Anatomical Landmarks of Edentulous Mandible

Anatomical Landmarks of Edentulous Mandible
Presentd by Dr. Sneha Deepthi. G I st yr. pg student Dept. of prosthodontics and crown & bridge Sibar institute of dental sciences Guntur .
Content
Introduction Anatomy of Mandible Muscle attachments of Mandible that influence Complete Denture fabrication Anatomy of supporting structures
Residual Ridges Buccal Shelf area
Anatomy of limiting structures

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Anatomy
Movable member of stomotognathic system Horse Shoe shaped Consists - Alveolar process
Ramus on each side Condylar process Caronoid process
Coronoid process
Anterior border continues into anterior border of ramus Dislodgement of the maxillary denture on protrusive & lateral movements of mandible in thick distobuccal flange of maxillary denture
Anatomy
External Oblique line
Lateral termination of buccal flange of mandibular dentures
Buccal Shelf Area

Bounded externally by external oblique line internally by slope of residual ridge Bone is dense resultant forces of elevator muscles are directed to this area & trabeculation is arranged to best resist these forces Long axes of artificial teeth should coincide with the resultant muscular forces
Anatomy
Mental Foramen
Extensive loss of RR occupies superior position of RR relief in denture bone pressure of mental nerve causes numbness of lower lip
Mylohyoid line
Irregular, rough, bony crest extending from 3rd molar region to lower border of mandible in the region of chin Lingual flange of mandibular denture should extend inferior to, but not lateral to the mylohyoid line Sharp, prominent act as stress bearing area or fulcrum point surgical intervention
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Anatomy
Lingual tuberosity
Bony prominense on distal end of mylohyoid line Excessively prominent under cut surgically removed or rounded
Mental spines
Sharp interfere with denture retention & function Genioglossus muscle Interfere n extensive RRR Muscle attached to geniohyoid muscle below
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Anatomy
Muscle attachments to mandible & their influence on mandibular denture
The origins of several of the muscles of facial expression are near enough to the denture bearing areas. Their action must be considered as definitely influencing the denture borders. Their influence is in proportion to the contour & quality of RR present in vertical direction. Higher the RR less influence.
Anatomy Mentalis Muscle

Origin extends higher than the fornix of the vestibule Contraction makes lower vestibule shallow RR same height as fornix of vestibule dislodges mandibular denture Dictates the level of extention of labial flange of mandible denture below the crest of ridge Surgical repositioning sometimes advised
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Anatomy Incisivus labii inferioris

Origin mandible alveolar process Course laterally to blend orbicularis oris muscle Present beneath mucous membrane Flange extention affects denture retention
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Anatomy
Buccinator Muscle
Origin horse shoe shaped line along the outersurfaces of the maxillary & mandibular alveolar process in area of 1st molar region. Pterygomandibular ligament Lower Jaw
Part of denture bearing area Severely resorbed ridges Covers the bony support
Acts paralell to occlusal plane no dislodgement of denture Present perpendicular to masseter muscle Action of masseter muscle medial movement of buccinator muscle dislodging force Recorded as massetric groove in denture bases
Anatomy
Mylohyoid muscle Origin Mylohyoid line Insertion Posterior fibres hyoid bone (body) Median fibrous raphae from symplysis to hyoid bone Action Elevates hyoid bone, tongue & floor of the mouth during swallowing Denture flange extended below but not under mylohyoid line Inferior border of denture in compatable position with tongue Extensive bone loss surgically detached & reattached more inferiorly on the body of mandible without apparent impairment of function
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Anatomy
Geniohyoid muscles
Origin inferior mental spine No problem unless extensive resorbtion of RR Surgically reattached inferiorly on the mandible
Tongue
The denture flanges are contoured to allow the tongue to have its normal wide range of functional movements The muscular activity of tongue
Intrinsic muscles Extrinsic muscles
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Anatomy
Genioglossus
Origin superior mental spine
Palatoglossus muscle
Palatoglossus arch follows the movements of tongue Protrusion or lateral movement of tongue forward movement of the arch Posterolingual extent of lower denture is extended backwards so that it prevents this forward movement of the arch Most forward position of the arch determines the posterolingual edge of the lower denture
Anatomy Superior constrictor Origin

