Dr.

Shriya Marya Department of Prosthodontics

INTRODUCTION DEVELOPMENT OF MANDIBLE OSTEOLOGY ORAL ANATOMIC CONSIDERATIONS IN PROSTHODONTICS

ANATOMIC LANDMARKS MUSCLE ATTACHMENTS ANATOMIC CONSIDERATIONS FOR IMPLANTS

INNERVATION OF THE MANDIBLE BLOOD SUPPLY OF THE MANDIBLE AGE CHANGES CONCLUSION REFERENCES

 The mandible forms the lower jaw and holds the lower teeth in place It is the largest, strongest and lowest bone in the face It has a horizontally curved body that is convex forward and two broad rami that ascend posteriorly It articulates with the glenoid fossa in the temporal bone in the base of the skull

 Stomodaeum (future mouth) is a depression bound by

Cranially by the bulging process of the brain Caudally by the pericardium

Formation of neck:
Elongation of the region between the stomodaeum and the pericardium A series of mesodermal thickenings appear in the wall of the cranial most part of the fore gut

Known as Pharyngeal or Branchial arches

 Each arch has a skeletal element, a striated muscle, and an arterial arch. Also each arch is supplied by a particular nerve The first arch is called the mandibular arch. As the mandibular arches grow towards each other, they give off a bud from its dorsal end which leads to the formation of the maxillary arch The cartilage of the first arch is known as Meckels cartilage

 The cranial ends of the Meckels cartilage are connected with the ear capsules, and their distal extremities are joined to one another at the symphysis by mesodermal tissue. From the cranial end of each cartilage the malleus and incus are developed The next succeeding portion, as far as the lingula is replaced by fibrous tissue, which persists to form the sphenomandibular ligament The cartilage is surrounded by thick fibrocellular tissue membrane in which intra membranous ossification occurs

Mandible of human embryo (24mm long) outer aspect

 Ossification takes place in the membrane covering the outer surface of the ventral end of Meckels cartilage. Each half of the bone is formed from a single center which appears near the mental foramen. This intramembranous ossification forms the body and ramus of the mandible.

The portion of Meckels cartilage which lies below and behind the incisor teeth is surrounded and invaded by the membrane bone. The rest of the meckels cartilage disappears, except for the spheno-mandibular ligament

 Somewhat later, accessory nuclei of cartilage make their appearance

Wedge-shaped nucleus in the condyloid process and extending downward through the ramus Small strip along the anterior border of the coronoid process Smaller nuclei in the front part of both alveolar walls and along the front of the lower border of the bone

 The condylar secondary cartilage appears during the 10th week of IUL. Cartilage cells differentiate from its center and the cartilagenous condylar head increases in size by interstitial and appositional growth. 14th week First evidence of endochondral bone in the condyle region Much of the cartilage is replaced with bone by the middle of the fetal life; but its upper end persists into adulthood , acting as both growth centre and articular cartilage. At birth the mandible consists of two parts, united by a fibrous symphysis, in which ossification takes place during the first year

Mandible of human embryo (95mm long) outer aspect

 Consists of a Horse-shoe shaped body Pair of rami Coronoid process Condylar process

 Two borders
It contains the alveolar process with the sockets for the teeth

Extends postero-laterally from the symphysis to join with the ramus at the angle of the mandible. It consists of a concavity on either side of the symphysis, after that it is rounded and smooth

 line at which two halves of the mandibular process join median triangular projection

 lies between the roots of the pre molars The mental nerves and vessels exit from here continuation of the sharp anterior border of the ramus which runs downward and forward depression just beneath the incisors

 Ridge that runs downwards and forwards. The mylohyoid muscle attaches here It is sharp and distinct near the molars and fades anteriorly

 Hepression beneath the mylohyoid line. It lodges the submandibular gland Hollow above the mylohyoid line that lodges the sublingual gland Four small elevations on posterior surface of symphysis menti The upper ones give attachment to the genioglossus and the lower to geniohyoid

 Quadrilateral in shape Two surfaces:

flat with a number of longitudinal ridges. It bears attachment to the masseter muscle lies a little above the middle of the ramus at occlusal level of the teeth. The inferior alveolar nerves and vessels enter the mandibular canal through this sharp tongue shaped projection forming anterior border of the mandibular foramen begins just below the mandibular foramen

