CHAPTER 9 BIOLOGIC CONSIDERATIONS OF MANDIBULAR IMPRESSIONS. ‘The same fundamental principles are in volved in the support of « mandibular den ture as are involved in support for maxil lary dentures (Chapter 7). The denture bases must be extended to cover the maxi- ‘mum area possible without interfering with the health or function of the tissues, whose support is derived from bone. The support for the mandibular denture is supplied by ‘the body of the mandible. ‘The total area of usable support from the mandible is less than it is from the masae eens the the mandibles es capable of reiting. ocual forcs, than the masillae and that much care is essential if the available support is to be used to advantage, SEQUELAE TO THE LOSS OF TEETH When the teeth are removed from the mandible, the alveolar tooth sockets will tend to fill with new bone, but the bone of the alveolar process will start resorbing, This means that the bony foundation for the mandibular dentures becomes shorte “vertically and narrower buecolingually. Tn this manner the bony foundation for thy basal seat becomes progeessively less favor able as a support for the denture, The ony erest of the residual ridge becomes es sharper. Often, sharp bone spicules remain, which can cause tender- ness when pressure is applied by a denture ‘The total width of the bony foundation and mandibular basal seat becomes great. 158 cer in the molar region as resorption con tinues. This is because the width of the inferior border of the mandible from side to side is greater than the width of the mandible at the alveolar process, from side to side (Figs. 9-1 to 93), Other changes occur on the occlusal sur- face of the bone. The shrinkage of the theo rower ip te trl eon ‘moves the residual bony ridge lingually at first, Then as resorption continues, this bony foundation may move progressively further forward, Bone loss in this region often continues onto the mandible below the level ofthe alveolar process Resorption of the alveolar process often develops occlusal contours of residual ridges that make them become curved from a low level anteriorly to a high level pos- teriorly when viewed from the side, These conditions can cause severe problems of stability, which must be considered in im- pression maki and in occlusion. Dentures must be made for people who have these unfavorable conditions. This means that the impressions must be made in such a way that maximum advantage is gained from each part of the support from the basal seat MACROSCOPIC ANATOMY OF SUPPORTING STRUCTURES Support for the lower denture is pro- vided by the mandible (the bone) and the soft tissues overlying it, Some parts of the mandible are more favorable for this160 NENADILITATION oF EDENTULOUS PATIENTS ous mandible with a flat ridge showing the underevt an a the cancellous, rough. sharp center of the ridge, srhich : lower in the center than the outer portions after the cortical Iyer over the center. This type of mandible praduces very litle evidence of a residual 1 the mouth; yet a low rough spiny crest is always present. This roughness cannot be de tected when covered by mucous membranes. Location of the spiny roughness can be dis cerned by the narow fibrous hand along the center of the ridge. Sot tissue over these sh Sharp spines is leated easly. The impression and the Gnished denture are relieved to re nove the bearing frm this unfavorable area Buceal ange a ‘The area between the mandibular buc- a riding onthe musle bythe denture. The cal frenum and the antedor edge of the [ebntraction of this muscle wll not ft masseter muscle is known as the buceal — lower denture. This area is the principal Shelf or boceal ange area. It bounded ~Beatlig‘surface of the mandibular denture medially by the residual ridge, anteriorly and takes the occlusal load off the sharp by the buceal frenom, latertily by the narfow crest that so many edentulous man extemal oblique live, and distally by the dibs present (Fig, 4 reromolar pid. Thi area may be very xy Ther incl shell of the mandi wideqgphich is advantageous for rSlting! covered with good smooth cortical be Tilting fore. ‘The bearing surface of the and itis ustally at right anges to th bhueal ange, the buceal shelf ofthe man. clusal plane. Hovweyer, the sft kssue ov dibles As at right angles tothe direction'y_ ering itis thicker than the. soft tisues SA et ee ore + Sie rtd wadial geen Wore fi exellent resistance to the force, Some ferfor attachment of the bucenator muscle wsele bers are located under i in the buceal shelf tn the molar region a and buceal shelf / son it allows a fortunate impingement and buccinator flange because the mandibular These relative conditions vary f the buee pa attachment of this muscle is close to the tient to patient, so that a choive must be rest of the ridge. This attachment is made as to the best distribution of pres dissimilar to other muscle insertions insures. the mandibular basal seat that it attaches in this area parallel to If the residual bony ridge is unfavorable the bone and the denture does not resist that is, if it is sharp, spiny, or full of the contracting force of the muscle. The nutrient canals, some of the ‘masticatory lower side of the muscle is attached in the pressures should be transferred to. the bbuccal shelf of the mandible. For this rea» buccal shelf (Fig. 95). Otherwise, the x Fig Paand The ift a cipal harp 161 oe Fig 84 Schema dian puter muscle Nite thatthe attachment of the ule a hat will aid the muscles to press the denture to place Sentute with polished surface conton ret of displacing st. C. Lingual fang thonyconfour of the man Jace. D, Lingual polished surfa the denture. E, Mylo impinged upon. Fig. 95, Cast showing the distribution of force ina selective presene impression procedure. A, Primary stres-bearing area when the cidge favorable, B, buceal shel is used as the primary trerbearing area if the test of the rest ridge i sharp, this, and wnlavorable Pd, eto molar pad mst be covered by the denture base fe atea, Note how this Range extends dbl and is out under the ‘contour provides tongue. space and places roid muscle whose contraction in swallowing sl sgt ai sealing the denture in on ather than aid ot be residual ridge can carry the load effectiv ly. The accuracy of the diagnosis