posterior border of medial pteygoid palate & pterygoid humulus pterygomandibular raphae Posterior end of mylohyoid line Side of the tongue Action exerts pressure on distal extremity of mandible denture Over extension painful perforate the tissue
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Anatomy
Tongue Tongue acts in the following way in retaining & stabilising the complete dentures
The dorsum is pressed against the back of the upper denture to prevent it dropping when incising The tip is pressed forwards & downwards against the anterior lingual surface of lower denture when the lower lip tends to force the denture backwards The lateral borders of the tongue rest on the occlusal surfaces of lower denture when opening the mouth
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Anatomy of Supporting Structures Residual alveolar Ridges

Vary in size & shape Ultimate form is dependent on
Developmental Structure Size of the natural teeth Amount of bone lost prior to extension of teeth Amount of Alveolar process removed during extension of teeth Rate & degree of resorption Effect of previous dentures
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Anatomy of Supporting Structures

Broad & well deveoped ridges Favourable
Large area prevent lateral & anteropostetior movement Close peripheral seal adequate lungual, labial, buccal sulcus
Ridges exhibiting undercut area Unfavourable

Relief in the denture causes food lodgement Loss of seal
Well developed but narrow or knife like ridges Unfavourble

Pressure on mastication pain Less area
Flat ridges Unfavourable

No resistance to lateral & A P movements Very much resorbed to the level of attachment of muscles
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Classification of mandibular anterior residual ridge (Atwood DA) Order I preextraction Order II- postextraction Order III high well rounded Order IV knife edge Order V low well rounded Order VI depressed

Direction of resorption of ridges
Bony foundation for the mandibular dentures becomes shorter vertically & narrower buccolingually The total width of bony foundation & mandible basal seat becomes greater in molar region as resorption continues Why? width of inferior border of mandible from side to side is greater than the width of mandible at alveolar process from side to side The shrinkage of alveolar process in outer region among the RR lingually at first. Further resorption moves the bony foundation forward
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Anatomy of Supporting Structures Primary areas of support

Buccal shelf Posterior ridges Retromolar pad (pear shaped pad)
Soft, covered to complete retromylohyoid flange & buccal shelf
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Secondary areas of support
Anterior ridge & all ridge slopes
Crest of the ridge

Bone is cancellous, thus not favourable for stress bearing Mucous membrane keratinised histologically capable for support underlying bone not favorable submucousa attaches to the periosteum Proper relief in final impression
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Buccal shelf area (or) Buccal flange area
The area between the mandible buccal frenum & the anterior edge of the masseter muscle Boundaries
Medially crest of residual ridge Anteriorly Buccal frenum Laterally External oblique line Distally retromolar pad
Buccinator muscle fibres present beneath the buccal flange Antero-posteriorly parellel to bone Contraction does not dislodge the denture Bone in this area is very dense & the trabeculation is arranged almost at right angles to the path of closure

Forces of occlusion are applied nearly at right angles Buccal shelf is the area of bone between the extension sites of molars & the external oblique line Intact cortical plate & tends not to resorb due to stimulation of attachment of buccinator Flat ridges buccinator center of ridge Flaccid & inactive - covered by denture Buccal shelf is a platform of bone buccal to the position of molar teeth

Anatomically, the buccal shelf is defined as that part of the basal seat that is located posterior to the buccal frenum and extends from crest of the lower residual ridge to the external oblique ridge Mucous membrane covering
Loosely attached, less keratinized Thick submucosa certain buccinator muscle fibers Histologiclly may not be suitable for support but compact bone with Haversion system and the horizantal supporting surface provided by buccal shelf suitable for support Final Impression tray direct contact tissue slightly displaced
Anatomy of LimitingStructures Labial frenum

Band of fibrous connective tissue that helps to attach orbicularis oris muscle Sensitive & active Carefully fitted to maintan a seal without causing soreness Fibrous band that can be influenced by incisiors & orbicularis oris muscles It is usually shorter & wider than maxillary labial frenum
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Anatomy of Limiting Structures

