4th year Lect Prosthodontics ‫د ظر‬ .‫د‬.

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Anatomy and physiology as related to dental prosthesis

In order to construct a prosthesis a dentist require an understanding
and a thorough knowledge of the anatomy and physiology of the
supporting structures to assure successful results.
Osteology
The osseous structures not only support the denture but have a direct
relation on the impression making procedure, position of teeth and the
contours of the finished denture.
It is quite essential to have knowledge of the tissues that support the
maxillary and the mandibular dentures. These tissues also help the dentures
in obtaining their retention and stability. There are certain tissue areas or
regions in the maxillary and mandibular edentulous foundations, which are
better suited to bear the stresses due to mastication, and are called as stress
bearing areas. While there are other tissue areas which are not quite suited
to take up these stresses, either due to their anatomy or due to the structures
that lie beneath them and are called stress relief areas. The structures which
limit the extension of the maxillary and mandibular complete dentures are
called border-limiting areas.

The mucous membrane that lines the oral cavity varies in character in
different zones and denture border depends on the function of the different
zones. The sub-mucosa, which is a connective tissue, attaches the mucosa
to the underlying structures. The submucosa varies in composition
depending on whether the mucosa is firmly or loosely attached to the bony
structure and whether there is muscle tissue between itself and the
underlying bone. The blood vessels present in the submucosa supply blood
to the edentulous foundation and the nerves innervate it.
It is better understanding of the oral anatomy which would act as positive
guides to successful removable prosthesis.
Factors that influence the form and size of the supporting
bone include the following:
1. The original size and arch form before extractions.
2. The severity of periodontal disease.
3. Amount of alveoloplasty at the time of tooth extraction.
4. Forces developed by the surrounding musculature.
5. Forces accruing from the wearing of dental prostheses.

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 6. The relative length of time different parts of the jaws have been
edentulous.
7. Unknown genetic predisposition to bone resorption.
STRUCTURES RELATED TO THE MAXILLARY AND
MANDIBULAR EDENTULOUS FOUNDATION
These structures can be divided into two categories:
1. Supporting structures: These are the structures that support the denture
2. Border limiting structures: These are the structures that limit the border
extent of the denture (maxillary and mandibular denture).

Osteology of the oral cavity: the maxilla:

The maxillary denture is supported by two pairs of bone the maxillae and
the palatine bones whereas the mandibular denture is supported by one
bone the mandible. There are two maxillae each consisting of a central
body and four processes: alveolar, frontal, zygomatic and palatine. Some
area of the body and two of the processes are involved in the support of the
maxillary denture.

Supporting Structures in the Maxillary Edentulous Foundation

1. Zygomatico-alveolar crest (malar process).
2. Alveolar process
3. The palatine bone
4. Palatine process of the maxilla
5. The incisive fossa
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 6. The pterygoid hamulus
7. Maxillary tuberosity
8. The greater palatine foramen
9. Cuspid eminence.

Zygomatico-alveolar crest (malar process):

This is located opposite the 1st molar region some denture require relief
over this area to prevent soreness and aid in retention especially in sever
resorbed ridge.

Alveolar process:
It arises from the lower surface of the maxilla. It consists of two parallel
plates of cortical bone which unite behind the last molar to form the
tuberosity. The part of the alveolar process that remain after loss of teeth
is called the residual alveolar ridge. The maxillary ridge act as a secondary
stress bearing area. The slopes of the ridges do help in the stability of the
denture during function. Hence, some of the stress does get transmitted
through the slopes.

The palatine processes of maxillary bone:

They arises as horizontal plates from the body of the maxilla. The two
plates unite in the mid line forming the mid palatine suture. Sometime

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overgrowth of bone seen in this area called torus palatinus. The hard palate
resist resorption (primary stress bearing area).
The area of sutural joint (mid palatal raphe) is covered by firmly adherent
mucous membrane to the underlying bone with little submucosal tissue.
There is, therefore, no resiliency in this region and stress cannot be applied
in this region. This is a stress relief area in the maxillary edentulous
foundation and consideration is needed for stability of maxillary denture.
Clinical consideration:
During final impression procedure the mid palatal raphae is relieved in
order to create equilibrium between the resilient and non-resilient tissue
supports.
The palatine bone:
The horizontal plate of palatine bone
unite with the posterior rough border of
the horizontal palatal process of
maxillae. The posterior border of palatine
bone unite at midline forming the
posterior nasal spine. The soft palate is
attached to this posterior border. The PPS
is placed at the junction between
immovable and movable parts of the soft palate.
Posterior palatal seal area: The soft tissue area limited posteriorly by the
distal demarcation of the movable and nonmovable tissues of the soft
palate and anteriorly by the junction of the hard and soft palates on which
pressure, within physiologic limits, can be placed; this seal can be applied
by a removable complete denture to aid in its retention.
Vibrating line:
An imaginary line across the posterior part of the soft palate marking the
division between the movable and immovable tissues; this line can be
identified when the movable tissues are functioning.
Incisive foramen:
The incisive foramen is located in the palate on the median line posterior
to the maxillary central incisor. In edentulous mouth it comes nearer to the
crest of the ridge as resorption progress. Failure to relieve this area may
result in irritation and burning sensation at the anterior part of the palate.

