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In the name of Allah most graceful most merciful Today we are going to discuss the anatomy of the mandibular ridge , and how its being different from that of the maxillary ridge . Although theres some degree of similarity between the upper and lower arches . for example , both have the labial and buccal mucosa , there are a lot of differences between them from many aspects such us : type of mucosa , the underline mucosa ,type of bone , the surface area , the bone and muscle attachment on the lingual surface . the presence of tongue greatly affects the way that the mandibular denture is made in comparison to the maxillary denture .

Last week in the lab , we have completed the first clinic , we have taken
the primary impression , then we have fabricated the custom trays .

This week in the lab , we took how to make the secondary impression
and did a demonstration for pouring up the secondary impression to have a final or secondary cast , so this week well complete the second clinic and part of the second lab .

Next week ,we will complete the second lab by making the record
blocks. The maxillary denture usually has a greater degree of success than the mandibular denture ,we are going to see why is that during this lecture. In the mandible , there is no palate . instead we have the tongue with very active groups of muscles , the extrinsic and intrinsic muscles and they will greatly affect the borders which we extend from the complete denture. As we know , for a good support we require the maximum denture bearing surface area , the presence of the tongue limits this extension , which reduces the support .

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And because we have greater active border in the mandible due to the presence of those muscles , they are going to cause displacement of the denture in the mandible . while in the maxillary arch , muscles affecting there such as the baccinator , orbicularis oris and others cause less effect , they are not that strong . tongue is a very powerful muscle and its much more active than the buccinator . So in the mandible , we have less surface area and more active muscles , that is why the mandibular denture is less stable . In the previous lecture , we said that after teeth extraction the alveolar bone ( or the residual ridge ) will continue to resorb . it atrophies according to a certain path , not randomly . The direction of resorption is related to the angulation of the alveolar bone , which is related to the angulation of the teeth were there before extraction . and almost everywhere in the mouth , the direction of the teeth is to the outward , proclined posteriorly and anteriorly in the upper arch and anteriorly in the lower arch . one exception to that is the lower posterior mandible . in the premolar area the direction is straight up . As the resorption occurs , different shaped ridge results . there is a difference in the amount of resorption between the types of ridges , usually residual ridge resorption occurs most within the first year after extraction. it continue to resorb throughout life , but at the beginning it is always faster than at the end , logically so because the amount of bone left becomes less at time goes on. An important thing to remember , another reason why the mandibular ridge is not well suited to support the denture , is that the mandibular residual ridge resorbs faster than the maxillary residual ridge .

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During the first year of resorption , the mandibular residual ridge resorbs twice as fast as the maxillary residual ridge . After that time , it resorbs four times faster , that means that within the first year both residual ridges are resorbing quickly . This creates imbalance between both arches . To summary, there are three reasons why the mandibular denture

creates problems ; less surface area , more active tongue muscles and faster resorption of the residual ridge .
Anatomical landmarks of the mandible is usually divided into static area and dynamic area; the denture bearing area which is the surface of the ridge , and the border where the muscle attachment occurs which are the dynamic structures limiting the borders of the denture , respectively . (The doctor is viewing a picture )In a sagittal view of the mouth , if we look at the anterior portion of the upper residual ridge , at resorption occurs , we go from the yellow to the blue to the green and finally down to the basal bone ( direction of resorption from up to down ) . You will notice that the center of the ridge progressively moves from facial ( or labial ) towards palatal . In the lower anterior portion is the same thing , after extraction the bone tends to go in a lingual direction . In all cases there will be reduction in height (vertical direction of

bone resorption ) wherever the bone is in both arches( . ) however, horizontal bone resorption differs depending on the region( , ) usually it goes from the anterior to the posterior so the arch becomes smaller , and this is logical because you can see the face of an old patient losing its support.

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Posteriorly in the upper arch the molars are proclined , having a buccal angulation . In the lower posterior, they have a lingual angulation , and the bone follows. So when teeth are extracted . ( from a picture ) if the center of the ridge was A and B, as time goes on we notice that the center moves further palately in the upper posterior and further buccally in the lower arch . and this is the main exception and it's really important when we set the teeth according to where they originally were . Without the understanding of where the ridge is and where it was before extraction it is difficult to put the teeth in the correct position , and the occlusion will be in reverse by putting the upper teeth too much toward the palatal and the lower teeth directed too buccally , and cross bite results. From the fact that the resorption in the lower arch is pretty fast , vital structures which are normally buried in the bone , become exposed affecting the borders of the denture . So borders of the lower denture is not only affected by muscle

