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ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS

OF IMPRESSION PROCEDURES PRILIMINARY AND FINAL


IMPRESSION & PPS
If dentures and their supporting tissues are to coexist for a reasonable length
of time, the dentist must fully understand the macroscopic and microscopic
anatomy of the supporting and limiting structures involved.
MACROSCOPIC ANATOMY OF SUPPORTING STRUCTURES
The foundation for denture (DBA) is made up of bone covered by mucous
membrane, mucosa and submucosa. Each type of tissue found in the oral
cavity has its own unique ability to resist external forces. Therefore the
distribution of forces applied to the basal seat by the denture should be
planned in relation to the types of tissues found in various parts of the basal
seat.
Support for the maxillary denture
The ultimate support for a maxillary denture is the bone of two maxillae and
the palatine bone. The palatine processes of the maxillae are joined together
at the midline in the median suture.
The centre of the palate may be very hard because the soft tissues covering
the bone in the region of the median palatal suture is extremely thin. If the
hard palate is less resilient, it should be relieved to prevent a tendency of the
denture to rock and or development of soreness. The relief for the median
palatal suture and its overlying raphae can be developed in impression
making
Residual ridge
The shape and size of the alveolar ridge change when the natural teeth are
removed. The resorption of the alveolar margin is rapid at first, but it
continues at a reduced rate throughout life, and causes the foundation for
the maxillary denture to become smaller and change shape.
If a denture is made soon after the teeth are removed, the apparent
foundation may be large but it also may be tender to pressure. This is the
result of incomplete healing and lack of cortical bone over the residual
alveolar ridge.
Stress-bearing areas
The residual ridge and most of the hard palate are considered the primary
stress bearing areas in upper jaws. The crest of the residual alveolar ridge is
covered with a layer of fibrous connective tissue, which is most favorable for
supporting the denture.
The rugae in the anterior part of the hard palate are irregularly shaped rolls
of soft tissue that serve no function in humans. They should not be distorted
in an impression technique, since rebounding tissue tends to unseat the
denture. The rugae area is thinly covered by soft tissue and contributes to
the stress bearing role as well as retention, though in a secondary capacity.

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The third area of special concern is the glandular region on each side of the
midline in the posterior part of the hard palate. This region should be
covered by the denture, but it should not provide significant support for the
denture because of its higher resiliency.
Incisive papilla
The incisive papilla covers the incisive foramen and is located on the line
immediately behind and between the central incisors. It is located on the
centre of the ridge after resorption has occurred in the mouth that has been
edentulous for a long time.
Relief for the papilla should be provided in every denture to avoid
interference with the blood and nerve supply.
Posterior palatal area
The posterior palatine foramina are so thickly covered by soft tissues that
they not need to be relieved except in extreme cases of resorption.
Bone of the basal seat
Important components of the bone of basal seat include; the incisive
foramen, the zygomatic process, the maxillary tuberosity, sharp spiny
processes and torus palatinus.
Incisive foramen: Incisive foramen is located in the palate on the median
line at the lingual gingivae of the anterior teeth; it comes near to the crest of
the ridge as resorption progresses. Relief for the incisive should be provided
in the denture to prevent impingement on the nasopalatine nerves and blood
vessels.
Zygomatic process: The zygomatic or malar process, which is located
opposite the first molar region, is one of the hard areas in the mouth. Some
dentures require relief over this area to aid retention and prevent soreness of
the underlying tissues.
Maxillary tuberosity: The tuberosity region of the maxilla often hangs
abnormally low; when the maxillary posterior teeth are retained after the
mandibular molars have been lost and not replaced. Often the low hanging
tuberosity is complicated by an excess of fibrous connective tissues and
prevent location of proper occlusal plane if it is not removed.
Sharp spiny processes: Frequently there are sharp spiny processes on the
maxillary and palatal bones that are deeply covered with soft tissue.
However, in patients with considerable resorption of the residual alveolar
ridge, these sharp spines irritate the soft tissues left between them and
denture base.
Torus palatinus: A hard bony enlargement that occurs in the midline of the
roof of the mouth is called torus palatinus. It occurs in 20% of the population.
The relief provided in the palate should conform accurately to the shape of
the hard area.