 Four borders:
thin and forms a notch called the mandibular notch
its the backward continuation of the inferior border of the body of the ramus thin and continuous with the anterior border of the coronoid process it is thick and continues as the neck of the condyle

 It projects upward and slightly forward as a triangular plate of bone Its posterior border bounds the mandibular notch and the anterior border is continuous with the ramus The temporal crest is a ridge that runs on its medial side from the tip of the process till its base The temporalis muscle is attached here

 Strong upward projection from the postero-superior part of the ramus The upper end expands to form the head, while the constriction below the head forms the neck When viewed from above the head is ovoid in shape, with the antero-posterior diameter half of the mediolateral diameter
3/4th inch (19mm) wide Less than inch (12.5mm) long anteropsteriorly

 The neck of the condyle is constricted to about half of the size of the head The anterior surface of the neck contains the pterygoid fovea, where the lateral pterygoid muscle attaches

 The condylar process of the mandible articulates with the glenoid fossa of the temporal bone to form the temporomandibular joint It allows for hinge as well as gliding movement hence it is a called a Ginglymo-arthroidial joint

 It consists of:
Bony components: Condylar process of mandible Mandibular or glenoid fossa of temporal bone Articular disc Its is a biconcave dense fibrous tissue disc that divides the TMJ into the upper (meniscotemporal) compartment and the lower (meniscomandibular) compartment Ligaments Fibrous capsule Lateral/temporomandibular ligament Sphenomandibular ligament Stylomandibular ligament

Glenoid fossa Articular disc Articular eminence Condylar process

 A prosthesis must function in harmony with the tissues that support them and those that surround them Hence the dentist must understand the macroscopic as well as microscopic anatomy of the supporting and limiting structures of the denture This knowledge aids in determining
The selective placement of forces by the denture bases upon the supporting tissues The form of the denture borders that will be harmonious with the normal function of the limiting structures that surround them

Retromylohyoid fossa Pterygomandibular raphe

Retromolar pad

Tongue
Buccal shelf Residual alveolar ridge

Buccal vestibule

Premylohyoid eminence Lingual frenum

Buccal frenum

Lingual flange

Labial frenum

Labial vestibule

 Denture support is the resistance to vertical forces of mastication, occlusal forces and other forces applied in a direction towards the denture-bearing area The supporting structures are those areas of maxillary and mandibular edentulous ridges that are considered best suited to carry the forces of mastication when dentures are in function
Support for the lower denture is provided by the mandible and the soft tissues overlying it Some parts of the mandible are more favorable for this function than others and pressure must be selectively applied only in these areas that can resist the stresses of

 The areas of support are divided into 1. Primary

Usually at right angles to the occlusal forces Do not resorb easily Buccal shelf area Either at an angle greater than 90 to the occlusal forces, or parallel to them Tend to resorb at a higher rate Slopes of the ridge

2. Secondary

 It is defined as the portion of the alveolar ridge and its soft tissue covering which remains following the removal of teeth. It forms the main supporting area in edentulous maxillae and mandibles It can be classified as:
Inverted U Inverted V Knife edged

The surface of the ridge can be

Smooth-even Rough-uneven

 The ideal ridge:

high ridge with a Flat crest and parallel sides. It will give maximum amount of support and stability.

As age advances
the ridge resorbs and either become flatter, V shaped or Knife edged. Knife edged ridges with multiple bony spicules offer the poorest prognosis. Incapable of withstanding occlusal force. Can easily become sore.

 CREST
It is covered in a healthy mouth by keratinized stratified squamous epithelium The mucosa is firmly attached by its sub mucosa to the periosteum of the mandible The extent of its attachment to the bone varies greatly

 It might be loosely attached to the bone over the entire crest, rendering the mucosa movable Movable soft tissue must be registered carefully in its resting position In relatively few patients the mucosa is firmly attached which is capable of providing soft-tissue support for lower denture

 Mostly the underlying bone in this region is cancellous and hence prone to resorption due to the lack of a cortical bony covering Even though the fibrous tissue closely attached to the bone is favorable for resisting the occlusal load, if the underlying bone is cancellous, this advantage is lost Therefore in such scenarios the area should be relieved while making the impression