attachment around the peripheries , but also by vital structures within the bone ; nerves and bony prominences .
(The doctor is viewing another picture)Notice the position of the mental foramen in relation to the premolar area , and how it gets close to the surface at time goes on , due to resorption . The bone sometimes gets so thin to a point that you will be able to

snap it between your fingers, or to cause cracks in it especially while taking a forceful impression !
The doctor is showing a radiograph in the symphysis region ( in the middle of the jaws ) showing a jaw with a new denture , and another radiograph showing the same jaw after a while of having the denture in , the denture appears radiopaque in both of the radiographs due to a certain material , just to see what happens to the denture as time goes
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on . in the first one , the denture is really large , and the internal surface of the denture is concave setting on the top of the ridge , notice what happens when time goes on , in the other picture , I have a flat surface setting on a flat surface, wheres the stability ! Its difficult to compare natural teeth to the mucosa after extraction , the reason is that this mucosa was not designed to withstand the force of a denture , technically its a scar tissue formed at the junction between the buccal and lingual gingiva after healing , so its a not normal healthy mucosa . it was designed to take a tension force not compression . normally when we chew , food passes across the ridge or the buccal mucosa and come on contact with it ( tension) but not compressing on it , we dont use our mucosa to smash food . In natural teeth , the roots set within the bone through a very specialized attachment that is the Periodontal Ligament , and the direction of the fibers is very well designed for Biting force , it transmits the compression to tension , the oblique fibers ( ) are stretched when the patient bites , only at the apex this does not happen because the force it takes is compression , but usually along the periodontal ligament fibers are well designed to take an occlusal force . so the direction of fibers( and the receptors they have ) in the PDL

is much better designed for axio- occlusal force than normal mucosa , though its total thinner but there is muchbetter sensory perception in PDL .
from book (page 9 ) : periodontal ligament provides the means by which force exerted on the tooth is transmitted to the bone that supports it , the two principle function of the PDL are support and positional adjustment of the tooth , together with the secondary and dependent function of sensory perception .

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But even if we take this point aside >>> which is that 1 square cm of PDL is not equal to 1 square cm of mucosa by means of effectiveness ( , ) its less than edentulous mucosa . however , if we stretch the PDL of all teeth forming a flat surface area , it has been found that the dentulous maxilla has a PDL surface area of about 45 square cm and the same in the mandible . however the edentulous mucosa in the maxilla is double that in the mandible , and the maxilla is half that of natural dentition . so the mandibular edentulous surface area is about the original surface area of the PDL . we conclude that the support from the edentulous mucosa is not very effective . we can tell from these numbers that the mandible is very bondable and its not well suited to support the denture . Stress bearing area : Theres a very important part of the anatomy of the mandible and that is the Buccal shelf area ; it is located in the posterior buccal sulcus , the borders of this area are laterally : the external oblique ridge at the attachment of the buccinator , medially : the crest of the residual ridge , anteriorly : the buccal frenum and posteriorly it extends to the pterygomandibular raphe which is located posterior to the retromolar pad. The buccal shelf area is important because it is the area of the residual ridge that is compact and have strong bone and instead of being sharp at the tip , it is horizontal . if we take a look at the residual ridge we will find that the type of bone on the crest is Cancellous bone(not very strong). the crest of the ridge can take force but not to the best degrees due the type of tissue and bone there . and some types of ridges are very thin and very narrow . The pterygomandibular raphe has to some degree pressure from

the masseter and buccinator muscles and forms the posterior border of the buccal shelf area .

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 So this area is good for the denture support , because : 1- It is more horizontal than vertical . 2- It has a compact type of bone . Even when resorption occurs , this area does not resorb very much . as ridge resborbs the buccal shelf tends to look like its larger . so we have two shelfs at the sides of the jaw that regardless of what happens to the rest of the ridge provides us with some support to the mandibular denture . External oblique ridge is the attachment of the buccinator muscle. We can go slightly beyond this attachment because there are horizontal fibers there where we can press without affecting the movement of the denture . Pterygomandibular raphe is the point where the superior constrictor muscle meets the buccinators ( this is what the doctor was showing in a horizontal section of the patients head ). After the teeth are extracted the depth of the sulcus also changes with the atrophy of the ridge . The fibers of the buccinators inferiorly tends to be more horizontal than diagonal , this means that the fibers will contract anterio-posteriorly not superior inferiorly , when they contract they will have less affect on waving the denture . so to get more surface area , its found by experience that we can encroaches on the buccinator attachment by a 12 mm to cover more area of the mandible . the mylohyoid ridge : it is on the buccal surface , it is the attachment of the mylohyoid muscle , which runs from the internal surface of the mandible to the hyoid bone . its function is to raise the tongue when we swallow , when we swallow the floor of the mouth rises (and so does the tongue) this is due to
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contraction of the mylohyoid muscle . the ridge of the attachment will effect the borders of the muscle , the ridge itself creates a problem .