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MACROSCOPIC ANATOMY OF LIMITING STRUCTURES (peripheral or
sealing area of a denture)
To follow the basic principle of impression making and to extend the
impression to cover the maximum area possible within the limits of the
health and function of tissues one must possess a thorough knowledge of the
functional anatomy of the limiting structures.
The limiting structures of the maxillary basal seat can be analyzed in
different regions. The anterior region extends from one buccal frenum to the
other on the labial side of maxillary ridge and is called the labial vestibular
space. In this region three objectives are apparent. First, the impression must
supply sufficient support to the upper lip to restore the relaxed contour of the
lip. This means the thickness of the labial flange of the final impression must
be developed. Second, the labial flange of the impression must have
sufficient height to reach the reflecting mucous membrane without distorting
it. Third, there must be no interference of the labial flange with the action of
lip.
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. The labial notch in
the denture must be just wide enough and just deep enough to allow the
frenum to pass through it.
Orbicularis oris
The orbicularis oris is the main muscle of the lips, lying in front 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.
Buccal frenum
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 its action than the labial frenum does. The orbicularis oris
pulls the frenum forward, and the buccinator pulls it backward.
The borders of the denture should be functionally molded to fit exactly the
depth and the width of this frenum.
Buccal vestibule
The buccal vestibule is opposite the tuberosity and extends from the buccal
frenum to hamular notch. The size of the buccal vestibule varies with the
contraction of the buccinator, the position of the mandible, and the amount
of the bone lost from the maxilla. When the mandible moves forward or to
the opposite side, the width of the buccal vestibule is reduced. The distal end
of the flange must not be too thick or the ramus will push the denture out of
place during opening or lateral movement of the mandible.
Pterygomaxillary (hamular notch)

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The hamular notch is situated between the tuberosity of the maxilla and the
hamulus of the medial pterygoid plate. The posterior palatal seal must be
placed through the centre of the deep part of the hamular notch. It is used as
a boundary of the posterior border of the denture back of the tuberosity.
Palatine fovea region
The fovea palatinae are indentation near the midline of the palate formed by
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.
Vibrating line of the palate
The vibrating line 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 hamular notch to the other. At midline it usually passes
about 2mm in front of the fovea palatinae. The vibrating line is not be
confused with the junction of the hard and soft palates, since the vibrating
line is always on the soft palate. In most instances the denture should end 1
or 2 mm posterior to the vibrating line.
MICROSCOPIC ANATOMY OF SUPPORTING TISSUES
The mucous membrane covering the crest of the upper residual ridge in a
healthy mouth is firmly attached to periostium of the bone of the maxilla by
the connective tissue of the submucosa.
The compact bone in combination with the tightly attached mucous
membrane, makes the crest of the upper residual ridge best able to provide
primary support for the upper denture.
The mucous membrane along the slopes of upper residual ridge is loosely
attached to the underlying bone and has non-keratinized or slightly
keratinized epithelium. So less stress is placed on the slope of the ridge
during making of final impression.
The soft tissue covering the hard palate varies considerably in consistency
and thickness in different location even though the epithelium is keratinized
throughout. These tissues should be recorded in rest position, because when
they are displaced in the final impression they tend to return to normal forms
within the completed denture.
The submucosa in the region of the median palatal suture is extremely thin.
Little or no stress can be placed in this region during the making of final
impression.
MICROSCOPIC ANATOMY OF LIMITING STRUCTURE
The microscopic anatomy of the limiting tissues of the upper denture will be
described for the vestibular spaces, hamular notch, and the posterior seal
area.
The mucous membrane lining the vestibular space is relatively thin and non-
keratinized. The sub mucosal layer is thick with loose areolar tissues and
elastic fibers which makes it easily movable.

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The hamular notch has thick submucosa with loose areolar tissue. Additional
pressure can always be placed on this tissue to complete the posterior
palatal seal.
The submucosa in the region of vibrating line on the soft palate contains
glandular tissue. The vibrating line can be repositioned in the impression to
improve the posterior palatal sea area.