Labial vestibule
Sulcus between the buccal frenums or between the 1st premolars if the freni are absent or in unusual location The incisivus inferioris, mentalis, orbicularisoris muscles, position of fixation of the modiolus, all affect this area which accommodate labial flange of denture The length & thickness of labial flange vary with the amount of tissue that has been lost. (ridge fair to good thin border 1-2 mm flat ridge thick border) Tone of skin of lip & orbicularis oris muscle depends on thickness of flange & position of teeth No muscle from RR to lip between two triangularis muscles support for lip by extending the length & thickness of labial flange
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Buccal frenum
Connects as a continuous band through the modiolus at corner of the mouth and on upto the buccal frenum attachment of maxilla It overlies depressor anguli oris muscle Clearance achieved in denture base to avoid dislodgement Buccal frenum is a fold or folds of mucous membrane extending from the buccal mucous membrane reflection to or toward the slope of the crest of RR in region just distal to cuspid eminence. This membrane may be single or double, U or V shaped. The reflection is in antero-posterior direction

Buccal vestibule
Extends from buccal frrenum posteriorly to the outside back corner of retromolar pad & from the crest of the residual alveolar ridge to the cheek Width & length are mainly dependent on the buccal shelf & the buccinator muscle The extent of buccal vestibule is influenced by buccinator muscle, which extends from modiolus anteriorly to pterygomandibular raphae posteriorly & lower fibres attached to modiolus & exterior oblique ridge Palpation of external oblique ridge helps to ascertain the relative amount of resistance, or lack of resistance, of border tissues in this region The buccal flange extends to external oblique ridge, up on to it, or even over it, depending on location of mucobuccal fold The denture should completely cover the buccal shelf despite the fact that it will rest directly on the fibres of buccinator muscle

Distobuccal area (Massetric Notch)
The distobuccal border at the end of the buccal vestibule, must converge rapidly to avoid displacement by contracting masseter muscle, whose anterior fibres run outside, behind the buccinator muscle When masseter contracts it pushes the buccinator inward & produces a bulge in to the mouth The masseter influences denture base at this point during opening & closing movements of mandible Effect of masseter muscle on distobuccal border
Moderate activity will create straight line Active muscle will create a concave border Inactive muscle will create a convexity
Active muscle ramus perpendicular & zygomatic arch medial muslce pull directly on distobuccal border concave border Inactive muscle - convex border Recorded by applying downward pressure at the premolar region when the patient closes the mouth or elevates the mandible Under extension may result in loss of support and resistance to displacement.
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Anatomy of Limiting Structures Distal Extension of Mandibular Impression

Limited by
Ramus of mandible Buccinator muscle crosses buccal to lingual as it attaches to pterygomandibular raphae Superior contrictor muscle Sharpness of lateral bony boundaries of retromolar fossa continuation of external & internal oblique ridges as they ascend on the ramus
The desirable distal extension is slightly to the lingual of these bony prominences & includes the pear-shaped retromolar pad

Retromolar region and pad
Sicher described the retromolar pad as a soft elevation of mucosa that lies distal to the third molar Gaddock coined the term Pear-shaped pad that refers to the area formed by the residual scar of a third molar & the retromolar papilla Triangular soft pad of tissue at the distal end of he lower ridge Bounded
Posteriorly temporalis tendan Laterally buccinator Medially pterygomandibular rephae superior constrictor muscle
Contains loose connective tissue with an aggregation of mucous glands


Retromolar region and pad
Importance Retromolar pad position is fairly constant, as alveolar resorptiion is not generally pronounced here. Because of the insertion temporalis muscle tendons in the region bone responds to the tensile stimulation by growth & opposition which causes the muscle attachments not to resorb Land mark for placement of occlusal plane the occlusal surfaces of natural molar teeth will be only slightly above the height of retromolar pad Histology
Mucosa non-keratinized Submucosa glandular tissue & muscle fibres & tendon
Recorded in resting position


