CHAPTER 13 Developing an An the Maxillary De David M, Davis If dentures and their supporting tissues are to coex- ist for a reasonable length of time, the dentist must fally understand the anatomy of the supporting and limiting structures involved, for these are the foun- dation of the denture-bearing area, The denture base must extend as far as possible without inter- fering in the health or function of the tissues, It is Convenient to regard the impression surface of a denture as comprising two areas: a stress-bearing or supporting area and a peripheral or limiting area Each of these is discussed separately, but like the sides of a coin they are inseparable. ANATOMY OF SUPPORTING STRUCTURES The foundation for dentures is made up of bone of the hard palate and residual ridge, covered by mucous membrane. The denture base rests on the mucous membrane, which serves as a cushion between the base and the supporting bone. Mucous Membrane The mucous membrane is composed of mucosa and submucosa. The submucosa is formed Dy SO nective tissue that varies in character from dense Joose areolar tissue and also varies congrats thickness. The submucosa may contain sisnuint fat, or muscle cells and Cen ne a supply to the mucosa Beer NsLO PY chet bone the ata between the submucosa and the peri ‘occurs covering of the bone. alogue/Substitute for nture-Bearing Area The mucosa is formed by stratified squamous epithelium, which often is keratinized, and a subja- ‘cent narrow layer of connective tissue known as the lamina propria. In the edentulous person, the mucosa covering the hard palate and the crest of the residual ridge, including the residual attached gingiva, is classified as masticatory mucosa. It is characterized by a well-defined keratinized layer on its outermost surface that is subject to changes in thickness depending on whether dentures are worn and on the clinical acceptability of the dentures. Although the importance of the mucosa from a health standpoint cannot be neglected, the thick- ness and consistency of the submucosa are largely responsible for the support that the mucous mem- brane affords a denture because in most instances, the submucosa makes up the bulk of the mucous membrane. In a healthy mouth, the submucosa is firmly attached to the periosteum of the underlying supporting bone and will usually withstand suc- cessfully the pressures of the dentures. When the submucosal layer is thin, the soft tissues will be nontesilient, and the mucous membrane will be easily traumatized. When the submucosal layer is loosely attached to the periosteum or it is inflamed or edematous, the tissue is easily displaceable, and the stability and support of the dentures are adversely affected. Hard Palate The ultimate support for a maxillary denture is the one of the two maxillae and the palatine bone, The palatine processes of the maxillae are joined fogether at the medial suture (Figure 13-1). The 211212 Part Three Rehabilitation of the Edentulous Patient: Fabrication of Comp! ete Dentures Figure 13-1 Both the maxillae and the palatine bone provide support for an upper den- ture, Individual differences in form determine how forces should be directed to these bones during function. A, Spiny projections that would itate tissues under a denture. B, Rough and irregular bone of the maxillary ridges. C, Incisive foramen, which comes to lie closer to the crest of the ridge as resorption takes place. Thus the location of the incisive papilla, which covers the incisive foramen, in relation to the crest of the ridge is a guide to the overhanging edge to it. palatine processes of the maxillae and the palatine bone form the foundation for the hard palate and provide considerable support for the denture. More important, they support soft tissues that increase the surface areas of the basal seat. r A cross section of the hard palate shows that the palate is covered by soft tissue of varying thickness, even though the epithelium is keratinized through. out. In the region of the medial palatal suture, the submucosa is extremely thin, with the result that the mucosal layer is practically in contact with the ~ underlying bone. For this reason, the soft tissue covering the medial palatal suture is nonresilient and may need to be relieved to avoid trauma from the denture base. Anterolaterally, the submucosa contains adipose tissue, and posterolaterally it con- tains glandular tissue, This tissue is displaceable, amount of resorption that has occurred. D, Greater palatine foramen, which often has a spiny and although it contributes to the support of the denture, the horizontal portion of the hard palate lateral to the midline provides the primary support area for the denture. In the area of the rugae, the Palate is set at an angle to the residual ridge and is tather thinly covered by soft tissue. This area con- tributes to the stress-bearing role, though in a sec- ondary capacity. The submucosa covering the incisive papilla and the nasopalatine canal contains the nasopalatine vessels and nerves, Residual Ridge The shape and size of the