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Incisive Papilla
It is a pad of fibrous connective tissue anteriorly overlying the incisive
foramen. The submucosa in this region contains the nasopalatine nerves
and vessels.
Significance
A able landmark is related to the incisive foramen through which the
neurovascular bundle emerge and lies on the surface of the bone.
I i a bi me ic g ide gi ing inf ma i n ab l ca i n f ma illa
canines (a perpendicular line drawn posterior to the center of the incisive
papilla to sagittal plane passes through the canines).
I i a bi me ic g ide gi ing inf ma i n n i i nal ela i n f cen al
incisors, which are about 8-10 mm anterior to the incisive papilla.
Clinical consideration:
During the impression procedure, care should be taken not to compress the
papilla. This is one of the relief areas of the maxillary edentulous
foundation. Hence the incisive papilla should be relieved.
Anterior (greater) palatine foramen:
This is located medial to the third molar at the junction of the ridge and
horizontal plates of palatine bone .Rarely would a relief be required in the
denture base over this area since the nerve and blood vessels are housed in
a groove and covered by thick soft tissue.
Maxillary tuberosity:
It is that part of the residual ridge that extend distally from the area of the
2nd molar to the hamular notch. The tuberosities often are dense fibrous
connective tissues with minimal compressibility. In this situation,
considerable support is offered to the denture. Sometimes cause problem
in maxillary denture construction such as:
1. Enlargement of the tuberosity with the presence of bilateral
undercuts effect the insertion and removal of denture.
2. The presence of pendulous tuberosities cause a reduction in the
interarch distance in the posterior region against the retro molar pad.
3. To prevent oro-antral fistula, it is important to have an occlusal
radiograph before surgical resection of the tuberosity.

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4. In case of severe undercuts at the tuberosity region, the undercut on
the preferential chewing side should be reduced.
5. The last posterior tooth should not be placed on the tuberosity.
Hamular notch:
It is a narrow cleft of loose connective tissue, which is approximately 2
mm in extent antero-posteriorly. This structure is bounded by the
maxillary tuberosity anteriorly and the pterygoid hamulus posteriorly
and marks the postero-lateral limit of the upper denture. The submucosa
in this region is thick and made up of loose areolar tissue. A seal can be
obtained by utilizing this area as it can be displaced to a certain extent
without trauma.
Significance
1. Constitutes the lateral boundary of the posterior palatal seal area in
the maxillary foundation.
2. The pterygomandibular raphe attaches to the hamulus.
Clinical considerations: The denture should not extend beyond the
hamular notch, failure of which will result in:
1. Restricted pterygomandibular raphe movement.
2. When mouth is wide open, the denture dislodges.
3. Pterygomandibular raphe may be sandwiched below the denture.

Cuspid eminence:
It is a bony elevation on the residual ridge formed after extraction of the
canine located over the canine root and serve as a guide for positioning
of artificial canine.

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 The limiting structures of the upper denture can be divided
into three areas: (1) the labial vestibule, which runs from one buccal
frenum to the other on the labial side of the ridge; (2) the right and left
buccal vestibules, which extend from the buccal frenum to the hamular
notch; and (3) the vibrating line, which extends from one hamular notch
to the other across the palate.

Osseous structures associated with the mandibular denture:

1. Coronoid process.
2. Residual alveolar ridge.
3. Buccal shelf area.
4. Mental foramen.
5. Mylohyoid ridge.
6. Lingual tuberosity.
7. Genial tubercles.
8. Torus mandibularis.
9. External oblique ridge.

The mandible is the movable member of the stomatognathic system. It

is consist of:
A. The body of the mandible.
B. The rami: Each ramus terminate at its upper extremity into two
processes, posteriorly the condyloid and anteriorly the coronoid process.

Coronoid process: It is the anterior process and continuous with the

anterior border of the ramus. If the distobuccal flange of maxillary denture
is too thick it will cause discomfort and dislodgment of upper denture when
the mandible is protruded and move from side to side. Trimming of the
flange will solve the problem.

