1|Page

In the name of Allah the most gracious, the most merciful

***Please return to the slides while studying, because I didnt have them when doing this lecture. -Today we will talk about the anatomy of the Edentulous Ridges. For the past two lectures we were going pretty slowly. Today we will be slow but you will see for the coming lectures how the dr will pick up slides quite quickly. So if you miss the reading assignments, you will have lot of reading to do by the time when we come to the midterm and final examination. "The reading assignment for the anatomy lectures from the text book are (pg211 to pg251)", this includes the impression procedure and the anatomy for the maxillary and mandibular arches. The anatomy for the maxillary arch is about 6-7 pages in the beginning of the chapter. Last week we talked about primary impressions and pouring up the primary impression. This week were working on making the custom trays to make the primary impressions so that next week you can make your final impression using materials that you will be using in the clinic. Ultimately ending with alginate impression or the impression compound for taking the primary impression, ,and finally ending with a primary cast which we used to make a custom tray. - When we talk about the anatomy of the maxillary arch, it will be a good idea to talk a little bit about the extra oral anatomy; not the extra oral anatomy that we used to, such as the extra muscle for facial expression and so on. Actually, some of the landmark that we will talk about when we talk about history examination of the patient.

2|Page

- There are specific landmarks that you are very familiar with. The first is the vermilion border of the lips; It is essentially the meeting of the oral mucosa with the skin ) ( vermilion = . . Vermilion borders are important because whether the lips have support from the dentures or not, determines whether the vermilion borders will be clear or more hidden or straight. When the lips are supported by teeth the vermilion border is more clear, however; with age or teeth extraction the lip get smaller.( , ) ** You can see the upper and lower vermilion borders in the picture. -You might be familiar with terms such as: mesio- labial groove and labiomental groove. All of these specific facial features become more expressed with age. If we dont have teeth support they become even more exaggerated. They are signs of age. - Why?? - Because we are losing essential facial support as we have no teeth. Not only we lose the support anterio-posterior and laterally, but also we lose the support as the jaws become closer and more approximate to each other. We lose anterior facial height " " So we have loss of facial tone. -Some patients can do quite a lot of facial expressions; you will be surprised how close jaws could be brought together!! The dr has seen patients who could bring their lower lips above their nose. The atrophy is continuous after extraction and it continues for life.The early the patient
3|Page

extract the teeth, the less bone they will have.The resorption will continue through the alveolar bone to the Basel bone. The bone is so cutinize that in fracture and dissolves by itself. ((

- Bone resorption means there is no support for the facial tissue. -Do you know what the Philtrum is? The Philtrum is essentially a small area in the midline in the upper lip ( .) But in the opposite of the philtrum we have something that is called columella. -The columella opposes the philtrum . So we have a depression in the upper lip. The columella is essentially below the bridge of the nose, it's the area between the nares " openings of the nose". It's like a column, and if you follow the columella down there is the philtrum . - The angle between the columella and the philtrum ,if there is adequate or sufficient labial support ,is supposed to be approximately 90 like the picture because we have a lip support with the other lip. What we attempt to see is that there is an angle between them. But If the patient loses his other lip support. What will happen? -The angle will become obtuse ( ,) the lip will lose it support. ) .( This is important fact when we actually set teeth we do (jaw relationship record).
4|Page

We talked about specific guidelines we must follow when we set the teeth and do jaw relationship record, one of the main guidelines that we look for is: this angle. Whats the main muscle in the cheek? It is the Buccinator. Behind the mandible ( ( we have the masseter muscle. We are just mentioning this because later on you will see that it functions in the denture in an indirect way. Those of you who have taken the lab have already heard some of the things that Im going to talk about today. Hopefully the repetition will help you. When we talked about the intra-oral anatomy of the Edentulous Arches (the maxillary and the mandibular), we essentially divided the anatomy into two parts: 1- A part which supports the denture (the denture bearing area, the support area). 2- Peripheral structures (the limiting structures around the denture). We said that the object of taking the primary or secondary impression is to register the entire surface area and the Edentulous Ridge, so that we have better support for the denture. Its in our interest and the patients interest to cover the largest area. If I cover a small area, and the patient chews the denture will hurt the patient in that area. The more support I have, the greater surface area, the better and the more comfortable the patient is. So Ill cover as much as of the Edentulous Arch as I can. As I said, if I enlarge this support area and I keep reaching the borders beyond the Edentulous Ridge Im going to run into the tissues that move because Ive muscles.