alveolar ridges change when the natural teeth are removed. The Tesorption following extraction of the teeth is rapid at first, but it continues at a reduced rate throughout life. If theChapter 13. Developing an Analogue/Substtue fr the Maxillary Denture-Bearing rea 213 teeth have been out for many ye Fidge may become small, and the erect may ak a smooth, cortical ony mucosa. There may be large, a the HIE mucous membrane covering the exest of th ealthy mouth is firmly ajtached to fe periosteum of the bone by the connective tissue ofthe submucosa. The stratified squamous epithe ium is thickly keratinized, The submucosa is devoid of fat or glandular cells and is characterized by dense collagenous fibers that are contiguous with the lamina propria. The submucosal layer, though relatively thin in comparison with other paris of the mouth, is still sufficiently thick to pro- vide adequate resiliency to support the denture The crest of the edentulous ridge is an impor- tant area of support. However, the bone is subject to resorption, which limits its potential for support, unlike the palate, which is resistant to resorption Because of this, the ridge crest should be looked on as a secondary supporting area, rather than a pri- mary supporting area. The inclined facial surface of the maxillary ridge provides little support, the residual of the ridge surface under the although the peripheral tissues should be contacted. to provide a border seal. ‘As the mucous membrane extends from the crest along the slope of the residual ridge to the reflection, it loses its firm attachment to the underlying bone (Figure 13-2). The more loosely attached mucous membrane in this region has a nonkeratinized or slightly keratinized epithelium, and the submucosa contains loose connective tissue and elastic fibers. This loosely attached tissue will not withstand the forces of mastication transmitted through the denture base as well as the mucous membrane covering the-crest of the ridge and the palate. Histological studies of the effect of wearin dentures on the keratinization of the mucosa of the crest of the residual ridges and the palate have pro- duced conflicting results. However, most studies indicate that wearing dentures does not seem to be harmful to the epithelium, even though in den- ture wearers the keratinization is of reduced thick- ness. Cytological studies indicate that increased amounts of keratinized material are present in edentulous ridges when the clinical quality of the Figure 13-2 Arrows denote the line of demarcation between the attached and unat- tached mucous mem! is the peripheral area i ft. However, it fe Attached mucous membrane is desirable for suppor tat contributes to the border seal. Notice the prominent incisive papilla lying anteriorly on the center of the residual ridge,214 Part Three Rehabilitation of the Edentulous Patient: Fabrication of Complete Dentures dentures is good, an indication that well-fitting den- tures may be important in maintaining the normal histological condition of the mouth. Stimulation of the mucosa of the residual ridge through tooth- brush physiotherapy also increases the presence of keratinized material. Histologically, removing the dentures from the mouth for 6 to 8 hours a day, preferably during periods of sleep, allows kera- tinization to increase and the signs of inflamma- tion, often found in the submucosa when dentures are worn, to be dramatically reduced. Shape of the Supporting Structure The configuration of the bone that provides the support for the maxillary denture varies consider- ably with each patient. Factors that influence the form and size of the supporting bone include (1) its original size and consistency; (2) the person’s gen- eral health; (3) forces developed by the surround- ing musculature; (4) the severity and location-of periodontal disease (a frequent cause of tooth loss); (5) forces accruing from the wearing of dental prostheses; (6) surgery at the time of removal of the teeth; and (7) the relative length of time different parts of the jaws have been edentulous. In addition, a number of anatomical features influence the shape of the hard palate and residual ridge. These are described in the following material. Incisive Foramen This is located beneath the incisive papilla, which is situated on a line imme- diately behind and between the central incisors. It lies nearer to the crest of the ridge as resorption progresses (see Figure 13-2), Thus the location of the incisive papilla gives an indication as to the amount of resorption that has taken place. The nasopalatine nerves and blood vessels pass through, the foramen, and care should be taken that the den- ture base does not impinge on them. Maxillary Tuberosity The tuberosity region can hang down abnormally low because when the max- illary posterior teeth are retained after the mandibular molars have been extracted and not replaced, the maxillary teeth overerupt, bringing the process with them (Figure 13-3). These enlargements often are fibrous but can be bony. This excess tissue can prevent proper