and the skill with which the impressions are made Will determine the effectiveness of the dis- tribution of pressure to selected parts of the basal seat. The requirements of man- dibular impressions can be fulfilled by a selective pressure technique Fibrous ridge erest In adults the edentulous ridge is an un- natural condition and therefore pathologic, which leads to various tissue conditions. Along the crest of the ridge is usually found a band of Sbrous co which manifests itself in a raised ridge of fibrous connective tissue that is slightly movable, Eor this reason an_ impression technique should be employed that pulls the tissue upward instead of distorting it with a downward pressure, The raised ridge of fibrous tissue may be a protective sheath for the sharp bone that results from nective tissue, aye Ym162 nratantLsTaTION oF xoENTULOLS PATIENTS Fig. 96. Diagrammatic drawings. showing th relationship of the mylohyoid muscle in varios regions. A Cross section. of thied olor regen showing the mylohyoid ridge level with the crest Of the fesidul alveolar edge in 8 mandible with tmsiderable resorption, ‘By Crees. section inthe fint molar region. C, Cross section in the pre solar region. D. Cross section in the canine on. The angle of the posterior part th Hua anges alfcted bythe angle ofthe ms oid muscle. Anterior only the length of the flange is allected by the mylohyoid mace resorption of bone from the sides. The total is mot covered by muscles and their attachments is very small and would allow only a meager bearing surface if certain of these muscles umount of area U could not be covered, The bearing area is only 2 or 3 mm in width in mouths that have been edentulous for a long time if its width is to be judged by nonmusele attaching areas. In Fig. 96 are diagram: matic drawings illustrating eruss sections of the mandible to show the level of the related structures in the various parts of the mandible from the incisal through the third molar region. Note the various levels of the mylohyoid muscle. as it extends from the posterior to the an- terior region, In the last section itis elose to the inferior border of the mandible, and in the first section it is almost flush ‘with the superior surface of the ridge. These progressive positions teach a great deal about the making of an impression for a complete mandibular denture, Flat mandibular ridges On the labial surface of the anterior region several muscles show a proximity to the crest of the ridge, especially in badly resorbed ridges, and this proximity ac counts for the short Ganges. necessary in this region. These muscles should not be impinged on because their action is nearly at right angles to the ange. Many edentu: Tous mandibles are very fat because of the loss of the cortical layer of bone. The surface is weakened and changed in form by the more rapid resorption of the can- cellous portion of the mandible; the bear- ing surface often becomes concave, allow ing the attaching structures, especially on the lingual side of the ridge, to fall over ‘onto the ridge surface. Such conditions require placement of the tissue by the impression, Such a treatment will gradually establish by this placement a suitable beat ing surface. These greatly resorbed ridges often have the crest at the level of the mental foramina, in which condition ind blood vessels are impinged on easily unless the area is palpated and relieved on the impression, A study of the buccinator muscle shows how. close this muscle attaches to the center of the idge and how impossible it would be to build a denture that did not rest on it ‘The fact that these fibers run parallel to the border of the denture instead of at right angles to it accounts for the fact that the denture can rest on the buceinator iuscle without being displaced. xBone of the basal seat The configuration of the bone that forms the basal seat for the mandibular denture varies considerably with each patient. Fac tots that influence the form of the sup. porting bone of the basal seat were listed previously in Chapter 7 Timportant via tions of the bone of the basal seat for the mandibular include stages. of change in the mandible, sharp mylohyoid ridge, mental foramen area resorption, i saificent space between the mandible and the tuberosity, low mandibular ridges, di rection of resorption of ridges, and torus mandibular “Stages of change in mandible. Fig. 0-7 shows the mandible at various stages. In the final figure the mandible is shown fully developed, with the loss of the alveo: lar process down to a point opposite the mental foramen, “Sharp mylohyoid ridge. Fig. 1-14 shows, a mandible that illustrates another source of aggravation and soreness. The soft tis- sues usually hide the sharpness of the mylo hyoid ridge, which can be found by palpa- tion. As the alveolar process is progressive- ly lost, the attaching structures converge so that the bearing area becomes more and more limited. “Mental foramen area resorption. The| mental foramen on or near the crest of the residual ridge of greatly resorbed man- dibles results in an impingement on the mental nerves and blood vessels if relief is not provided in the denture base. Pres- sure on the mental nerve can cause numb- ness in the lower lip. Insuficien space between the manibl()) and the tuberosity. The maxillary” sin enlarges throughout life if it is not 1 stricted by natural teeth or dentures, thus moving the tuberosity downward. The angle of the mandible is frequently made more obtuse by the early loss of the pos- terior teeth and the retention of the an- terior teeth, Removal of the posterior sup- port destroys the necessary counterbalance against the muscle pull at the angle of the mandible, This straightening of the oN OF StyspinutAR FAEPHESSIONS 163 and denture bases. of resorption of cortical and cancellous bone. Lingually ments of the structures in the floor of the mouth, This makes the lingual fange of the denture more difficult to adapt. Direction of resorption of ridges. ‘The rmasillue resorb upward and inward to come progressively smaller because of the direction and inclination of the roots of the teeth and the alveolar process. Conse- quently, the longer the maxillae have been edentulous, the smaller is their bearing area, The