5|Page

We said that we have the Buccinator in the cheek and orbicularis oris around the opening of the mouth and posteriorly I have the soft palate and levator and tensor veli palatini, there are a number of muscles that attach the maxilla to the mandible into the tongue. And in the mandibular arch I have the tongue with extrinsic and intrinsic muscles. These tissues move and I cant extend the denture into this movement. Extending the denture to the movable areas leads to one of two things : 1- Dislodgement and movement of the denture which is uncomfortable to the patient. 2- The denture is relatively stable so it will cause trauma ( ( So I have a dilemma! I want to cover as much as possible but I dont want to go beyond the normal movement. These things are important when I talk about the impression, because as you will see the impression is taken in two stages: 1- Figuring out what the limiting structures are. (Border molding around the sides of the tray as you saw in the lab). 2- Then we take an impression of the whole area. So we have the external structure around the denture and then the denture bearing areas. Quick review to the things that we'll be talking about today: we can take a look at the palate, the residual ridge, the vestibule externally and the soft palate posteriorly. The prominence of bone as you know is what remains after the teeth are extracted; we said that it is called the alveolar bone or the residual bone. It constantly changes shape after extraction. And the way it resorbs or atrophies is very typical from patient to patient. The resorption occurs in specific directions, sometimes more resorption happens on the labial than the lingual side, while other parts resorbs from the
6|Page

lingual more than the labial, depending on the density of the bone and the anatomy of the bone in that area. At the end of the residual ridge in the maxillary arch we have two large prominences called the maxillary tuberosities (designated with the squares), sometimes they are small depending on whether they were removed during extraction. So essentially the residual ridge extends from one maxillary tuberosity to the other. The ridge can have different shapes, it can be prominent, atrophied, regular, irregular, symmetrical or nonsymmetrical. At the junction of the anterior part of the palate and the residual ridge you have the incisive papilla (the circle). The incisive papilla is essentially small prominence which over lays the exit of the naso-palatine nerve and blood vessels. Its a sensitive part, we dont like to load it, its what we call a relief area!! We dont want pressure in this area. If you feel the upper part of your mouth, just behind your central incisors you will find a small prominence, is the incisive papilla. Behind the incisive papilla in the anterior part of your mouth, we have an irregular area called rugae; we will talk about it in more detail.
7|Page

In the midline, at the junction between the palatine process of the maxillae and the palatine bones we have the mid palatine suture (mid palatine raphe). If we go further behind we will run into the soft palate, if we go further facially, we'll end up into a pocket like structure called a vestibule (sulcus). This is divided anteriorly and posteriorly into the labial sulcus and the buccal sulcus on either side. The labial sulcus is divided from the buccal sulcus by the buccal frenum on either side. In the middle of the labial sulcus we have labial frenum. In the back, we have the (Hamular Notch) which is a depression between the maxillary tuberosity and the hamular process of medial pterygoid plate. Microscopically the tissue found in the mouth on the residual ridge is a scar tissue. If you cut yourself the tissue will heal and it will leave a scar. When we extract teeth the tissue that remains after extraction is a scar tissue (healing tissue). It wasnt designed to withstand the force of a denture. Its important to understand this. The Edentulous mouth wasnt designed to support the denture. We take advantage of it to support the denture, but the tissue and the mucosa above it arent specifically designed for denture. It is a sensitive mucosa. You know that the tissue in the mouth before extraction is divided into keratinized and non- keratinized (masticatory mucosa and lining mucosa) or specialized mucosa (like the surface of the tongue where we have the taste bud). If you take a look on the maxillary Edentulous Ridge, you will notice that the entire palatal surface and the residual ridge are keratinized mucosa