ANATOMICAL & PHYSIOLOGICAL CONSIDERATION FOR MANDIBULAR


IMPRESSION PROCEDURE
The basal seat of the mandible is different in size and form from the basal
seat of maxilla. The mandibular basal seat contains anatomic structures that
are different from those found in the upper jaw. In addition, the nature of the
supporting bone on the crest of the residual ridge usually differs between the
two jaws. These variances often require major modifications in impression
procedure for the mandible. The presence of the tongue and its individual
size, form, and activity complicate the impression procedure.
The same fundamental principles are involved in the support of a mandibular
denture as are involved in the support of a maxillary denture. The denture
bases must extend as far as possible without interfering in the health and
function of the tissues.
The total area of support from the mandible is significantly less than from
maxilla. The available denture bearing area for an edentulous mandible is 14
cm2 where as for an edentulous maxilla it is 24 cm2.
SEQUELLE OF TOOTH LOSS
When the teeth are removed from the mandible, the alveolar tooth socket
tends to fill with new bone but the bone of the alveolar process starts
resorbing. This means that the bony foundation for a mandibular denture
becomes shorter vertically and narrower bucco-lingually.
The shrinkage of the alveolar process in the anterior region moves the
residual bony ridge lingual at first, then, as resorption continues, this
foundation moves progressively forward.
MACROSCOPIC ANATOMY OF THE SUPPORTING STRUCTURES
Support for the lower denture is provided by the mandible and soft tissues
overlying it. Some parts of the mandible are more favorable for this function
than others.
Crest of the residual ridge
The fibrous connective tissue closely attached to the bone is favorable for
resisting externally applied forces, such as those from denture. However, if
the underlying bone is cancelous, this advantage is mostly lost.
Buccal shelf
The area between the mandibular buccal frenum and the anterior edge of
the messeter is known as the buccal shelf. The buccal shelf may be very
wide and at right angle to the vertical occlusal forces. For this reason it offers
excellent resistance to such forces.
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The buccinator is attached in the buccal shelf of the mandible but they run
anteroposteriorly, paralleling the bone, and the denture does not resist the
contracting force of the muscle. The buccal shelf is the principle bearing
surface of the mandibular denture. It is covered with good smooth cortical
bone, which is usually at right angle to the occlusal forces.
Flat mandibular ridges
Many edentulous mandibles are extremely flat because of loss of cortical
bone. On the labial surface of the anterior region of the mandible several
muscles are close to the crest of the ridge so short flanges in the denture are
required. The bearing surface often becomes concave allowing the attaching
structures, especially on the lingual side of the ridge to fall on to the ridge
surface which requires displacement of these tissues by the impression. The
crest of greatly resorbed ridges is often at the level of foramina, the nerves
and blood vessels are easily compressed unless the area is relieved in
impression.
Bone of the basal seat
The configuration of bone that forms the basal seat depends upon that
includes; the stages of changes in the mandible, sharp mylohyoid ridge,
mental foramen, insufficient space between the mandible and the tuberosity,
low mandibular ridges, the direction of resorption of ridges, and a torus
mandibularis.
Stages of change in the mandible
As the alveolar process is progressively lost, the attaching structures
converge and thus the supporting surface of the denture becomes more and
more limited.
Mylohyiod ridge
Soft tissues usually hide the sharpness of mylohyoid ridge. The shape and
inclination of the ridge vary among edentulous patients.
Anteriorly the muscle attaches close to the inferior border of the mandible
and posteriorly it may flush with the superior surface of the residual ridge.
Mylohyiod ridge may be bulbous, irregular and severally undercut. Extremely
thin and sharp mylohyoid ridges are another source of soreness for
edentulous patients.
Mental foramen area resorption
Severe resorption of bone near mental foramen results in compression of
nerve and blood vessels if relief is not provided and may cause numbness of
the lower lip.
Insufficient space between the mandible and the tuberosity
The maxillary sinus enlarges throughout life if it is not restricted by natural
teeth or dentures thus moving the tuberosity downward. The angle of
mandible becomes obtuse by early loss of posterior teeth. Both of these
conditions cause loss of maxilla-mandibular space and insufficient space for
the teeth and denture bases.
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Low mandibular ridges
Lingually, on the greatly resorbed mandibles the bone has shrunk down to
the level of attachments of the structures in the floor of mouth which makes
the lingual flanges of the dentures more difficult to adapt.
Direction of ridge resorption
The maxilla resorbs upward and inward to become progressively smaller
because of the direction and inclination of the roots of the teeth and the
alveolar process. The opposite is true of mandible, which inclines outward
and becomes progressively wider. This progressive change of the mandible
and maxilla makes many patients appear prognathic.
Torus mandibularis
The torus mandibularis is a bony prominence found on the lingual side near
first and second premolar region mid between floor of mouth and the crest of
the alveolar ridge. It varies in size from a pea to hazelnut. The torus may be
covered by thin layer of mucous membrane, and for this reason may be
irritated by slight movement of the denture. It should be surgically removed
if relief cannot be provided.
MACROSCOPIC ANATOMY OF THE LIMITING STRUCTURE