 It is the PRIMARY support of the mandibular denture Also known as Buccal flange area Boundaries:
Anteriorly by the buccal frenum Distally by the retro molar pad Medially by the crest of the residual alveolar ridge Laterally by the external oblique ridge

RETROMOLAR PAD BUCCAL SHELF TONGUE

RESIDUAL ALVEOLAR RIDGE

 It is usually quite wide (4-6mm wide on an average mandible, 2-3 mm in a narrow mandible) Factors making buccal shelf ideal for stress bearing:
Perpendicular to the direction of occlusal forces The mucous membrane here is less keratinized and more loosely attached than ideal, but the bone has a layer of compact bone containing haversian systems The fibers of the buccinator run horizontally in the sub mucosa and are attached here. The contraction of these muscle fibers directed antero-posteriorly tend to stabilize the denture instead of displacing it. This allows the denture to rest on this part of the muscle without damage to the muscle as well

 SLOPE OF THE RESIDUAL ALVEOLAR RIDGE

It serves as the secondary stress bearing area in the mandible The sub mucosa here is firmly attached to the periosteum The epithelium is keratinized

A Crest of residual alveolar ridge B Buccal shelf (cortical bone) C Mental foramen D Genial tubercles E Coronoid process

 Sicher has described the retromolar pad as a soft elevation of the mucosa that lies distal to the third molar It is covered by smoother, less keratinized epithelium than the crest Contents :
Glandular tissue Temporalis tendon posteriorly Buccinator enters buccally Medially - pterygomandibular raphe and superior constrictor

 The term Pear-shaped pad was coined by Craddock It forms the distal termination of the ridge The mandibular denture should terminate over the distal edge of this pad Importance:
It is an area that rarely resorbs the temporalis muscle exerts tensile stimulus onto the bone, which responds by growth and apposition It ensures the peripheral seal of the denture is maintained It can be used as a landmark for placement of occlusal plane

 Teeth should not be placed on the retromolar pad. Reason:

Bone is situated in a inclined plane and hence forces exerted on teeth in this area will not be directed perpendicular to the bone This would lead to dislodgement of the denture It would lead to soreness of tissue

 The mucosa covering the residual alveolar ridge has been classified by HOUSE as:
Class 1: healthy Class 2: irritated Class 3: pathologic

 The denture should be extended as far as possible within the limits of health and function of tissues and structures that support and surround them 1. 2. 3. 4. 5. 6. 7. 8. Labial frenum Labial vestibule Buccal frenum Buccal vestibule Lingual frenum Alveololingual sulcus Retromolar pad Pterygomandibular raphe

 Usually a single narrow band, but may consist of 2 or more bands It is shorter and wider than the maxillary frenum It contains a band of fibrous connective tissue that helps to attach the orbicularis oris

 It is an active frenum and hence quite sensitive The activity of this frenum is mostly in a vertical direction, hence a narrow notch should be made in the denture to accommodate the frenum and maintain the peripheral seal without causing soreness The incisivus (depressor labi inferioris) may also alter the extent of the denture in this region

 It is the region between the labial frenum and the buccal frenum The major muscle in this region is orbicularis oris The muscle fibers in this region are mainly horizontal hence care must be taken not to over extend the impression in this area The mentalis muscle originates from the mental tubercles and inserts into the lower lip. It is a vertical muscle and may be very active in some patients Hence careful border moulding in this area is essential

 Excessive muscle activity here may leads to a very short denture flange which may affect the seal of the denture But the drape of the lip and cheeks usually creates a facial seal which compensates In a ridge with a good vertical height, the labial denture border should be thin (1-2mm) since a thicker border might distort the lip But if the ridge is flat, a thicker border is needed for lips and cheek support and to provide a better seal

 It connects as a continuous band through the modiolus at the corner of the mouth and on up to the buccal frenum of the maxilla This usually exists in the area of the pre-molars It is mostly made of multiple bands Muscles:
Buccinator Depressor anguli oris

 The muscular activity in this region is more in a horizontal direction rather than in a vertical direction ( such as while puckering, grinning) The fibrous and muscular tissues pull across the denture borders, hence the extent of the denture in this region is less. Hence proper functional trimming of the denture is essential here

 The frenum attachment level has been classified by House:

: low in the mandible with respect to crest of the

ridge
: medium : freni encroach on the crest of the ridge and may interfere with the denture seal

 It extends from the buccal frenum up to the retro-molar pad Its width and length are mainly dependent on the buccal shelf area and the buccinator muscle The length of the buccal flange usually extends up to the lateral end of the buccal shelf or the external oblique ridge. Palpation of the external oblique ridge is a valuable aid in helping to determine the amount of resistance or the lack of resistance offered by the border tissues in these areas This length is not very critical for the peripheral seal because the drape of the cheek provides facial seal

 The thickness of the borders in this region should always be smooth and round so as not to irritate the cheek Their thickness should be about 2mm The buccinator in this region does not displace the denture as the direction of muscle fibers and their action is parallel to the borders of the denture The resistance offered to the denture in this region decreases within a few weeks of wearing the denture as the tissues are stretched

 Muscular attachment level (by House):

Class 1: attachment is low in the mandible with respect to crest of the ridge (0.5 inches or more between level of attachment and crest of the ridge) Class 2: attachment height in relation to the crest of the ridge is between 0.25 0.50 inches Class 3: attachment height is less than 0.25 inches from the ridge crest

 The distobuccal corner of the mandibular denture must converge rapidly to avoid displacement because of contracting pressure of the masseter muscle whose anterior fibers pass outside the buccinator muscle in this region Contraction of the muscle alters the shape and size of the distobuccal end of the lower vestibule as it pushes inward If the ramus has a perpendicular surface and the origin of the muscle on the zygomatic arch is medial-ward the muscle pulls more directly across the denture border

 Registration of this pull can be done by:

Softening of the compound in the distobuccal region Insert in patients mouth Apply downward pressure by placing the index finger in the second molar region Asking patient to exert closing force

 Pic frm levin page 42

STRAIGHT

CONCAVE

CONVEX

Moderate Activity Straight Line Active Muscle Concave Inactive Muscle - Convex

 Distal extension of the mandibular impression is limited by

The ascending border of the ramus By the buccinator as it crosses the mandible from buccal to lingual to join the pterygomandibular raphe and the superior constrictor muscle By the sharpness of the lateral bony boundaries of the retromolar fossa (formed by continuation of the external and internal oblique ridges as they ascend the ramus)

The desirable extent is slightly lingual to these bony prominences and including the retro molar pad under the denture forms an excellent soft-tissue seal

 It is a fold of mucous membrane extending from the floor of the mouth to the ventral surface of the tongue The height and the width of the lingual frenum varies considerably. High frenum attachment is called a TONGUE TIE. It should be corrected as it affects the denture stability.

 It is the space between the tongue and the residual alveolar ridge It extends from the lingual frenum to the retromylohyoid curatin It can be divided into three parts:
Anterior vestibule (sublingual crescent area) Middle vestibule (mylohyoid area) Distolingual vestibule (lateral throat form)

 Also known as sublingual crescent area or anterior sublingual fold Extent: from the lingual frenum point where the mylohyoid ridge curves down below the level of the sulcus Roberts has written that the anterior vestibule should have a border that is as thick as possible, similar to a dam, in order to ensure a better seal

 On palpation a depression known as premylohyoid fossa can be felt Due to the mandible joining the convexity of the mylohyoid ridge Influenced by:
Genioglossus Lingual frenum Sublingual gland (to some extent)

 Lingual frenum is superimposed over the genioglossus which raises the tongue If the mandibular ridge is highly resorbed the attachment of the genioglossus lies almost at the level of the crest of the alveolar ridge. Surgical sulcus deepening may be required in such scenarios

 The width of the border of the denture in this region is usually about 2mm. But the width depends on the tonicity of the genioglossus The genioglossus and the lingual frenum are recorded by asking the patient to moderately protrude the tongue as these tissues do not tolerate impingement

 Also known as mylohyoid vestibule Forms the largest part of the alveololingual sulcus Influenced by:
Mylohyoid muscle Sublingual glands

 The mylohyoid ridge is close to the crest of the ridge in the molar region and close to the lower border of the mandible in the anterior region

 It is important to determine the prominence of the ridge because:

It may interfere with the development of a correct lingual flange A sharp ridge may cause pain