Mylohyoid muscle and mylohyoid ridge
The mylohyoid muscle arises from the whole length of mylohyoid line, extending from about 1 cm back of distal end of mylohyoid ridge to the lingual anterior portion of the mandible at the symphysis It lies deep to sublingual gland & other structures in 2nd premolar region & does not affect the denture border Posterior part molar region affected during swallowing & moving the tongue This can be minimized by making the flange parallel to the mylohyoid muscle when it is contracted Lingual flange goes beyond the muscle attachment & away from the body of mandible to be suspended under the tongue by reaching the mucolingual fold of soft tissue for border seal This distance depends on
Functional movements of floor of the mouth Amount of residual ridge resorption
The advantage of this position of lingual flange

Lack of direct pressure on the sharp edge of the ridge Properly shaped & extended flange will provide border seal & guide the tongue to rest on the top of the flange
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Retromylohyoid fossa or space
Area posterior to mylohyoid muscle Lingual flange in this region is not influenced by the mylohyoid muscle can be back toward the body of the mandible S shaped curve Boundaries
Medially tonsillar pillar Posteriorly retromylohyoid curtain formed
Posteriorly sup. Constrictor muscle Laterally mandible, pterygomandibular raphae Anteriorly lingual tuberosity Inferiorly mylohyoid muscle
Denture border should extend posteriorly to contact retromylohyoid curtain when the tip of the tongue is placed against the front part of the upper residual ridge Protrusion causes retromylohyoid curtain to move forward
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Sublingual gland region
In the premolar region when floor of the mouth is raised the sublingual gland causes close to the ridge, thus prevent development of long flange in the anterior region
Lingual frenum
It is a fibrous band of tissuethat overlies the center of genioglossus muscle.
Anterior attachment of tongue Functional trimming of denture border to provide most of lingual frenum without displacing the denture. Careful clearance is needed
inadequate clearance may result in pain or displacement of denture. over clearance may result in loss of seal and loose denture.
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Lingual vestibule (or) Alveolingual sulcus
It is the space between the residual ridge & the tongue Extends posteriorly from lingual frenum to retromylohyoid curtain
Anterior lingual vestibule

Syn- sublingual cresent area Anterior sublingual fold Influenced
Genioglossus muscle Lingual frenum anterior portion of sublingual glands
Extent lingual frenum to premylohyoid fossa Impression should extend down to make definite contact with mucous membrane of floor of the mouth when the tip of the tongue touches the upper anterior residual ridge The width of the border is usually about 2 mm varies depending on activity & tonicity of genioglossus muscle & lingual frenum

Middle region (or) mylohyoid vestibule
Extent
Premylohyoid fossa to distal end of mylohyoid ridge
The sulcus curves medially from body of mandible caused by prominence of mylohyoid ridge. Influenced by mylohyoid muscle Nagel & Sears have shown that, at the maximum contraction, the fibres are still in downward & forward direction so that the denture can be extended below the muscle attachment of mylohyoid ridge The length & width of mylohyoid flange is determined by the membranous attachment of tongue to mylohyoid ridge & width of hyoglossus muscle Average mylohyoid border is 4-6 mm below the mylohyoid ridge. Width of 2-3 mm
Anatomy of Limiting Structures Distolingual vestibule

Syn
Lateral throat form Retromylohyoid fossa
Extent
End of mylohyoid ridge to retromylohyoid curtain
Neil described this area & noted that denture could have 3 possible lengths depending on tonicity, activity and anatomic attachments of adjacent structures
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Anatomy of Limiting Structures Distolingual vestibule

Class III throat form
Minimum length & thickness The border ends 2-3 mm below or sometimes at the mylohyoid ridge
Class I deep accommodate fairly long & wide flange Class II moderate half as long & narrow as class I and about twice as long as class III Mostly class I & II are seen Class III shallow . This form is rarely seen.
Histology of Limiting Structures Epithelium thin, non keratinized Submucosa loosely arranged CT fibres mixed with elastic fibres Mucous membrane of alveolingual sulcus is freely movable for necessary movement of lips, cheeks & tongue.
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Anatomical Landmarks of Edentulous Mandible

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Anatomical Landmarks of Edentulous Mandible

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Anatomical Landmarks of Edentulous Mandible

Anatomy of limiting structures

Buccal Shelf Area