adjacent to the labial

notch in the border of the denture. A shallow bead can be formed in the

denture base around the notch to help perfect the seal.

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2) ORBICULARIS ORIS: - It is the main muscle of the lips, lying

infront of and resting on the labial flange and teeth of the denture. Its tone

depends on the support it receives from the thickness of the labial flange

and the position of the arch of teeth.

3) BUCCAL FRENUM: - The denture border between the labial and

buccal frena is known as the labial flange. The buccal frenum is

sometimes a single fold of mucous membrane, sometimes double, and in

some mouths, broad and fan shaped.

It requires more clearance for it action than the labial frenum does. The

border of the denture should be functionally molded to fit exactly the

depth and width of this frenum when it is in function, being moved.

Inadequate provision for the buccal frenum or excess thickness of the

flange distal to the buccal notch can cause dislodgement of the denture

when the cheeks are moved posteriorly as in a broad smile.

4) BUCCAL VESTIBULE: - Is opposite the tuberosity and extends

from the buccal frenum to the hamular or pterygomaxillary, notch. 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

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maxilla. When the mandible moves forward or to the opposite side, the

width of the buccal vestibule is reduced. The size and shape of the

posterior part of the buccal vestibule are altered by the lateral movements

of the mandible.

5) HAMULAR NOTCH: - It is situated between the tuberosity of the

maxilla and the hamulus of the medical pterygoid palate. It is used as a

boundary of the posterior border of the posterior border of the maxillary

denture back of the tuberosity. The posterior palatal seal must be placed

through the centre of the deep part of the hamular notch, since no muscle

or ligament is present at a level to prevent the placement of extra

pressure.

6) PALATINE FOVEA REGION:-The Foveae palatinae are

indentations near the midline of the palate formed by a coalescence of

several mucous gland ducts. They are close to the vibrating line and

always in soft tissue, which makes them an ideal guide for the location of

the posterior border of the denture.

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 7) VIBRATING LINE OF PALATE:-It is an imaginary line drawn

across the palate that marks the beginning of motion in the soft palate

when the patient says ah. It extends from one pterygomaxillary notch to

the other. At the midline it usually passes about 2mm in front of the

foveae palatinae. This line should be confused with the junction of the

hard and soft palates, since the vibrating line is always on the soft palate.

This is not a well-defined line and should be described as an area rather

than a line. The distal end of the upper denture must extend at least to the

vibrating line. In most instances the denture should end 1 or 2 mm

posterior to the vibrating line.

MICROSCOPIC ANATOMY OF SUPPORTING TISSUES

The microscopic anatomy of the supporting tissues of the upper

impression will be described for the

1. Crest of the upper residual ridge, the 2. slopes of the residual ridge, and

the 3. Palatal tissues.

The mucous membrane covering the crest of the upper residual

ridge in a healthy mouth is firmly attached to the periosteum of the bone

of the maxillae by the connective tissue of the submucosa.

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 The submucosal layer, though relatively thin in comparison to other

parts of the mouth, is still sufficiently thick to provide adequate resiliency

for primary support of the upper denture.

The outer surface of the bone in the region of the crest of the upper

residual ridge may be compact in nature, being made up of haversian

systems. This compact bone, in combination with the tightly attached

mucous membrane, makes the crest of the upper residual ridge

histologically best able to provide primary support for the upper denture.

One should take advantage of the nature of this tissue when providing for

additional stress to be placed on the crest of the ridge of the upper jaw

during final impression making.

The soft tissue covering the hard palate varies considerably in

consistency and thickness in different locations even though the

epithelium is keratinized throughout. Anterolaterally, the submucosa of

the hard palate contains adipose tissue and posterolaterally it contains

glandular tissue. These tissues should be recorded in a resting condition,

because when they are displaced in the final impression they tend to

return to normal form within the completed denture base, creating an

unseating force on the denture or causing soreness in the patients mouth.

Proper relief of the final impression tray aids in recording these tissues in

an undistorted form.