Mandibular denture should extend as far as possible within the limits of
health and function of tissues that surround them. The same principle that
governs the extent of maxillary denture; but it is more difficult to apply to
mandibular denture than maxillary denture. It is because of greater range of
movement of structures that surround them.
Buccal and lingual borders
Mandibular denture should be wide back of the buccal frenum and narrow in
the anterior region. The mandibular labial frenum contains a band of fibrous
connective tissue; therefore frenum is quite sensitive and active and must be
carefully relieved.
The buccal frenum connects as a continuous band through the modiolus at
the corner of the mouth to the buccal frenum in the maxilla. These fibrous
and muscular tissues pull actively across the denture border, therefore
denture should extend less in this region and the impression must be
functionally trimmed.
Buccal vestibule
The buccal vestibule extends from the buccal frenum posteriorly to the
outside back corner of the retromolar pad and from the crest of the residual
alveolar ridge to the cheek. The buccinators action occurs in a horizontal
direction, so it can lift the lower denture even though the buccal flange of
denture will rest on its inferior attachment.
External oblique ridge and buccal flange
The buccal flange area, which starts immediately posterior to the buccal
frenum and extends to the anterior portion of the messeter, is nearly at right
angle to the biting force, thus providing the lower denture with its greatest
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surface for resistance to vertical occlusal forces. The buccal flange may
extend to the external oblique ridge, or up onto it, or even over it. However
palpation of external oblique ridge is a valuable landmark.
Masseter muscle region
The distobuccal borders of the mandibular denture must converge rapidly to
avoid displacement because of contracting pressure of the messeter muscle.
When the messeter contracts, it alters the shape and size of the distobuccal
end of the buccal vestibule.
The distobuccal of the mandibular impression encounters the action of the
messeter muscle.
Distal extension of the mandibular impression
The distal extent of the mandibular impression is limited by the ramus, the
buccinator fiber and the superior constrictor, and by the sharpness of the
lateral bony boundaries of the retromolar fossa. If the impression extends on
to the ramus, the buccinator and adjacent tissue will be compressed
between hard denture border and the sharp external oblique ridge. This will
not only cause the soreness but also limit the function of buccinator, which is
part of kinetic chain of swallowing.
Retromolar region and pad
The retromolar pad (a triangular pad of tissue at the distal end of the lower
ridge) must be covered by the denture to perfect the border seal in this
region.
Lingual borders
The Lingual extention of mandibular impression has been the most abused
and misunderstood because of the peculiarities of the tissue under the
tongue.
The mandibular impression is easily carried down along the bony surface into
the undercut below the mylohyoid ridge, since the mylohyoid muscle is a
thin sheet of fiber that in a relaxed state will not resist the impression.
However, extension of the lingual flange under the mylohyoid ridge cannot
be tolerated in function causing soreness and limiting function.
Mylohyoid muscle and mylohyoid ridge
An extension of lingual flange well beyond the mylohyoid ridge but not into
the undercut has the advantage. But if impression is made with pressure on
or slightly over the ridge, displacement of the denture and soreness are sure
to result from vertical and lateral stresses. If the flange is properly shaped
and extended, it will complete the lingual border seal in the retromylohyoid
fossa and guide the tongue on top of the flange.
Sublingual gland region
This region should be registered in the impression when the floor of the
mouth is raised.
Lingual frenum area
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This is sensitive area and comes closer to the crest of the ridge when in
function although at rest it is much lower.
Direction of the lingual flange
The lower border of the lingual flange runs parallel to the lower edge of the
mandible from the lingual frenum to the posterior end of the denture. This
makes the lingual flange short in the anterior region and long in the posterior
region because the crest of the ridge of the mandible turns up sharply as it
approaches the ramus.
Alveolingual sulcus
The alveolingual sulcus extends posteriorly from the lingual frenum to the
retromylohyiod curtain. Part of it is available for the lingual flange of the
denture.
The alveolingual sulcus can be considered in three regions.
(1) The anterior region
This extends from the lingual frenum to where the mylohyoid ridge curves
down below the level of the sulcus. Here a depression (the premyloyoid
fossa) can be palpated and a corresponding prominence (the premyolohyoid
eminence) can be seen on the impression.
(2) The middle region
This part extends from the pre mylohyoid fossa to the distal end of the
mylohyoid ridge.
When the middle of the lingual flange is made to slope toward the tongue, it
can extend below the level of mylohyoid ridge. Otherwise, it must end at the
level of mylohyoid ridge. If flange slopes towards the tongue and extends
below the mylohyoid ridge, the tongue can rest on top of the flange and aid
in stabilizing the denture on the residual ridge.
(3) The posterior region
This part of the alveolingual sulcus is retromylohyiod space or fossa. It
extends from the end of the mylohyoid ridge to the retromylohyiod curtain.
The denture border should extend posteriorly to contact the retromylohyiod
curtain when the tip of the tongue is placed against the front of upper
residual ridge.
When the lingual flange is developed in the impression, the border of the
flange has a typical S curve as viewed from the impression surface.