8|Page

(masticatory mucosa), it will withstand a certain amount of friction even thought it wasnt specifically designed to have a denture sitting on top of it. The further out we go, were running to a junction. Masticatory mucosa is attached mucosa; its attached to the bone in the palate or to the residual ridge. However, when we go further out to the vestibule, there will be a junction at which the tissue is no longer attached. So, we have attached and un-attached tissue. We want to extend just onto the un-attached tissue but not much farther beyond. The un-attached tissue will be lining mucosa (no keratinization). Friction and movement of this part of the mouth might cause ulceration and trauma. Its not so much only that we want to extend to the extent of the muscle we also want to have support from tissue that can withstand friction and force. Whats underneath the mucosa? We have the sub-mucosa and mucosa have squamous epithelium, lamina propria and the sub-mucosa which has blood vessels , glandular tissue and adipose tissue and so on (It provides support). The thickness of the sub-mucosa varies in different parts of the mouth, and in our case it varies in the maxillary arch. Some parts of the arch have a thick submucosa, some of them have loose sub-mucosa and some of them have very thin area. Depending on the thickness of sub-mucosa, we'll find that some areas are designed well to stand stress from the denture while other areas are not! We need to relieve or avoid them from the denture so they wont cause pain, ulceration or friction in the patients mouth. We already said that in the incisive papilla area we have a group of blood vessels and nerves (a relief area). In the posterior part of the palate, we have the greater and lesser palatine nerves (we dont want a heavy load in this area either). Thankfully, we have thick sub-mucosa so it wont be a problem. In the midline palatine raphe, the mucosa is very thin, so it's a relief area. Depending on the tissue and the sub-mucosa, whether it's thick or thin you will see that some areas are considered primary stress bearing areas, areas
9|Page

are considered secondary stress bearing areas and some are considered relieve areas (we dont want to place force on them). If you look closely in some mouths you will actually see a groove (depression of the residual ridge), it indicates where the facial and lingual gingiva met after healing (like we said its a scar tissue). The position of this groove is sometimes helpful to us when we set teeth just as the incisive papilla is! It tends not to move that much so it's a good guideline of setting of the teeth. What can we see behind the maxillary tuberosity (the small depression referring to the slides? Its the hamular notch, it's a soft area with relatively thick sub-mucosa, the only thing that you can find here are tendinous attachments for two muscles of the soft palate which are the : levator veli palatini and tensor veli palatini. You cant extend the denture behind this area for a specific reason, because behind it we have a rigid tissue, it's called pterygo mandibular raphe. It attaches to end of the pterygoid hamulus of the medial pterygoid plate. ***In the body when you have a tuberosity or a prominence or attachment (attachment of the muscle) it's there for a reason. If you find the bone raised when looking at the skeleton and its not raised because there is tension on this area ,then it is usually attachment of muscle or a tendon. Pterygo-mandibular raphe : is an attachment from the hamulus down to the posterior part of the mandible in an area we call it retromolar pad" We will learn about it next week inshallah". Its not there for no reason, its a junction between muscles, its an anastomosis of two muscles, which are the Buccinator and the superior constrictor muscles. This tension allows the hamulus to move. If you want to look for the hamulus in a young child, you properly wont find it, it wont be very clear. Just like the mastoid process, it wont be very large.
10 | P a g e

Young children dont have large sternocleidomastoid muscles. These bones tempt to be larger and more prominence and angular as time goes on. There is tension on these areas. So, back here we have bony process and in the end of the bony process we have pterygo mandibular raphe. So, I cant extend beyond here because I essentially have pterygo mandibular raphe and beneath it cant press so much because I have the thin attachment of the soft palate muscles. However, the (Hamular Notch) is important because it delineate the posterior part of the denture. posterior part of the denture is very important.