opposite is true of the mandible, which inci io a s outward and becomes pro gressively wider according to its edentue Tons age. This progressive change of the mandible and maxillae in the edentulous state makes many patients appear to be prognathie (Fig. 98) Torus mandibularis. The torus mandi latis is a bony prominence usually found n the region between the frst and second premolars, midway between the soft tissue of the floor of the mouth and the crest of the alveolar process. In edentulous mouths in which considerable resorption has taken place, the superior border of this promi rence may be Aush with the crest of the residual ridge on the lingual side. Its size varies from that of a pea to that of a hazelout (Fig 9-9). The cause for its occurrence is not known, but it is some- times coincident with a bulbous torus palatinus. The torus mandibularis is cov ered by an extremely thin layer of soft tissue and for that reason _may be iti tated by slight movements of the den: ture base. It should be removed surgically if relief cannot be provided for it inside164 neaniuitanioy oF epexretous parievts of development: A, At bith, Note the absence of the cx a ajle. B, ALG years of ute — © Mel; B to D red cM Fg. 9 body, ed 27, Pld tionsody Fig. 95. Progressive resorption of the marily and mandibular ridges, showing how the nasil Becomes narrower and the mandible wider. Lines AB represent the sa center ofthe ridges; note how the distance between Cand D becomes progressively greater ss the mandible andthe manila eso. Fig. 99. Torus mandibulais reproduced on a east, A. This condition needs surgical redve- tion so that the manelibular denture can be sealed satisfactorily si166 rEWaniLstATION OF EDENTULOUS PATIENTS the denture without breaking the border seal MACROSCOPIC ANATOMY OF LIMITING STRUCTURES Jhoull be extended Mandibular dentures as far as possible within the Timits of ealth and’ function of the tissues and “uctures that support and surround them. This is the same principle that governs the TMtent of maxillary dentures, but it more Somplicated to apply to. mandibular den Garee than to maxillary dentures. The reason what the structures on the lingual side must be considered a5 ett as thove around the labial and buceal 1 SMfaces of the denture, The structures on the hngual side of the mandible are more Complicated to handle than those on the Ductal and labial sides. The problem i= the greater range of their movement and speed of their actions. ff the mandib Buccal and labial border anatomy “The underlying structures around the order of complete dentures vary accord ing £0 the location. This fact i overlooked ioe tantly and is a reason why the possible Graximum mandibular denture coverage is Miigom attained. 1f a careful study is made soa used, the size of the mandibular den~ fare may be larger than might be eX pected. Mandibular dentures should. be Pode back of the buccal frenums and Marrow in the anterior labial region. The meanaibular labial frenum contains a band vegbrous connective tissue that helps to Sitach the orbicularis orix; therefore the frenurn is quite sensitive and active and must be carefully fitted to maintain a seal vnithout causing soreness (Fig. 9-10) The part of the denture that extends be- tween the labial frenum (labial notch) and the buccal frenumm (Tbuceal notch) is called the mandibular labial flange. This has 11 limited area for extension because the Iusele fibers of the orbicularis oris and the Incisivus labi inferioris ran fairly close t0 the erest of the ridge. The structure distal to the labial frenum is the buceal frenum, Fig 910. A, Labial 9 ial Ti abulae frenoe. B, Note i a ve, #11, Type contour of labial and boca Bie O10, Toes centue. A, Brad bacal border onda boca th fo he boca Barge: Benatar bal Sang: D. lbs eet or the bal eno “This attachment connects. 95 Tana though the modilss at >a pth ‘and on up to the buccal of the miachment onthe masa. These Krona a scuar basics pull actively 7 frou denture borders, plished 50 sero IN ent Therefore, the denture Hera extended less in this rein steele impression cst be fantional am ait Rave the ssi sal and yet ra eet the tip moved CP un). MAING tower ip must be supported to nent equal to that provided by the nat eee end their vesting structures Pig O12) The length and thickness of GeeSatat donge in the Tibial vetoes tne Mh theeamount of Woe that bas 1, Wat The tne of the skin of the ip veer tke orcas ort suse depends ave tikes of the ange (and the potion af the tet ee nme extending from the "othe ip between the Mes, tht the abil residual ridge two triangularis musethe corner the buccal xilla, These ull actively ishe “ur he cgiue his region functionally seal and yet displace joved (Fig. orted to an Wy the natu: structures hickness of | vestibules se that has 2 of the lip cle depends fe (and the vg from the eiween the at the labial Fig. 912, Conelaton of anatomie landmarks. A, Intraoral view of mandibular arch 1, Lablal feenwm: 2, ibial vetibule; 3, buceal Fenumy; 4, buceal vestibule: 5, aide aecoise ah 6, retromolar pad; 9, lingual tubercle; 10, alveosingual selets II, svelaing salivary carunele; 14 tongues 17, lingual femum. By Mandibula pectina Pression showing the comesponding denture landmarks (stay moceling for better definition). 1, Labial notch 2, labial ange, 3. buccal notch ‘masseter groove; 5, alveolar groove: 6, retromola fn; 7, plesygomandibular mechs & retromylohyold eminence; 9, lingual tuberelar fossa; 12, mylobyeid goes, ne for tongue: 15, mylohyoud Bunge, 18, geval spine fossa 17, Vogual noch of disection of the mandibular arch showing wnesyimg ators 9, triangularis muscle; 4, buccioatornniscley 4a, teal shel maseter_musce; 5, Bbrous connective tusue, Se, alveolar bone temporal tendon, 7, pterygomandibular raphe; 8, medal pterygoid muscles Sa, mpesor phan geal constrictor muscle, Ab, retromylohyoid curtain, 9, lingual tuberosity, 21, slanguak a 1a, mylohyoid masele; 11b, lingual nerve, 12, mylohyoid muscle attachniet and onlohced ridge; 15, alveollingual sulcus, 17, subwasilary carule. (From Martone, AL I. Dent, 19:4, 1969.) mponnd i ‘extemal oblique ridge 6, retromolar glands, 65, 167168, lange can be exterided in length and thick ness to suppl the lip (Fig. 9: Buccal ves necessary support for ule. The