location of Figure 13-3. The enlarged tuberosities limit the space available and will compromise the occlusal plane and distal extension of the mandibular denture the occlusal plane and may interfere with the lower denture, if it is not surgically removed. Sharp, Spiny Processes Frequently, there are sharp, spiny processes on the maxillary and pala- tine bones (see Figure 13-1). These usually cause no problems because they are*covered deeply by soft tissue, However, in individuals with consider- able resorption of the residual’tidge, these sharp spines can irritate the soft tissue left between them and the denture base. The posterior palatine foram- ina often have a sharp, spiny overhanging edge that may irritate the covering soft tissues as a result of pressure from the denture. Torus Palatinus The torus palatinus is a hard bony enlargement that occurs in the midline of the roof of the mouth and is found in about 20% of the population (Figure 13-4). It is covered by a thin layer of mucous membrane that is easily trauma- tized by the denture base unless a relief is provided. This relief should conform accurately to the shape of the torus because an extensive arbitrary relief robs the denture of part of its support area. ANATOMY OF PERIPHERAL OR LIMITING STRUCTURES The limiting structures of the upper denture can be divided into three areas: (1) the labial vestibule,Chapter el ter 13, Developing an Analogue/Substitute for the Maxillary Dentur Figure 13-4 A torus palatinus is covered by a thin layer of mucous membrane, which is easily trauma- ized by the denture base unless a relief is provided. which runs from one buccal frenum to the other on the labial side of the ridge; (2) the right and left buccal vestibule, which extends 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 (Figure 13-5). Bearing Area 215 Labial Vestibule The labial vestibule is divided into a left and right labial vestibule by the labial frenum, which is a fold of mucous membrane at the median line. It contains no muscle and has no action of its own. It starts superiorly in a fan shape and converges as it descends to its terminal attachment on the labial side of the ridge. The labial notch in the labial flange of the denture must be just wide enough and just deep enough to allow the frenum to pass through it without manipulation of the lip (Figure 13-6). The mucous membrane lining the labial vestibule has a relatively thin mucosa. The submu- cosal layer is thick and contains large amounts of loose areolar tissue and elastic fibers. The mucosa of the vestibular spaces is classified as lining mucosa. It is normally devoid ofa keratinized layer and is freely movable with the tissues to which it is attached because of the elastic nature of the lamina propria. Lining mucosa also forms the covering of the lips and checks, the alveololingual sulcus, the Figure 13-5 Correlation of anatomical Jandmarks. A, Intraoral drawing of the maxillary ; 2, labial vestibule; 3 hy 1, labial frenum; 2, labial vestibule; 3 pulge; 6, residual alveolar ridge; , maxilary palatal seal region; rugae. B, Maxillary buccal frenum; 4, buccal vestibule; 5, coronoid tuberosity; 8 hamular notch; 9, beset é foveae palatinae; 77, median palatine raphe; 12, incisive papilla; 1 erepresion shows the corresponding denture landmarks: labial notch; 2, labial flange; 3, buccal 4 flange; 5, coronoid cont \veolar i 7 notch; 4, buccal flange; 5, coronoid contour; 6, alveo! ve TT bes ity; 8, maxillary seal in area of hamular notch; 9, area of ; i groove; 7, ago posterior palatal seal; 10, fovea 73, rugae- . inae; 17median palatine groove; 12, incisive fossa;spilitation of the Edentulous Pater 216 PartThree Reta nt: Fabrication of Complete Dentures Figure 13-6 A, Abroad maxillary labial around the frenum. soft palate, the ventral surface of the tongue, and the unattached gingiva found on the slopes of the residual ridges. ‘The main muscle of the lip, which forms the outer surface of the labial vestibule, is the orbic- ulariy oris, Its tone depends on the support it receives from the labial flange and the position of the teeth. The fibers of the orbicularis oris pass horizontally through the lips and anasto- mose with the fibers of the buccinator muscle. Because the fibers run in a horizontal direction, the orbicularis oris has only an indirect effect on frenum. B, The labial flange must fit snugly the extent of an impression and hence on the denture base. The buceal frenum forms the dividing line between the labial and buccal vestibules. It is sometimes a single fold of mucous membrane, sometimes double, and, in some mouths, broad and fan shaped. The levator anguli oris muscle attaches beneath the frenum and consequently affects the Position of the frenum, The orbicularis oris pulls the frenum forward, and the buccinator pulls it backward. Thus it requires more clearance for its action than the labial frenum does (Figure 13-7).Chapter 13 Deve ipter 13 Developing an Analogue/Substitute for the Maxillary Denture-Bearing Area 217 igure 13-7 An upper denture formed notch for the buccal