-The junction between the hard and soft palate is not the end of the denture, I extend my denture just beyond the anatomic junction between the hard and soft palate, just onto the soft palate. How far is the soft palate? Thats determined by which part of the soft palate moves. We know that the soft palate goes up and down, it closes up the nose from the oropharynx and closes up the mouth from the nasopharynx when we breathe or eat. This movement will end on the soft palate not the hard palate, that means that I can take an advantage of the soft palate to determine the end of my denture. And usually the junction between the movable and the unmovable parts of the soft palate is called the vibrating line . Because the soft palate moves when the patient speaks or say aaaah , we take a look inside the patient s mouth and then we can see parts of the soft palate in this area vibrating ,here where we want our denture to end. The dr will
talk more about why we reached that point in the end of the lecture.

11 | P a g e

If we go posterior, the (Hamular Notch) on the bone will be about their referring to the slides . Its difficult to see and not every patient has a prominence tuberosity, usually well take an instrument like a mouth mirror or a blunt instrument and run it along the residual ridge until the instrument drops. When it drops we know weve reached depression we want. The vibrating line is not always visible as some of these clinical pictures. So, here we have the imaginary vibrating line which we said is usually not on the hard palate, its just into the soft palate , to find it we I do one of 2 things: I ask the patient to say aaaah and I look inside the mouth and I see where the motion stops and ends I take an advantage and use a special pencil (copier pencil) and I mark it inside the mouth to see which part of the soft palate moves and which part of the soft palate remains stable. And also can take an advantage of certain anatomic landmarks. We know there is small depression in the posterior part of the palate whichs called Fovea Palatine. The Fovea Palatine is usually located 12mm behind the vibrating line. When we see Fovea Palatine we mark them and we know where the vibrating line is , just in front of the Fovea Palatine by 1-2mm. we use a a copier pencil to mark so when I put a custom tray in the patients mouth, the denture it will imprint from the patients mouth into the custom tray and then I remove the excess. So, this is a primary impression, if I want to know the exact line in the primary cast where the line is? I can even imprinted on the primary impression before I take the impression
12 | P a g e

( , )custom tray And usually we take it at different stages during the fabrication of the denture. Like I said we take advantage of these Fovea Palatine. What are Fovea Palatine histologically?? They are essentially grooves at the mucous minor salivary gland. They dont have that much significant in the mouth except they provide good landmark to find the vibrating line. (In the posterior end of the denture). You will notice that the posterior part of the denture there is different types of compatibility. We said that the significant of the limiting structures is not the fact that we dont want the movement of the muscles to cause a displacement in the denture. We said that the way the denture remains inside the patient mouth is very significant, Do you know how exactly the denture is retained inside the patient mouth?. 1- Pressure 2- Some students said that we use some kind of glue to stay in its position (dr said we dont use adhesives to prevent the denture falling by the gravity 3- Physical forces that keep the denture in the mouth like (adhesion and cohesion) ( ) however in the mouth, this not enough, it is there, it helps us but its not enough to keep the denture in the patients mouth while the patient chews, speaks, shouts and whatever . It is there, it helps but it is not significant. Sometimes, we have mechanical retention. In some mouths we have prominent bone; we can keep the denture over the prominence but it is not permanent in every mouth and we cant take an advantage in every mouth even if its there. We said the primary method of the denture will remain in the patients mouth according to the Physical forces there is something called peripheral seal (
13 | P a g e