buccal vestibule extends from the buccal frenum posterior! to the outside back comer of ‘the retro. molar pad and from the crest of the resi. ual alveolar ridge to the check (Fig 9412). The buccinator muscle in the cheek extends from the modiolus to the pterygomandibular (pos Its Tower side attaches in the molar region in the buccal shelf of the mandible (the part of the bone between the residual ridge and the external oblique line), The buccinator muscle action occurs in a horizontal direction, so that it cannot lift the Tower denture even though the ‘buccal flange of a properly extended den. ture will rest on its inferior attachment External oblique ridge and buceal flange. ‘The mandibular extension labially and buceally is govemed by the same general factors. The impression area between th labial and buccal frenums is determined by the tum of the fold, which is not very extensive. The buccal fange area, which starts immediately posterior to the buccal frenum and extends to the anterior portion of the masseter muscle, swings wide into the cheek and is nearly at right angles to the biting force, thus providing the anteriorly) raphe teriorly), lower denture with its greatest area for biting resistance (Fig. 9413 The external oblique ridge does not govern the extension of the buceal flange because the resistance or lack of resistance ‘encountered in this area varies widely. The buccal flange may extend to the external ‘oblique ridge, or up onto it, or even over it However, palpation of the external oblique ridge is a valuable aid or landmark in help- ing to ascertain the relative amount of re sistance or lack of resistance of the border tissues in this region. This buceal flange area is successfully utilized, despite the fact that the buccina tor muscle Abers run close to the crest of the ridge and the denture bears directly ‘upon a considerable portion of this mus cle, which attaches in the buccal shelf ‘of the mandible. The bearing on muscle fibers would not be possible except for the fact that the fibers of the buccinator and its pull when in fonction are parallel to the border and not at right angles to it, as is the masseter muscle. The action of the buceinator is weak compared to that of the massater muscle; hence its dis placing action i very slight. More resist- ‘nce is encountered in this area when the denture is fst inserted than fested a few weeks after the patient has worn the completed dentures. In Fig, 019, Two dentures made for the same borers, B New denture with propery extend lent. A, OL denture with underestended orders The new denture takes advantage of al the available basil seat to crease retention, stably, and suppor. oe the tise valuabl that is ridg Masve ide th 94 Wher alters th end. of ele and The « mandibl the orig Fig bhtest area for 3 widely. The the external ternal oblique Imark in help amount of re of the border successfully the buceina: to the crest pears directly this: mus buccal shelf ng on muscle le except for he buceinator 1 are parallel ight angles to ©. The action compared to hence its dis More resist is area when than @qenani ve paieiut has res. In other leveatended words, it is possible to stretch and plac the tissues and thus create this ates, in valuable for biting resistance and stabil, that is so sorely needed when the residual Fidge is sharp or narrow Masseter muscle region. The distobuceal comer of the mandibular denture. must converge rapidly to avoid displacement due to contractin pressine of the muse side the buccinator in this region (Fig ona) When the masseter muscle contrat alters the shape and size of the dst nd of the lower bucea vestibule Tt pushes inward aguinst the bucemator mus ele and suetorial pad of the check The distobuceal border of the mandibu lar impression encounters the action of the masseter muscle to a eater or les de sree, depending on the shape of the ma. dible and the skull. Ifthe ramus of the ‘mandible has a perpendicular surface and the origin of the muscle onthe zygomatic arch is medialward, the muscle pulls move Mtpnessions 169 lirectly across the distobuccal denture border. Therefore it affects and drives inward the buccinator musele and tissues, n this area, If the opposite is true of the shape of the mandi and the relation of the maxillae, greater extension is allowed « portion of the mandibular impre tobnceal ion. This inasseter muscle pull can be registered on the impression by softening the compound with an alcohol flame along the distobuccal border, tempering the com fund in warm water, and, after seating the impression in the patient's mouth, exerting a downward pressure by placing the index fingers on the impression in the second premolar region, While this downward pressure is boeing exerted on the impression by the dentist, the patient is instructed. « closing force. These opposing forces will cause the masseter musele to contract and trim the compound in that area if the relation of the mandible and maxillae causes the masseter muscle to affect the dist ‘buccal border directly. The relative size of Fig, 9-14. Finthed zine oxide and eugenol paste impression with border outve Iandiarks AA, Mandibular Ibial notch; By mandibular labial ange, C mandibular buceal notch, D, boiceal flange; Ey area influenced by the mascter muscle; Fy wetromlar pad area, Note the S curve ofthe lingual Hanges, “a170 rexanutanion oF eoexrutoes Parizers ter muscle that i smaller in damn border. ae ‘ Distal extension of mandi impression The distal extent of the mandibular im pression is Kimited by the rami of the mandible, by the boccinator muscle that crosses from the buceal to the nga at itataches tothe pterygomendibuls phe ' and the superior constrictor muscle, and Fl 915. Cat showing rtomelar pad A, which by the shares ofthe intra bony bourse ama rman dna a) daries of the retromolar fossa, which is formed by a continuation of the intemal the lingual sie. The pterygomandibular and external oblique ridges as they ascend raphe enters the pad atts fop back iad the ramus. If the impression is extended corner. ‘The actions of these structures ' onto the ramus, the buclnator muscle init the extent of the dentere snd we and adjacent tissues would be impinged vent placement of extra pressure on ie on between the hard denture