frenum, The bac” frenum requires more clearance than the labial frenum because it will move posteriorly as a result of the action of the buccinator muscle and anteriorly as a result of the action of the orbiculars oris. Buccal Vestibule The buccal vestibule lies opposite the tuberosity and extends from the buccal frenum to the hamular notch. The size of the buccal vestibule varies with the contraction of the buccinator muscle, the posi- tion of the mandible, and the amount of bone lost from the maxilla. The size and shape of the distal end of the buccal flange of the denture must be adjusted to the ramus and the coronoid process of the mandible and to the masseter muscle. When the mandible opens or moves to the opposite side, the width of the buccal vestibule is reduced. When the masseter muscle contracts under heavy closing, pressures, it reduces the size of the space available for the distal end of the buceal flange. The extent of the buccal vestibule can be deceiving, because the coronoid process obscures it when the mouth is opened wide. Therefore it should be examined with the mouth as nearly closed as possi- ble. This space usually is higher than any other part pr he border. The mucous membrane ining the Paceal vestibule is similar to that lining the labial vestibule. vyatal to the buccal frenum lies the root of the zygoma, which is located opposite the first molar Fogion (Figure 13-8). With increasing reso"Pict of the ridge, it becomes more noticeable, and a den- ture may require, relief over this area 19 prevent soreness of the underlying tissue, qi ‘The hamular notch, which forms the distal litt of the buccal vestibule, is situated between the tuberosity and the hamulus of the medial pterygoid plate (see Figure 13-8). The mucous membrane of the hamular notch consists of a thick submu- cosa made up of loose areolar tissue. This tissue, in the center of the deep part of the hamular notch, can be safely displaced by the posterior palatal border of the denture to help achieve a posterior palatal seal. Vibrating Line ‘The vibrating line is an imaginary line drawn across the palate that marks the beginning of motion in the soft palate when an individual says “ah” Tt extends from one hamular notch to the other (Figure 13-9). At the midline, it usually passes about 2 mm in front of the fovea palatinae. These are indentations near the midline of the palate formed by a coalescence of several mucous gland ducts. They are always in soft tissue, which makes them an ideal guide for the location of the posterior border of the denture. The vibrating line is not to be confused with the junetion of the hard and soft palate because the vibrating line is always on the soft palate. It is not a well-defined line and should be described as an area rather than a line. The distal end of the den- ture should extend at least to the vibrating line. In ‘most instances it should end 1 to 2 mm posterior to the vibrating line. The submucosa in the region of the vibrating line contains glandular tissue similar to that in the submucosa in the posterolateral part of the hard palate. However, because the soft palate ddoes not rest directly on bone, the tissue for a few millimeters on either side of the vibrating line can be repositioned in the impression to improve the posterior palatal seal. Tn addition, the distal end of the denture must cover the tuberosities and extend into the hamular notches, Overextension at the hamular notches will not be tolerated because of pressure on the pterygoid hamulus and interference with the pterys: mandibular raphe, which extends from the hamulus to the top inside back corner of the retromolar pad in the mandible, When the mouth is opened wide, the pterygomandibular raphe is pulled forward (Figure 13-10). If the denture extends too far into the hamular notch, the mucous membrane covering the raphe will be traumatized.218 Part Three habilitation of the Edentulous Patient: Fabrication of Complete Dentures Figure 13-8 A, The root of the zygoma is close to the crest of the residual alveolar ridge because of the amount of resorption of the alveolar ridge. The bone is thinly covered by mucous membrane and may require relief of the denture border to prevent soreness. B, Hamular notch. C, Hamular process of the medial pterygoid plate. PRINCIPLES AND OBJECTIVES OF IMPRESSION MAKING The objectives of an impression are to provide sup- port, retention, and stability for the denture. An impression also will act as a foundation for improved appearance of the lips and, at the same time, should maintain the health of the oral tissues. The impression should record all the potential den- ture-bearing surfaces available. To a large extent, this surface is readily identified if the biological considerations of impression making are under- stood correctly. However, the denture’s retention is enhanced considerably if the denture extends peripherally to harness the resiliency of most of the surrounding limiting structures. An impression that records the depth of the sulcus, but not its width, will result in a denture that lacks adequate reten- tion, Although impression techniques, methods, and materials vary, they should be selected on the basis of biological factors. Too often techniques follow shortcuts without a consideration of the future damage that such procedures may induce. Fora successful impression to be achieved, the following concepts should be adhered to, irrespec- tive of the selected technique: 1. The tissues of the mouth must be healthy. 