The extension of the denture can go beyond the mylohyoid muscle line as the mucolingual fold is not in that area. Also as the fibres are directed in a forward and downward direction they allow for denture extension beyond the level of muscle attachment
Ensures soft-tissue peripheral seal

 Impression may depart from stress bearing area of lingual surface of ridge, hence the flange will be suspended under the tongue in soft tissues in a direction parallel to the direction of the mylohyoid muscle Advantage of this:
Lack of direct pressure on this sharp edge of bone will reduce chances of soreness Completion of border seal Even during muscle contraction of mylohyoid muscle the denture will not be displace

 During rest when the mylohyoid lies low, there will be a space between the mylohyoid muscle and the denture border But during muscle contraction this gap will close The final length and breadth of the flange can only be determined by skillful border moulding and impression procedure On an average the denture border lies usually 4-6mm below the mylohyoid line, but it varies from patient to patient

 They are located above the mylohyoid muscle Their size usually varies from small to big enough to lie at a level higher than the residual ridge

 Usually very soft and displaceable The sublingual gland cannot be visualised and need to be palpated Unless they are firm, they do not influence the impression much

 Also known as lateral throat form or retromylohyoid fossa Bound

Anteriorly Mylohyoid Muscle Laterally Pear Shaped Pad Postero-laterally Superior Constrictor Muscle Postero-medially Palatoglossus Medially Tongue

 The superior constrictor muscle originates from the pterygomandibualr raphe This raphe arises from the hamular process of the medial pterygoid plate and gets attached to the mylohyoid ridge. This raphe also gives origin to the buccinator along with the superior constrictor
The posterior extent of the mandibular denture is determined by the palatoglossus muscle and some what by the weaker superior constrictor muscle, which is easily displaceable This area is known as the retromylohyoid curatin

 The retromylohyoid curtain:

Overlies the superior constrictor muscle in the postero-lateral portion Covers the palatoglossus and the lateral surface of the tongue in the postero-medial portion The medial pterygoid muscle lies just posterior to it

Contraction of medial pterygoid can cause a bulge in the wall of Retromylohyoid curtain

 The S curve of the mandibular denture, results from the stronger intrinsic and extrinsic tongue muscles, which usually places the retromylohyoid borders more laterally and toward the retromolar fossa than in the mylohyoid area

 Neil classified the Lateral Throat Form: CLASS I

The anatomic structure will accommodate a fairly long and wide flange Thickness can vary from 2-3mm upto 4-5mm for better seal if the border is flat The retromylohyoid curtain area should be thinner (2-3mm) and very rounded and smooth so as not to interfere with the palatoglossus muscle

 CLASS III
It has minimum length Border usually ends 2-3mm below the mylohyoid ridge, or sometimes, at the mylohyoid ridge Thickness should be no more than 2mm, or even knife edged if it has to end at the mylohyoid ridge

 CLASS II:
Half as long and wide as Class I Twice as long as Class III Most common

1. Mylohyoid muscle 2. Palatoglossus muscle 3. Superior constrictor muscle 4. Pterygomandibuilar raphe 5. Buccinator muscle

 The proper extension of the mandibular denture into the lingual sulcus, within their anatomical and functional limits, ensure a proper peripheral seal Also, these flanges present favorable inclined planes to the tongue resulting in vectors of forces that help maintain the mandibular denture in place

 These are the areas that cannot bear the forces of occlusion These areas in the mandibular arch are: Mylohyoid ridge Mental foramen Genial tubercles Mandibular tori

 Soft tissues often hide the sharpness of the mylohyoid ridge which can be found by palpation. Mucous membrane over a sharp or irregular mylohyoid ridge will be easily traumatized by denture base, unless relief is provided in the denture base.

 As resorption takes place, the mental foramen will come to lie closer to the crest of ridge. In these circumstances, the mental nerve and blood vessels may be compressed by denture base unless relief is provided. Pressure on mental nerve can cause numbness of lower lip.

Severely resorbed mandible with the mental foramen placed close to crest of the ridge

 Like the mental foramina, the genial tubercles usually lie well away from the crest of the ridge. With resorption they becomes prominent and closer to crest In severly resorbed cases they may rerquire surgical correction

 Torus mandibularis is a bony prominence. Usually found bilaterally and lingually near the first and second premolars.