border and tetrosalr pod pan the sharp extemal oblique ridge. This ree would not only cause soreness but also Lingual border anatomy cal ke limit the fnetion of the Bucenator muscle. The lingual extension on impressions dale ' which is part of the kinetic chain of swal- has been the most abused and misunder becau Towing stood border cegion in complete dentures the t HK, The desirable distal extension isstightly Thi misunderstanding assed ‘by the treate 16 the lingual of these bony prominences, peculiarities ofthe tsnte under the tone from which include the pearshaped retromolar Such time has less dict resstence thas mater pad. This tssue forms a splendid soft that ofthe labial and baceal bowdes, and Tn tissue seal of the type that is so valuable yet it will wot tolerate overextension, Bor rout in camying out the. principles involved eause of their peculiar lack of immediate ina in impression sealing fesistance, these tisies are easily distorted apn Retromolar region and pad. The distal shen the impresion i being made, et fee nd of the mandibular denture region f such extension over along paiod of tine mylol hounded bythe anterior border of the will cause tissue soreness ur dilodgment Teng from ramus, which carries it over the retro- molar pad and defines its posterior limit (Fig, 9-15). The retromolar pad (the angular soft pad of tissue at the distal of the denture by tongue movement. This lingual border is easily carried down along the bony surface of the mandible into the undercut under the mylohyoid ridge, nd of the lower sldge) must be covered, nce the myahyadd muslin ee fina bythe denture to perect the border seal of Bers that fsa rlsed state wll aw mune RD is, his region. It contains some glandular the impression material to go down deep slanc Ghsue' and sme, fers of the temporal and eatry he thn mule bend With fon tn. fat aby hs ave sates However th extn heli ge oe working through it (Fig 8.28). Buecnator under the myloyold: masele sant. be oe Q eal barvente fe Ham, the BRP Qaeda tanciica tolibocr Sole terior Se and fers ofthe supevoe pharyogeal the denture, causing sorenes, and lining pres ave the function unless the flange is made thet constrictor of the pharynx enter it from ————ve pad, A, which valir denture egomandibular op back inside ese. structures ture and pre- fessure on the a: impose and misunder plete dentures fused by the Ser the tongue veitace tha Tho Qs, and stenion, Ber of immediate sal dtorted ing. made yet period of time FP dodgment ovement This td down along mandible into Volo ridge, is thin sect tate wil allow O down deep Sand with it, lingual dange Se cannot be out dplaing ‘nd timing vge i made MOLOGIC CONSIDERATIONS OF MEAXDINLLAN ISEPHESSIONS ITT Fig. 916. Posterior view showing the miscls ofthe Boor ofthe mouth, A, Mylahyold ms cle: B,geniohyid murd; €, hyd hone parallel to the mylohyoid muscle wher it is contracted. Although such a mechani cal lock might seem desirable to secure additional retention, it cannot be tolerated because of physiologic factors. Therefore the border tissues in this area must be treated in a distinetly different manner from one involving the usual methods and materials (Figs. 9:1 to 93), Influence and action of the floor of the mouth. A tolerable border that will result jn a stable denture can be secured with 4 proper understanding ofthe anatomy and function of the floor of the mouth: The mylohyoid muscle arises from the whole length of the mylohyoid line, extending from about 1 em back of the distal end of the ridge to the lingual anterior portion of the mandible. Medially, the fibers join their fellows of the opposite side and con- tinue posteriorly to the hyoid bone, This ‘muscle disappears under the sublingual sland and other structures about the re- sion of the second premolar, so that it ddoes not affect denture borders in. this area except indirectly. However, the pos- terior part of this muscle affects the im: pression border in swallowing and moving. the tongue. Fortunately, the posterior ev- tension of the impression can go beyond the mylohyoid muscle attachment line sinee the tissue fold is not in that area For this reason the impression may depart from a stress-bearing area and may be suspended in soft tissue on both sides of the border, thus reaching the fold of soft tissue for a seal. The distance that these lingual borders can be away from the bony areas will depend on the functional movements of the floor of the mouth and the amount that the residual ridge has resorbed (Figs, 9-16 and 9-4) Mylohyoid muscle and mylohyoid ridge. An extension of the lingual ange well beyond the palpable portion of the mylo hhyoid ridge has other advantages, une of which is that the lack of direct’ pres- sure on this sharp edge of bone will reduce a possible source of soreness. If the impression is made with pressure fon or slightly over this ridge, displace- tment of the denture and soreness are sure to result from lateral and. vertical stresses. On the other hand, if the border stops above the ridge, vertical forces will still cause soreness, and the seal will be broken easily. If the flange is properly shaped and extended, it will complete the Deal flange h Tingual border seal and guide the tongue desirab on top ofthe fan froved to be rather shallow in comparison iW top of the ANES, ion. In the pre- with the posterior portion. The lingwal i ne arte Tgual aide of the frenum area is likewle rather shavow Al sree Feo al glo willbe noted senate, and resistant. This frenum shout amid muscle. This be registered only in function beeause at hand there. rest the height ofits attachment is decep li wot clone to the evest of the tive. In function, 1 usually comes, qui d ait ing the development close to the crest of the ridge, whereas at pe pe in the anterior part of the rest itis much lower, 9.17) Direction of the lingual flange. The lin: F ‘ee (Ghee the sublingual gland gual extension of the mandibular impres: fn athe mplohyuid muscle, there is sion is now made according to an entirely pe i ee reostance in function, and the most diferent method from that followed in the sh th pal Al Fig. 9.7, Lingual view of the mandible. A, Position of the Ihe mylohyoid muscle at rest and i a salsed position; B, mylohyoid lie do study of lingual flange contour