2. The impression should extend to include all of the basal seat within the limits of the functions of the supporting and limiting tissues. 3. The border must be in harmony with the anatomical and physiological limitations of the oral structures, 4. A physiological type of border-moldinz Procedure should be performed by the de- tist or by the pati dance 0 the dergitt® Patient under the guidanChapter 13, Developing oping an Analogue/Substitute for the Maxillary Denture-Bearing Area 219 Figure 13-9 The vibrating line marked by an indelible pencil. Notice the two fovea palatinae (X) in the middle of the soft palate. 5. Proper space for the selected impression material should be provided within the impression tray. 6. The impression must be removed from the mouth without damage to the mucous mem- brane of the residual ridges. 7. A guiding mechanism should be provided for correct positioning of the impression tray in the mouth. 8. The tray and the impression material should be made of dimensionally stable materials. 9, The external shape of the impression must be similar to the external form of the com- plete denture. All of these factors will contribute to a successful impression, but probably the two most important factors in making satisfactory impressions are a properly formed and accurately fitting impression tray and proper positioning of the tray within the mouth. PREPARATION OF THE MOUTH al that the oral tissues ‘be healthy before . aa y aa are made. There should be no distortion or inflammation of the denture foundation tissues. These must be eliminated before the impressions are made; otherwise, the new dentures will not fit the tis sues once they are no longer distorted by the swelling, The patient will then complain that the den- tures, although fitting well initially, became loose after a few days. The most effective way of resolving the inflammation is to ensure that patients leave their dentures out of the mouth for at least 24 hours before the impressions are made, although a longer period often is required to resolve the problem completely. ‘Many patients understandably object to leaving their dentures out because it is extremely disfiguring. The use of tissue conditioners is a very effective alterna- tive, although patients should still be encouraged to eave their old dentures out as much as possi ble before the impressions are made. Preparation of the mouth before construction of the new dentures is discussed in detail in Chapters 7 and 8. MAXILLARY IMPRESSION PROCEDURES Impressions are made with a variety of materials and techniques. Some materials are more fluid than ‘thers before they harden or set. The softer materi- als displace sof tissue to a lesser extent and require220 Part Three Rehabilitation of the Edentulous Patient: Fabrication of Complete Dentures Figure 13-10 A, The maxillary tuberosity. 8, The pterygomandibular raphe, which is pulled forward when the mouth is opened wide. C, The retromolar pad of the mandible. The cheek lies to the right in this picture and the palate to the left. less force in their molding than do more viscous materials. These variations in the working proper- ties of materials make it possible to devise different techniques for controlling the position and shape of the oral tissues. Some techniques are intended to record the shape of the tissues with a minimum of displacement; others are intended to displace the border tissues to a predetermined extent, Still oth- ers are devised to obtain controlled displacement of the tissues under the denture. Impressions that, record the tissues with minimum displacement are described as mucostatic, whereas those that dis- place the tissues are classified as mucodisplacing. ‘There is, however, no evidence to indicate that one technique produces better long-term results than another, The choice is made by the dentist on the basis of the oral conditions, concept of the function _ of the tissues surrounding the denture, and ability to handle the available impression materials. _ Regardless of the type of impression being made, the tray is the most important part of the impression-making procedure. If the tray is 100 large, it will distort the tissues around the borders of the impression and will pull the soft tissues under the impression away from the bone, distort- ing the dimensions of the sulcus in the process. Ifit is too small, the border tissue will collapse inward onto the residual ridge. This too will distort the accurate recording of the border extension of the denture and prevent the proper support of the lips by the denture flange. A properly formed tray enables the dentist