) ! which we have a suction force, the patient faces the denture in mouth it sequences in a very small amount of air out. Now, the pressure underneath the denture is less than in the surrounding environment. If the patient tries to remove it, the pressure will be come less and it will be retaining more. So, we have negative atmospheric pressure underneath the denture. How can I keep the area seal? ( ... ) .. What I have is, Im very fortunate the limiting structures in the labial vestibule and a buccal vestibule are already there, I have the cheek buccally and the lip labially. Posteriorly, I have a problem because I dont have a muscle that comes down. I have a soft palate which moves but I dont have an actual muscle that comes down and helps the denture. So, what I said in the lab is the vibrating line is important because I dont want to extend on to the movable parts that of the soft palate but I want to go back as far as possible in order to extend the denture onto tissue that I can press up. The back part; the posterior part of the denture is made so that it compresses slightly into the tissue ( .. so the back end of the denture will actually stick into the tissue not a lot it wont hurt the patient it only goes half mm in the back. So, the around cheeks and the lips they will come down and they will create a seal. In the back, because the soft palate doesnt come down like that so what I want you to do with the denture is to go up into the soft tissue. So, the significance of the vibrating line is 1-I wants to go as far back as possible to make maximum coverage without going into mobile soft palate. 2- I want to meet the soft palate because I need soft tissue to be able to go into it. If I end the denture in the hard palate the tissue is very thin so I cant compress it without cutting or traumatizing the patient so locating the vibrating line is very important thing to create the seal it is called border or peripheral seal. It will give me retention for the denture.
14 | P a g e

4- Physiological forces/retention (muscular control): some patients even if the denture doesnt stay in the mouth by itself, they are able to keep the denture in their mouth just by trapping it between the muscles ( ) Buccinator and orbicularis oris ( ) this varies from one patient to the another. Some patients can control the denture and brace it and other patients are unable to do that) .so we try to make the denture as retentive as possible by itself as much as possible without burden the patient. The Physiological forces/retention from muscle is more important for the mandibular arch than the maxillary. The palatal form is different from person to person, some people are tall some people are shorter. The soft palate is sometimes more horizontal in some patients or more vertical in others . These positions make it easier or more difficult for us to create the posterior seal ( ) so the horzintal is class l , the vertical is class lll and class ll is the one in between , the most favorable is class l ~ House classification for soft palate form -In general, class I represents the gentle movement, class III represents the excessive movement, while class II lies in the middle.

-The tuberasity as you can see it can be very large. If the last teeth to be extracted are the molars sometimes with time the teeth supra-erupt. ( ) if I remove one tooth, the teeth they will lose the balance and drift or they will lose the balance and there will be a space. If I remove the lower tooth without removing the upper tooth sometimes the upper tooth will
15 | P a g e

drift and go down with the bone. Sometimes, if I leave posterior teeth too long, the tooth will super-erupt and will bring the bone with it. Sometimes, I end up with maxillary tuberasity thats so large that they come down and touch the lower arch. In such cases we do surgery to reduce the amount of bone, we have too much bone in this case. (the tuberasity is too large they went for surgery the above picture) -the residual ridge is important but the part of the hard palate is also important. Which shape do you think is better or more suitable to support the denture?? If you take these different examples, remember you need a residual ridge. So, the U-SHAPED palate is the best one because you have a residual ridge at the end to provide some stability from side to side. This one IS EXCLLENT retention but there is nothing on the sides; slight movement may hurt the peripheral seal. The rounded is acceptable. The V-shaped properly the poorest. The ridges how they can be? Sharp, rounded, prominent or undercut. A nice well rounded ridge is properly the best type. Nice ridges are properly a good support for the denture it wont cause pain at the vestibule of the ridge. Sometimes the tissue is so soft that moves you will found that the bone unlike what you might think = atrophy is much faster than the soft tissue. () so, when the bone resorpes , it means that the soft tissue, what will happen?? The tissue will become loose just like someone whos very healthy they lose weight so they become thinner suddenly then the clothes will be loose. In
16 | P a g e