of two preliminary wax or Adaptol Fis. 918, Compar ibular impressions made was duplicated. Note that the lingual ange 1s shorter in the anterior region than in the (ee ee ee the same mouth which reveals the fact that tip| ange has comparison hhe lingual er shallow om qd deed at at is decep- fomes quite whereas at xe. The lin ilar impres an entirely owed in the Adaptol Vin the past, The greatest credit should be given Wilfred Fish of London for the theoretical exposition of its conformation (Fig, 5-1) Although the methods described in. this ‘book difer from his, the principle is funda mentally. the same, The extension of the lingual flange tinder the tongue is a vastly different conception from the one held previously. Tt seems a rather singular fact that the lower border of the lingual flange runs parallel with the lower edge of the mandible from the lingual frenun to the posterior end, This fact makes the flange short in the anterior region and long in the posterior region because the crest of the ridge of the mandible turns up rather sharply. as it approaches the ramus (Fig 9-15). ‘The posterior extension is bounded partially by the action of the glossopalatine muscle, which usually is no farther back than the distal extent of the retromolar pad, “The alveololingual_suleus (the space between the residual ridge and the tongue) extends posteriorly from the Kingual fre- ‘num to the retromylohyoid curtain, of this sulcus is available for the lin ange of the denture The alveololingual sulcus can be con sidered in three regions. The anterior re gion extends from the lingual frenum to the place where the mylohyoid ridge curves down below the level of the sulaus. At this point, a depression (the premylohyoid fossa) can be palpated, and a correspond ing prominence (the premylohyoid emi: rence) can be seen on. impressions. The premylohyoid fossa results from the con: cavity of the mandible (as viewed from above) joining the convexity of the myo. hyoid ridge (as viewed from above) (Fig. 9.13), ‘The lingual border of the impression in this anterior region should extend down to make definite contact with the mucous membrane floor of the mouth when the tip of the tongue touches the upper in The middle region in the alveololingual sulcus extends from the premylohyoid fossa tothe distal end of the mylohyoid ridge (Fig. 9.12). The suleus curves medially from the bod of the mandible, The curvature is caused by the prominence of the mylohyoid ridge. When the mylohyoid muscle and the tinder the mylohyoid ridge. If an impression mnditions, the mus te and other tissues in this region would fdlge and buccal to gue are relaxed, the muscle drapes back sere made under these be trapped under # their position when they are in action or p when’ the tongue is placed against the upper incisors. The sublingual gland and submaxillary duct can be pushed down and laterally out of position by resistant im- pression material. This can be avoided by shaping this part of the lingual ange of ay to slope inward, toward the tongue and by making the Binal impression with a very soft impression material. When this part of the lingual ange is made to slope toward the tongue, it can extend below the level of the mylohyoid ridge. Other wise, the flange must end at the level of the mylohyoid ridge. If the lingual fange slopes toward the tongue and extends below the mylohyoid ridge, the tongue can rest on top of the Bange, The third and most posterior region of the alveololingual suleus is the retromylo. Ihyoid space or fossa It extends from the end of the mylohyoid ridge to the retromylo hyoid curtain, It is bounded on the lingwal side by the anterior tonsillar pillar, at the distal end by the retromylohyoid ‘curtain and superior constrictor muscle, and on the buccal side by the mylohyoid muscle, the ramus, and the retromolar pad. The superior support for the retromylohyoid curtain is provided by part of the superior pharyngeal constrictor muscle. The actions of this muscle and of the tongue (and their effects on the alveololingual sulcus termine the posterior limit of the extent of the lingual flange posteriorly ‘The denture border should be extended posteriorly to contact the rettomylohyoid curtain (the posterior limit of the alveolo.val suleus) when the tip of the to is. pla this part of the flange is shaped so. that it will guide the tongue on top of the Tingual fon "d_ against the front. part of the ‘upper residual ridge the denture (Fig reattachment ofthe mylohyoid muscle Such a contour ats the patient to oon SFeqss about 1 em distal to the end trol the denture without inericring cok the mylohyoid ridge, which prevents the functions of the soft tinuen When a the denture from locking against the bone flange is developed in th ner, the in this region (Fig. 9.19) K objectives are accomplished by extending the lingual Range Into this "area. Fira However, two border of the lingual flange has a typical S curve when viewed from the impression ace (Fig, 921 Lingual frenum and lingual notch. The region lingual frenum, that is, the antetior at and second, $¥ tachment of the tongue, is very resistant \ O\ sromole pad to the naa ' Fig, 919. Avcololingual sulcus hat an 5 shape slating atthe midline. Note thatthe 5 cape results from the contour of the redval rie and the prominence of the rsishyid se ‘The characteristic form is equally apparent on both the dissected (lee) and wndieted \ right) sides. Tinga side of the sdge as fc back av the prema aa, At the ante ful of the mylohyoid rig, the flange curves away from the bone toward the tongue distal end of the flange turns atrlly toward the bone to complet the S curve ¥ped so that top of the Fig. 9-20). eri sith & Whew the nanner, the as a typical impression noteh. The interior at ry resistant ite well ve. The a at and active and often wide, so that the denture border needs complete functional trimming to avoid having the attachment displace the denture (Fig. 9-22 Lingual flange, ‘The lingual flange of the denture occupies the alveololingval sulcus, the space between the residual al veolar ridge and the tongue, The distal nd of the alveoolingual suleus ends at the retromylohyoid curtain, This is a cur tain of mucous membrane that is supported above by the superior constrictor muscle, The