 Superior border of the torus may be flush with crest of the residual ridge in severe resorption The torus mandibularis is covered by an extremely thin layer mucous membrane It can be difficult to provide relief within the denture without breaking the border seal It often needs surgical removal

 Buccal or Facial attachments

Mentalis muscle Buccinator muscle Masseter muscle Platysma Depressor anguli oris Depressor labi inferioris

 Lingual or Medial attachments

Mylohyoid muscle Genioglossus muscle Medial pterygoid muscle Lateral pterygoid muscle Temporalis muscle

 Muscles of mastication have their origin from the bone of the skull and is attached to the mandible. These muscles are involved not only in the masticatory movements of the mandible, but also in the nonmasticatory movements.

 It is a quadrilateral muscle that covers the lateral surface of the ramus of the mandible It has three layers:
Superficial Middle Deep

 Origin:
Zygomatic arch

Insertion
Superficial: Lower part of lateral surface of ramus Middle: Middle part of ramus Deep: Upper part of ramus

Action
Elevates the mandible to bite

Influence in prosthodontics:
Distobuccal flange on lower denture

 It is a fan shaped muscle It fills the temporal fossa Origin:

Temporal fossa Temporal fascia

Insertion:
Margins and deep surface of coronoid process Anterior border of ramus

 Action:
Elevates the mandible Postrerior fibers retract the protruded mandible Helps in side to side grinding movement

 Significance of temporalis in prosthodontics:

It may affect the mandibular posterior denture border Elevator muscle -- co ordinates the closing movements, brings teeth in contact Significant positioning muscle of the mandible.

 It is a quadrilateral muscle It has two heads

Superficial Deep

Action:
Elevation Protrusion Unilateral contraction brings about movement of the mandible to the opposite site

 Origin:
Superficial head tuberosity of maxilla and adjoining bone Deep head medial surface of the lateral pterygoid and adjoining process of palatine plate

Insertion
Roughened area on the medial surface of angle and adjoining ramus of the mandible

Medial pterygoid m.

 It is a short conical muscle It has two heads

Upper head (smaller) Lower head (larger)

Origin:
Upper head infratemporal surface and greater wing of sphenoid Lower head lateral surface of lateral pterygoid plate

 Insertion
Pterygoid fovea on the anterior surface of the neck of the condyle Anterior margin of articular disc and capsule of temporomandibular joint

lateral pterygoid m.

 Actions:
Bilateral contraction brings about protrusion by pulling condyle down the eminence (acts with depressors) Unilateral contraction creates a mediotrusive movement of that condyle causes a lateral movement of the mandible to the same side

Inactive during jaw opening, becomes active only in conjunction with the elevators. Especially active during power stroke & when teeth are held together.

 Buccinator is a broad band of the muscle, forming the entire side wall of the cheek. It passes along the outer surface of the maxilla and mandible until it reaches the ramus, where it passes to the lingual surface to join the superior constrictor at the pterygomandibular raphe.

It originates in three sets of fibres with separate innervations Upper fibres Middle fibres Lower fibres The middle fibres constitute the most active muscle, whose function is primarily to control the food bolus during mastication. They also cross the modiolus and called orbicularis oris muscle.
Buccinator muscle

 The upper and lower fibres are relatively flaccid, especially at the area of origin. The insertion of the buccinator muscle into and through the modiolus, permits this muscle to move the angle of the mouth:
backward, with the middle fibres. upwards with the upper fibres. downwards with the lower fibres.

 A fan shaped muscle which forms the main bulk of the tongue Origin - Genial tubercles Insertion
Upper fibers into the tip Middle fibers dorsum of the tongue Lower fibers hyoid bone

Action
Upper fibers retract tip Middle fibers depress tongue Lower fibers protrude tongue

 Flat, triangular muscle Origin mylohyoid line on mandible Insertion

posterior fibers body of hyoid bone Middle and anterior fibers median raphe between mandible and hyoid bone