to carry the impression material to the mouth and control it without distorting the soft tissues that surround it, Individual or custom trays have borders that can be adjusted so they control the movable soft tis- Sues around the impression but do not distort them. At the same time, space is provided inside the tray so that the shape of the tissues covering the den- ture-bearing area may be recorded with minimal or selective displacement. Because each mouth is dif- ferent, these requirements cannot be achieved suc-Chapter 13 13. Developi ing an Analogues cessfully with stock trays. Ther i Therefore mos Paces anvolve taking a peice impression only ina stock tay. Ths is eS in artificial stone and the resulting ena; eo oe struct a custom tray, ee i The : made with the custom try, ny ImPresson is then PRELIMINARY IMPRESSIONS Stock trays are c : oe eee ineither meta or pase they are available in a ee pinot a ranj they cannot fit the upper few of ares an Siz, hoa detorte pePRet Jaw of each individu ea Tae, oft tissues. It is, however, Ps tat the preliminary impression is as accurate as possible. An unsatisfactory preliminary impression will result in an unsatisfactory custom tray. This will in turn require considerable effort and time-consuming modifications before it can be used to make the final impression. Even a correctly selected stock tray will not fit the denture-bearing area perfectly. Therefore when the impression is made, it is advisable to select an impression mate- rial that has a relatively high viscosity, thereby allowing the material to compensate more easily for the deficiencies of the tray, The most suitable mate- rials are alginate (irreversible hydrocolloid), silicone putty, or impression compound. Silicone putty impression material has a high. viscosity. It will flow beyond the tray to compen- sate for underextension of the stock tray, and once set, it will support itself in this position. It exhibits some degree of elasticity and so will record under~ cuts with reasonable accuracy. Its high viscosity means that it records surface detail poorly, and in addition, it cannot be added to if part of the impression is deficient. a Phe irreversible hydrocolloids record detail accurately if they are properly controlled. Because i the they do not absorb the mucous secretions from Bis they can exhibit defects in the palatal part of eee impression. -Fucthermorey thei lala i ture rapidly and can conse- hydrocolloids lose moisture rapidly ané eater -. The cast quently change their size. st be poured soon after the impressions te removed from the mouth. The weight of the artificial stone ici distort the bor- of the cast may be sufficient to di ders of the impression, particularly if they are not supported by the borders of the tay Substitute for the Maxillary Denture-Bearing Area 221 Impression compound is a thermoplastic material with a high viscosity. Like silicone putty the material will flow beyond the tray to compen- sate for underextension and will support itself in this position once it is chilled. Therefore it is not necessary to correct any underextension of the stock tray before using this material. Also, addi- tions can be made to it if part of the impression is deficient. Its high viscosity means that it records surface detail poorly. In addition, it is nonelastic and so will not record undercuts accurately. In pre- vious editions of this text, a technique is described whereby a preliminary compound impression is carefully and diligently “converted” into a superb custom tray. The technique has, however, been eclipsed by the one described in this chapter and in the next one on mandibular impression making, The current technique reflects a synthesis of three considerations: developments in biomaterials, a better understanding of the macroscopic and microscopic anatomy plus physiology of the ede1 tulous milieu, and compelling clinical experiences underscoring its applied merits. The material of choice for most dentists is now a high-viscosity alginate impression material. Tray Selection The space available in the mouth for the upper impression is studied carefully by observation of the width and height of the vestibular spaces with, the mouth partway open and the upper lip held slightly outward and downward. An edentulous stock tray that is approximately 5 mm larger than the outside surface of the residual ridge is selected. The dentist places the tray in the mouth and ini- tially positions it by centering the labial notch of the tray over the labial frenum. The posterior extent of the tray relative to the posterior palatal seal area is maintained, and then the handle is dropped downward to permit visual inspection (Figure 13-11). Posteriorly, the tray must include both the hamular notches and vibrating line. ‘Alginate impression material will not support itself away from the confines of the tray, so any areas of underextension need to be corrected with soft boxing wax before the impression is made ‘Acommon site for a stock tray to be underextended ig around the tuberosities and into the buccal