retromylohyoid curtain is pulled for Fig. 921. Modeling compound impresion hs lingval ange cur ports the tases of the he mouth to function normally and guides of the Ha ward when the tongue is thrust The distal estent of the lingual fangs lossopalatine arch, partly limited by the (hich is formed in part by the glossopala- tine muscle and in part by the lingual cle As we go forward on the I flange, the flange is influenced by the mylo- which attaches to the mylo hyoid ri medialward from the m aceupy the fold formed b the structures in the floor of the mouth This means that the buccal surface of the flange does not rest on mucous membrane in contact with bone, but on soft tissue The flange leaves the bony attachment at the mylohyoid ridge and slopes inward under the tongue to fil the fold. Thus there is a space between the flange and the mucous membrane when the mylohyoid oid ridge to the tongue and muscle is relaxed, and there is contact between the flange and the mucous mem. thrust Drane when the tongue is raised out, This mucolingual fold is ext fiexible and mobile because of the type ff tissue and the mobility of the e floor of the mouth. The border tissue on the lingual side of the residual unlike the border tissue in any other part of the mouth in regard to funetion and resistance in border molding (Fig. 9-4) It has so little resistance that it is easi distorted and for that reason needs a spe- Fig. $82, A, Lingual frenum area in a completed impression. The lingual frermm area & tually broad and clove tothe crest of the ridge176 nenamutanion oF enesretows aries cial type of technique and. impression material to record the correct tum of the fold. The forward part of the lange area of this region over the sublingual gland is usually shallow because of the mobility of the tissues that are controlled indirectly by the mylohyoid muscle, The mylohyoid mus cle in this region extends nearly to. the inferior der of the mandible, and yet the glandular and other tissues move above it, so that only a relatively short flange is usable (Figs, 9-16 and 9-18) The combination of the typical arch form of the lingual side of the body of the mandible, the projection of the mylohyoid ridge toward the tongue, and the retro mylohyoid fossa at the distal end of the alveololingual sulcus causes the border of the lingual ange to have a typical 5 shape when viewed from the impression surface Starting at the midline, the flange curves outward, following the curve of the resid. ual ridge. At the premylohyoid fossa, which is located at the front end of the mylohyoid ridge, a premylohyoid eminence forms in the flange. At this point the border of the lingual flange curves away from the body of the mandible to accommodate the mylohyoid muscle when it is contracted or ‘when the tongue is raised. At the distal end of the mylohyoid ridge, the lingual turns laterally toward the ramus whi under the mucous membrane in the retro: mylohyoid fossa to complete the typical $ form. The distal end of the lingual is called the retromylobyoid eminence. Its most prominent contour lies medial and distal to and below the level of the reteo: molar pad, MICROSCOPIC ANATOMY* In Chapter 7 the importance of micro- scopic anatomy to maxillary. impression making, the histologic nature of the soft tissue and bone of the oral cavity, « classifi cation of the oral mucosa, and clinical FWe with to acknowledge the assistance of Dr. Steve "Kol, Chavrman, Departnent of Oral Pathology, Mesical College. nf Georgi. Scho Dentistry, Augusta Considerations of oral microscopic anatomy were discussed. A review of this part of Chapter 7 will be helpful at this point be cause the material is also applicable te considerations for mandibular impressions Microscopic anatomy of supporting tissues The microscopic an ny of the support ing tissues of the lower impression will be described for the crest of the residual ridg and the buccal shelf Crest of the residual ridge. The mucous membrane covering the crest of the lower residual ridge is similar to that of the upper ridge in that in the healthy mouth it is covered by a comified layer and is firmly attached by its submucosa to the periosteum of the mandible, The extent of the attachment to the bone varies con siderably. In some patients the submucosa is loosely attached to the bone over the entire crest of the residual ridge, and the soft tissue covering is quite movable, In a relatively few patients, the submucosa is relatively firmly attached to the bone on bboth the crest and the slopes of the lower residual ridge. When the soft tissue is movable, it must be carefully registered in its resting position in the final impression, Oceasionally surgical procedures are indi cated to increase the amount of the “resid ual attached gingivae.” When these tissues Decome inflamed, the submucosa is ede ‘matous, with infiltration of numerous in flammatory cells. Obviously the tissue must bbe healthy at the time the Bnal impression is made ‘The mucous membrane of the crest of the lower residual ridge when securely at tached to the underlying bone is histolog cally capable of providing proper soft tis- sue support for the lower denture. How- ever, the underlying bone of the crest of the lower residual ridge tion to that of the upper residual ridge, is iellous in nature, being made up of spongy trabeculated bone (Fig. 923) Therefore the crest of the lower residual ridge may not be favorable as the primary in contradistine stress-be The me impress impress Hidge di * Bueca shelf is seat ar frenum lower re ridge. T buceal + less con ridge, a layer. 