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 The submucosa in the region of the median palatal suture of the

maxillary bones is extremely thin. The mucosal layer is practically in

contact with the underlying bone. Little or no stress can be placed in this

region during the making of the final impression or in the completed

denture if not the denture tend rock over the centre of the palate when

vertical forces are applied to the teeth.

MICROSCOPIC ANATOMY OF LIMITING STRUCTURES

1) VESTIBULAR SPACES

2) HAMULAR NOTCH

3) VIBRATING LINE

The microscopic anatomy of the limiting tissues of the upper denture will

be described for the vestibular spaces, the hamular notches and the

posterior palatal seal area in the region of the vibrating line.

1) Vestibular spaces: - A histologic section of the mucous membrane

lining the vestibular spaces depicts a relatively thin epithelium that is

nonkeratinized. The submucosal layer is thick and contains large amounts

of areolar tissue and elastic fibres. The nature of the submucosa in the

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vestibular spaces makes this tissue easily movable. Thus the labial/buccal

flanges of the upper impression can easily be overextended or

underextended.

2) Vibrating line: - The submucosa in the region of the vibrating line on

the soft palate contains glandular tissue similar to that in se the

submucosa in the posterolateral part of the hard palate. However, because

the soft palate does not rest directly on bone, the tissue for a few

millimeters on both sides of the vibrating line can be repositioned in the

impression to improve the posterior palatal seal.

3) Hamular notch: - The submucosa of the mucous membrane

contained within the hamular notch (the space between the posterior

part of the maxillary tuberosity and the pterygoid hamulus) is thick

and made up of loose alveolar tissue. Additional pressure can also be

placed on this tissue at the centre of the notch to complete the

posterior palatal seal. Space is provided in the final impression tray

except in the region of the vibrating line and through the hamular

notches before the final impression is made.

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CLINICAL CONSIDERATIONS OF MICROSCOPIC ANATOMY

A Knowledge of the microscopic anatomy of the oral mucous

membrane has direct clinical implications for dentists and directly affects

their success when they treat edentulous patients.

Histologically, removing the dentures from the mouth for 6 to 8

hours a day, preferably during periods of sleep, allows keratinization to

increase and the signs of inflammation, often found in the submucosa

when dentures are worn, to be dramatically reduced.

Nerves in the mucous membrane of the residual ridges in elderly

edentulous persons are greatly reduced, and those present are confined

mostly to the lamina propria adjacent to the underlying bone.

Alveolar and gingival arteries show signs of sclerosis. Age also plays a

major role in the ability of the oral mucous membrane to recover from

compression loading caused by pressures from the denture base.

The immediate changes in the form of the supporting mucous

membrane by pressures from the denture base seriously compromise

correction of the occlusion of dentures in the patients mouth or

correction of parts of final impression by the addition of impression

material directly to the defect rather than a remaking of the total

impression

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Residual ridge: - The portion of the residual bone and its soft tissue

covering that remains after the removal of teeth.

Stress-bearing area: - The surfaces of oral structures that resist forces,

strains, or pressures brought on them during function.

Rugae: - An anatomic fold or wrinkle of fibrous connective tissue located

in the anterior third of the hard palate.

Incisive papilla: - The elevation of soft tissue covering the foramen of the

incisive or nasopalatine canal.

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REFERENCES

1. Heartwell CM, Rahn AO :Syllabus of Complete

Dentures.ed 4.

2. Levin B :Impressions for Complete Dentures

3. Winkler S: Essentials of Complete Denture

Prosthodontics, ed 2

4. Zarb GA, Bolender CL, Hickey JC, Carlsson GE:

Bouchers Prosthodontic Treatment of Edentulous

Patients ed 10.

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 DEPARTMENT OF PROSTHODONTICS

Seminar on

BIOLOGICAL CONSIDERATIONS FOR

MAXILLARY IMPRESSIONS

Presented by

Dr. Ravi verma pothuri

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