the mouth this is the situation. I the mouth, the bone resorpes then the ridge become loose in some cases, in these cases its very important to remove excess tissue or we take an impression in a very special way. The labial vestibule on the maxillary arch is not significant as in the mandibular arch. Like I said we have buccal vestibule and the labial vestibule (which is divided by the Buccal Frenum- sometimes there is one frenum or there are two frena/frenum). Posterior to the buccal frenum beneath the vestibule you can spot a solid buccal bone (support) from the zygoma, this doesnt usually affect the fabrication of the denture unless there is a large amount of resorbtion in the ridge besides the zygoma there is another landmark that we must take into consideration when making a denture which is the coronoid process (found outside the maxillary tuberosity, the coronoid process comes forward when the jaw is opened completely (this movement must be taken into account when making the denture). Recall from your Head and Neck Anatomy Lectures the major muscles of facial expression: The Buccinator , the orbicularis oris and mentalis. All the major muscles of facial expression anastomose (join together) at the corner of the mouth; this anastomosis is called the modulus. The modulus is significant because it overlies the buccal frenum, so when the Buccinator pulls the cheek back, the buccal frenum will go back and when the orbicularis oris contracts the entire modulus ( ) when the patients smile the modulus will go up. This means when we make an impression we need to be careful in the area of the buccal frenum, we must create a notch in the denture that allows the buccal frenum to move freely without restriction. ( ))

17 | P a g e

Earlier we mentioned that the mid palatine raphe is important because the underlying tissue Is very thin, in the median suture of the midpaltine raphe sometimes there is a protrusion present called: Torus Palatinus, is is basically an excess of very compact dense bone found in one every five patients. The size of these Torus differ (can be small or very large) but the tissue underneath the bone is very thin, meaning that any excessive pressure in this area will cause trauma and irritations to the patients therefore we cannot rely on this area as a Denture support area because of patient sensitivity as well as the fact that its not present in most patients. Attempting to remove the Tori will lead to formation of heavy scar tissue and cause irritation. In fact there is Tori in the mandible usually lingual to the canine (not a tumor just a bone)( ) We only remove it in some cases when its too big and causes interference with removal/placement of the denture. Finally we will discuss the direction of resorption ( .) In different parts of the mouth the bone have different angulations. In the upper anterior part of the mouth the teeth & the alveolar bone are slightly proclined at around 15Degrees. ( ,) 51 , in the upper posterior part of the mouth the molars are angled very slightly outward so you can see the direction is towards the buccal (the alveolar bone of the posterior molars follows in the same angulation), the lower anterior teeth & alveolar bone are angulated slightly outwards. The only exception to this rule is the lower posterior teeth which are angulated in an inward direction (toward the tongue not toward the cheek) because they are trying to balance out the upper teeth which they are angulated outward. ** Lower posterior teeth are the only teeth that are angulated inwards.
18 | P a g e

Recall from the curves of occlusion that the occlusal plane is curved. (Curve of monson , curve of spee and the sphere of willson). When we extract a tooth the alveolar bone beneath it will become shorter, Compare the crest of the ridge before extraction and after extraction. Did it move towards the palate or toward the cheek?? It moved towards the Mandible. ( ,) another example: This is the residual ridge before and after (referring to the slides) ( ridge . ( The middle of the ridge becomes shorter and inward (further palatal). This is the case for all the Edentulous Ridges (Ridge & Bone) except the posterior of the mandible mandibular posterior is going out and the maxillary posterior is going in (they are moving opposite to each other). You will find that the movement/resorbtion of the ridge has a significant in making a denture and it has a significant in where we put the. In the upper arch we will put the teeth outside the Edentulous Ridges to put them back before they were extracted. In the mandible, we will try to put them further in before they were extracted. **The lower posterior teeth are the only ones that resorb differently. **Maxillary Arch becomes smaller **Mandibular Arch anteriorly becomes smaller, Premolar area stays the same & posteriorly it will become larger.

DONE BY: RAWAN YOUSEF MAKAHLEH

19 | P a g e