1 cinator tally in Ising thanatomy S part of point be- cab support. nn will be ual ridge the Tower outh Tris is Bly to the he extent over the nd the able. In a bone on the lower tissue is istered in pre >, the “resid. ose tissues a is ede- mipression oe) ny i ‘histlog 1 soft wre Hove see cadltinc- I eidge, de up of ie 903), resid pee em mn BIOLOGIC CONSIDERATIONS OF MANDIBULAR IStPRESSIONS 1 Fig. 923. Histologic drawing of the ret of the Ide, Submuccel layer of the mucous membrane covering. the crest may tbe of adequate thickness und rly altached to ridge. However, the lone that forms the rest of the lower rkige i cancellos, oF spongy, matre, Thesefore this part of the fdge & generally not ed for prinary support ofthe lower denture stress-bearing area for the lower denture The method of making space in the final impression tray prior to making the Bnal impression ensures that proper relief is provided for the crest of the lower residual ridge during the making of the final im- 'puccal shelf. Anatomically, the buccal shelf is defined as that part of the basal seat area located posterior to the buccal frenum which extends from the crest of the lower residual ridge to the external oblique ridge. The mucous membrane covering the bbuceal shelf is more loosely attached and less comifed than the mucous membrane covering the crest of the lower residual ridge, and it contains a thicker submucosal layer. Histologically, fibers of the buc- cinator muscle are found running horizon. tally in the submucosa immediately over lying the bone. Compact Fig. 924. Histologic deawing of the buccal shelf of the mandible. The hose Torming the bucel Shelf is compact in nature, in contrast tothe Spongy, tone forming the crest of the lower ie nature of cm fdge (Fig, 9-29). The hi fact bone maker the buccal the. primary stesbearing aren for entre Tic inecre, Sees coring Jie buccal elf may mot be os sual ite ley to prove pinay supper forthe overbing the crest of the ler esa Sige However the bone of the baa thei coveed bya apr of compact bone compre of aves ster Eig 34 The mare ofthe tone pas the hoot Epporng suare proved be bone >< SEE mate the lnostsutable rary The boon’ rection of the Aber of the bucanator musce allows the dente damage tothe muscle or dupacement af the denture The method of forming the lower Ena impesion tay allows atonal Toad to ber placed onthe uct he during th malig ofthe Bal impesiom (Fig 825) tact with the meen ofthe ucel she178 neMAMUTATION OF EDENTULOUS PATIENT {the final impression tray in the region ofthe buccal shelf arrow Fa ares uth dhe easton both sides when the tray is made, This past aze lef in eet conc the mucosa of the buccal shell doving the making of the fa the tony ee gens additonal load in these region The reat of the tray has be Teed froma the east by a8 Fig. 925. Buccal a 8 fossa, the soft palate ap of mucous membrane lining the rtromslahyoi 1 by Sheek EE, lovee lip, RMC, retomylobyoid curtain, forte ray constrictor nusee, AP, retvomolar pal; BMC favtain Tes atthe psteror end of the 9.26, Photo retroralar pad and th the mucars menbrane covering the super buccal mucona of the cheek, The retiomslohyoid alveoolingual sleus and is the posterior boundary of the retromlohyotd fous. The iicates the cation of the histloge section shown diagrammatically sn Fig 9-2 and thy the fn Micro: Th tissue space The vestib suleus lining loose© final | palate, cd by BMC, of the Fig. 927, Histologic drawing made posterny through the retromylohyoid curtain a Semcon site ofthe astersk in Fig. 0-26. Note the superior constrictor muscle and posterior toi the imadial pterygoid muscle. Contraction of the medial thle forthe posterior part ofthe Lingual Range in thee and the soft tissue is slightly displaced as the final impression is made. Microscopic anatomy of limiting tissues ‘The microscopie anatomy of the limiting tissues will be described for the vestibular spaces, the alveololingual sulcus, and the retromolar pad The mucous membrane lining the vestibular spaces and the alveololingual suleus is quite similar in nature to that lining the vestibular spaces of the upper jaw. ‘The epithelium is thin and non: comified, and the submucosa is formed of loosely arranged connective tissue bers mixed with elastic fibers. Thus the mucous membrane lining the vestibules and the gol mascle limite the space avail- rnplohyoid fossa alveololingual sulcus is freely movable which allows for the necessary movements of the lips, cheeks, and tongue. Anteriorly the submucosa of the mucous membrane Tining the alveolol components of the subl attached to the genioglossus musele, In the molar region, the submucosa attaches to the mylohyoid muscle, and the mucous membrane covering of the retromylohyoid I suleus contains igual gland and is curtain is attached by its submucosa to the superior constrictor muscle. Posterior to the superior constrictor muscle fibers, which run in a horizontal ditection, i found the internal pterygoid muscle running in a vertical direction. (See Figs. 926 and 9.27.) The length and form of the lingual 2submucosa @ endar Seven succinate gf tendon Compact bone the retromolar pad sh Comstctor muscle medially on of the Fig. 026, Vertical histologic drawing through, the Fig 2 Taterally and of oor the_penygoman vp these structures. Beease The be dspace during nal impress ithe hat161182. nenanniirATIoN OF EDENTULOUS PATIENTS tbe eniggsses ansle; CHM, gen tiekes AYatar nyfshynd rnc, E, oral eptelim. (From Pend Asoc. 21:488, 1934) these. str tend to ¢ The re fend of th Histolog composes tissue, fb constric! phe, at of the w183 the tied molar in a jw tht hd vm ‘sorption. Note tht the bod andthe basa le attachment line, the mandibule denture only 0 few mili to the me ‘weal ange bruccinatoe mele; F, mandala eal. (Co ange of the lower final impression tray must reflect the physiologic activity of these structures; otherwise their normal movement will be restricted, or they will tend to dislodge the lower denture. ‘The retromolar pad lies at the post end of the erest of the lower residual ridge! Histologically, the mucosa of the pad is composed of a thin, noncornified epithe: lium, and in addition to loose or areolar tissue, its submucosa contains glandular tissue, bets of the buccinator and superior constrictor muscles, the pterygomandibular raphe, and the terminal part of the tenidon of the temporal muscle (Fig. 9-28). Be- ction of mandible of a 404 arold man, This sect rdentolous for Tong time with com alot meet the ie nature of the retro molar pad, it should be registered in a resting position in the fnal lower impr cause of the histol Crosssectional anatomy of the mandible ross sections of the mandible reveal th proximity: of muscle attachments and the lack of a broad bearing surface. The bony contour naturally {s much narrower and sharper than the soft tissue contour, This fact often deceives the dentist as to the width and contour of the bearing surface (Figs. 9:29 t0 931