when extending the lingual flange , we can only go to the muscle attachment , beyond that we will go over the bony ridge , and if the border of the denture reaches there it will hurt the patient because its passing over this ridge . So the location of the mylohyoid ridge and the contraction of the

mylohyoid muscle has a significant affect on the lingual border of the mandibular denture .
so if we take a look from underneath the mandible, we can see the mylohyoid is on the right and left , and that the attachment of this muscle is different anteriorly than posteriorly ; anteriorly the mylohyoid attachment is closer to the lower border of the mandible , whereas posteriorly it is closer to the crest of the residual ridge .

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 The main effect of this muscle on the border of the denture is posteriorly more than anteriorly , in the middle of the lingual flange region . in the anterior part the main effect is from the lingual frenum , and we can extend it anteriorly as long as we dont encroaches the lingual frenum . however , as the flange go posteriorly it should be raised due to the presence of the mylohyoid ridge .

The premylohyoid fossa : It is the region infront of this rising of the lingual flange . it is located posteriorly to the mylohyoid muscle . it is like a pocket between the tongue and the bone infront of the premylohyoid eminence . The retromylohyoid fossa : is the area behind the premylohyoid eminence. And these structures are important for the border molding and the border of the denture, they affect the peripheral seal and stability of the lower denture .
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There is this pocket between the tongue and the ridge , the floor of this pocket is the submandibular gland . we have to go all the way back to reach the muscles ; the superior constrictor and the palatoglossal which attaches the tongue to the palate . This pocket area has no muscles ( It is behind the mylohyoid muscle and in front of the palatoglossal) and in this area the flange goes down and it is free to move there . There are other structures within the bone ( not only the mylohyoid ridge ) which are normally buried in the bone like nerves and blood vessels , and that when the bone resorbs might get exposed and become more apparent . the mental foramen is a common one , which is located in the canine, 1 & 2nd premolar area . As the bone gets down, the nerve coming out of that foramen in the bone becomes near the surface . so to a patient who is wearing denture , when such thing occurs , it will become very annoying that everytime he bites it presses on the nerve . this is also a reason why a lower denture is less comfortable than an upper one ! In some cases when this continues , numbness from the nerve,

parasthesia and sometimes anesthesia may result.

So at the extreme cases the mental foramen becomes on the top ( the doctor is showing a picture of that ) . We have to relief this area and provide alternative ways of support , benefiting from the buccal shelf area and sometimes a bone compensation procedure is needed or by using dental implants to raise the support away from the bone towards something else . In very sever cases , the inferior dental nerve becomes exposed at

the top , it appears as a grey line on the surface of the residual ridge in the radiograph .
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Torus mandibularis : it is present in only 1 out of 5 people , it varies in size , located in the lingual surface of the 1st and 2nd premolars . this structure even it is a compact bone with irregular shape it is covered by a very thin layer of mucous membrane , and that creates problems because lingual flange of the denture can not be extended to that area . If the size of torus mandibularis is large , they have to be surgically removed , if they are small , we have to work around them and relief under this area . the doctor showed a picture of a patient having tora mandibularis ( more than one ) extending all the way to from premolars to molars area , this is an extreme case . Remember understanding the anatomy of the borders of the denture

will affect the way we border mold , the way we do tracing around the denture to take the impression correctly .
Now talking about the sections of the anatomy of the edentulous mandible , we have the buccal shelf area which extends from the buccal frenum to the retromolar pad . The muscles that affects the denture are the buccinator , and superficial to the buccinator we have the masseter muscle located behind the ramus .

How does the master muscle affects the denture ? The masseter does not come in a direct contact with the borders of the denture , but its located outside the buccinators . and when it contracts it compresses through the buccinators and press on the denture . particularly in patients where the direction of the masseter is more
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medial . just to remind you , the masseter muscle runs from the angle of the mandible to the zygomatic arch , and if it was directed more medial than vertical or towards the back , then its effect on the posterior part of the denture is greater . and that varies between a patient and another depending on the anatomical shape of his face .