Residual alveolar ridge:

It is that part which remain after loss of teeth. The bone underlying the crest
of RR is cancellous which makes it unfavorable for resisting applied forces
from a denture.

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Buccal shelf area:
The buccal shelf is the area between the mandibular buccal frenum and the
anterior edge of the masseter muscle. Medially it is bound by the crest of
the ridge and laterally by the boney external oblique ridge and distally by
the retromolar pad. The buccinators muscle fibers attach horizontally
along the boney oblique ridge. As resorption of the ridge occurs, the buccal
shelf does not resorb because of its muscle attachments on the posterior
and lateral borders. The alveolar ridge of the mandible is significantly
medial to the inferior border of the mandible; therefore, as the ridge
resorbs, the denture-bearing surface becomes flatter and widens towards
the buccal shelf. The shelf is dense cortical bone and lies at right angles to
vertical occlusal forces, and is therefore a primary stress-bearing area for
the denture.

Mental foramen:
It is located on the lateral surface of the mandible between 1 st and 2nd
premolar half way between the lower border and alveolar crest. The mental
nerve exits the mental foramen below the alveolar ridge, but with continued
resorption of the ridge, the mental foramen can become positioned at the
crest of the ridge and be compressed by the denture. This causes pain or
even altered sensation in the lip (numbness in the lower lip).
Mylohyoid ridge:
It runs along the lingual surface of the mandible. Anteriorly the ridge lies
close to the inferior border of mandible while posteriorly, it lies flush with
the residual ridge. The thin
mucosa over the mylohyoid
ridge may get traumatized and
should be relieved. The area
under this ridge is an undercut.

Lingual tuberosity:
It is an irregular bony prominence distal to mylohyoid ridge when it
became prominent should be relieved, rounded or surgically removed.

Genial tubercles:
Also called mental spines, 2- 4 in number situated on the lingual surface of
the body of mandible in the mid line. They represents the muscle
attachment of the genioglossus and geniohyoid muscle .it is usually seen
below the crest of the ridge.
Significance
In a severely resorbed ridge, it is seen above the residual alveolar ridge
and hence, it should be relieved.
 The m c a c e ing he genial be cle i hin and igh l adhe en
the underlying bone.
Clinical consideration:
It should be relieved with a spacer, failure of which leads to ulceration.

Mandibular tori
Mandibular tori are lingual bilateral or unilateral prominences of cortical
bone in the premolar area. But they may extend posteriorly to the molar
area. Small tori may only require relief in the denture. Large tori require
removal before a denture can be fabricated.

External oblique ridge:

It is a ridge of dense bone extended from just above the mental foramen
superiorly and distally to be continuous with the anterior border of the
ramus. In most individual it is the anatomic guide for lateral end of the
buccal flange of lower denture.

Retromolar pad:

The retromolar pad is a triangular pad of tissue at the distal end of the
residual ridge. The anterior portion of the triangle is keratinized tissue of
the remnant gingiva of the third molar called the pear-shaped pad. The
posterior aspect of the triangle is composed of thin, nonkeratinized
epithelium; loose connective tissue; glandular tissue; fibers of the
temporalis tendon and of the buccinators and superior constrictor muscles;
and the pterygomandibular raphe. The underlying bone is dense cortical
bone because of the muscle attachments and is resistant to resorption. The
denture should cover the retromolar pad because of the support and lack of
long-term cortical bone resorption.

Maxillary and Mandibular Stress-Bearing Areas

Maxillary
1° firm tuberosities
1° hard palate on either side of palatal raphe
2° alveolar ridge
2° rugae
Mandibular
1° buccal shelves
1° retromolar pads
2° alveolar ridge
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Areas Requiring Relief in Impression
2° stress-bearing areas
Palatal torus
Median palatal raphe
Mandibular tori
Retromylohyoid ridge
Undercuts or sharp boney prominence on ridges.

The pattern of bone resorption:

The maxilla resorb upward and inward to become progressively smaller
(centripetal) .while the mandible resorb downward and incline outward to
become gradually wider (centrifugal). This progressive change of the
mandible and maxillae makes many edentulous patients appear to be
prognathic.

The mean denture bearing area for edentulous maxillae are 23cm2
while for mandible 12cm2 in contrast with 45cm2 area of PDL in each
dental arch.
The masticatory loads recorded for the natural teeth are about 20 Kg
while maximum forces of 6 Kg during chewing have been recorded
with complete denture. In fact , maximal bite forces appear to be five
to six times less for complete denture wearer than person with natural
teeth.

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