Lingual frenum and lingual notch


The lingual frenum is extremely resistant, active and often wide. It forms the
lingual notch in the lower impression. The impression needs functional
trimming so the denture will not create soreness of this sensitive band of
tissue.
Lingual flange
The combination of a typical arch form of the lingual side of the mandible,
the projection of the mylohyoid ridge toward the tongue and the existence of
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retromylohyiod fossa at the distal end of the alveolingual sulcus causes the
border of the lingual flange to assume typical S shape when viewed from
impression surface.
MICROSCOPIC ANATOMY OF SUPPORTING STRUCTURE
The microscopic anatomy of the supporting tissues will be described for the
crest of the residual ridge and the buccal shelf.
Crest of the residual ridge:
The mucous membrane covering the crest of residual ridge is similar to that
of upper ridge. It is covered by keratinized layer and firmly attached by its
submucosa to the periostium of the mandible. When the soft tissue is
movable, it must be registered in its resting position in the final impression.
The mucous membrane of the crest of the lower residual ridge when securely
attached to the underlying compact bone is capable of providing proper
support. However when the underlying bone is cancelous and spongy, may
not be favorable as the primary stress bearing area. The method of
incorporating space in the final impression is made to insure that proper
relief will be provided for the crest of lower residual ridge during final
impression making.
Buccal shelf
The bone of the buccal shelf is covered by a layer of compact bone which
makes it the most suitable primary stress-bearing area for a lower denture.
The method of forming the final impression tray allows additional load to be
placed on the buccal shelf when the making of final impression. The tray
comes into direct contact with the mucosa of the buccal shelf, and soft tissue
is slightly displaced as the final impression is made.
MICRSCOPIC ANATOMY OF LIMITNG STRUCTURE
The microscopic anatomy of the limiting tissue is described for the vestibular
spaces, the alveo- lingual sulcus, and the retromolar pad.
The mucous membrane lining the vestibular space and alveolingual sulcus is
quite similar to the lining of the vestibular spaces of the upper jaw. The
epithelium is thin and nonkeratinized and the submucosa are formed of
loosely arranged connective tissue fibers mixed with elastic fibers. Thus the
mucous membrane lining the vestibular spaces and alveolingual sulcus is
freely movable. The length and form of the lingual flange of the lower final
impression tray must reflect the physiological activity of these structures so
that their normal movement is not restricted and do not dislodge the lower
denture.
The retromolar pad lies at the posterior end of the crest of the lower residual
ridge. Because of its nature, the retromolar pad should be registered in a
resting position in the final impression.

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