The labial frenum ; in the lower anterior area is a very common area that causes trauma if the denture was not fitted carefully in that area .

The buccal frenum : is significant like that in the maxilla because it is attached to an area where the modiolus is there ( its a notch of muscles , a point where muscles of facial expression meet ) so I need the denture to get a free movement in that area in all directions ; anterioposteriorly and superioinferiorly .

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 buccal frenum buccal frenum . So when we do the border molding , we need to move the buccal

frenum backwards and forwards , upwards and downwards .

Lingual frenum ; sometimes its more prominent in some patients than others , sometimes it extends all the way to the crest of the ridge when we have excessive resorption. The doctor showed a picture of that case , if we stretch the tongue the tension goes all the way from the tongue to the lip as if they were attached together , because a little of the residual ridge is remained due to extreme resorption .

Mentalis muscle : is a particularly active muscle in the lower labial region ; when it contracts it extends the lip upward ( the lip becomes longer ) and it makes the flange thinner.

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 Both mentalis and orbicularis oris affect the shape of the labial vestibule . orbicularis oris is located in the body of the lip .

An important picture >> if we look horizontally to a patients head , its like if there are circles of muscles around the patients mouth , from the mouth all the way back to behind the esophagus . we have the orbicularis oris attached to the buccinator through the modiolus , the buccinator goes around the cheek , then when it reaches the body of the mandible it cant go any further back , it has to go medially and inside to reach the pterygomandibular raphe which attaches it to the superior constrictor . So these three muscles are the main effector muscles on the

movement of the lower denture . These muscles are like a curtain , behind this curtain there are a group of strong muscles that effect the denture through it . Examples of these are :
1) Masseter , It acts to raise the jaw and clench the teeth , when it contracts powerfully it compresses on the buccinator as mentioned previously and makes a notch in the distobuccal part of the flange in the back end of the buccal shelf area . this is called masseteric notch . 2) Lingually , on the inside of the mandible , there is the medial pterygoid muscle ( the counterpart of the masseter muscle at the inside of the ramus ) , its a very powerful muscle . it elevates the mandible and closes the jaw . it affects the lingual flange () through the superior constrictor . So Masseter through the buccinator , and medial pterygoid

through the superior constrictor . Remember that !

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3)Now in the very back area of the mouth , there is the palatoglossal muscle , forming with the mucous membrane covering its surface two arches)on both sides that narrows the space when the patient swallows . To summary , there are two groups of muscles ; one that affect the border directly and the other one indirectly . Retromolar pad area : the mucosa in this area is non keratinized so its is not designed to take an occlusal force , though it provides some support. The posterior part of the retromolar pad contains glandular tissue ( minor salivary glands ) , it is also the attachment of : the pterygomandibular raphe , the buccinator , the superior constrictor and some of the fibers of the temporalis muscle . The retromolar pad has a pear shaped ,we cover only half or two thirds of its height . we cant go further behind because we will weaken the muscles there (mentioned above ). The doctor is reviewing some structures : Lingual to the retromolar pad we have the premylohyoid fossa ,then mylohyoid muscle goes upward , where the premylohoid eminence is , ( the highest point where the muscle ends ) ,So the flange is shaped by

the lingual frenum and the mylohyoid muscle .

Behind the premylohyiod eminence the flange can go down again , because of an area called the retromylohyoid fossa ,the boundaries of this fossa are medially : the tongue , laterally : the mandible , anteriorly : the posterior border of the mylohyoid muscle ,inferiorly : the mucolingual fold (no muscles ) . deep to this fold there are submandibular glands . thats why we should be careful not to go too deep in that area while taking impression , these glands are soft and if

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the flange compresses on them they cause pain and less stability to the denture .

The retromylohyoid fossa provides lateral stability , because its like a pocket that is deep and vertical . we should not forget that the buccal shelf area is also a stabilizing structure for the denture .

Now Posteriorly : postolaterally , the superior constrictor . postomedially , the palatoglossal . The palatoglosssal is like an arch and the superior constrictor is like a curtain from behind .

With this we conclude the anatomy of the maxillary and mandibular

denture , the doctor apologizes about the slides ( he did not give them to us ) , he wants us to read these topics from the textbook and to set according to the oral pathologys seat numbers from now on .

Best of luck to all of you , Aya Qassem Alali

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