Action
Elevates floor of the mouth Depression of mandible Elevate the hyoid

 MANDIBULAR CANAL AND MENTAL FORAMEN

The canal - may be placed at high, low or intermediate location may be divided into two or three rami Hence it is essential to conduct proper radiographic examination using conventional and tomographic radiography, as well as MRI At the distal aspect of first molar, the canal is at its lowest point. So this is the safest place for implant placement In the horizontal plane , the canal: -begins posteriorly at the lingual cortical plate -crosses over laterally to the buccal cortex to exit at the mental foramen --1stmolar region: midway between the two cortical plates

 An adequate safety margin of about 2 mm above the inferior alveolar canal is recommended In excessively resorbed ridge, the mental foramen with its neurovascular contents can be found on the crest of the ridge. Surgical manipulation of mucoperiosteum in this region must avoid the injury to these vital structures

 Lingual nerve
Since the nerve lies just medial to the retromolar pad, incision in this region should remain lateral to the pad

Nerve to mylohyoid
Motor branch of inferior alveolar nerve given off just before the nerve enters the mandibular foramen. Since the nerve is closely related to the ramus of mandible, surgical interventions in this area may lead to injury of this important motor nerve.

 Long buccal nerve

Nerve courses between the two heads of lateral pterygoid muscle, then proceeds medial to and sometimes within the medial tendon of temporalis, to gain access to the surface of buccinator muscle Surgical manipulation in this area during insertion of a sub periosteal implant may injure this nerve.

 Mucoperiosteal reflection
While reflecting the mucoperiosteal flap for subperiosteal implants, lingually the mylohyoid muscle gets reflected in the second molar region Similarly, surgical manipulation of the tissue of the floor of the mouth may lead to edematous swelling of the sublingual space Ecchymosis from blood accumulation may occur in sublingual or submandibular space

 Superior genial tubercles

May be located near to the crest of mandibular edentulous ridges. Hence the muscle also has the chance of getting detached when mucoperiosteal flap is reflected lingually However, the muscle should not be completely detached from the tubercle, as this may result in retrusion of the tongue and possible airway obstruction.

Attachment of the temporalis muscle

Superficial tendon located laterally and deep tendon medially. The incisions placed on the anterior ascending ramus for subperiosteal or blade implants should be inferior to the insertion of the two tendons of temporalis

 Mentalis muscle attachment

Complete reflection of mentalis muscles for the purpose of extension of a subperiosteal implant or symphyseal intraoral graft may result in witchs chin, probably caused by the failure of muscle reattachment. If the muscle is completely detached to expose the symphysis then an elastic bandage is applied externally Hence, the inferior portion of the mental protuberance should not be interfered with.

 Infection, in some cases, may start and spread lingually and lead to an abscess or cellulitis in the sublingual or submandibular space Extensive bilateral sublingual and submandibular cellulitis is a life threatening condition known commonly as Ludwigs Angina Masseter muscle
The muscle can be easily deflected during surgery to expose the bone for the ramus extension needed for lateral support of the subperiosteal implant. The space between the masseteric fascia and the muscle is a potential surgical space, the masseteric space, into which the infection may spread, causing myositis and trismus

 Medial pterygoid muscle

Forms the medial boundary for pterygomandibular space This space is entered when an inferior alveolar nerve block is administered. This space may also be entered when surgery for unilateral subperiosteal implant is performed Infection of this space is dangerous because of its proximity to the parapharyngeal spaces and potential of the infection to spread into mediastinum

 Ideally it is aligned with the forces of occlusion and is parallel to the long axis of the prosthodontic restoration. The alveolar bone angulation represents the root trajectory in relation to the occlusal plane. Rarely does this bone angulation remain constant after the loss of teeth Posterior mandibular region.
Submandibular fossa mandates implant placement with increasing angulation as they progress distally. Second premolar region 10 degrees First molar region 15 degrees Second molar region 20-25 degrees.

 INFERIOR ALVEOLAR NERVE

Branch of posterior division of Mandibular nerve It appears at the inferior border of the lateral pterygoid muscle, courses downward and enters the mandibular foramen on medial aspect of the mandible Branches: Nerve to mylohyoid Mental nerve Incisive nerve

 LINGUAL NERVE
Branch of posterior division of Mandibular nerve It also appears at the inferior border of the lateral pterygoid muscle anterior to the inferior alveolar nerve and enters the oral cavity above the posterior edge of the mylohyoid muscle It is joined by the chorda tympani nerve in the infra-temporal fossa which carries taste fibers from anterior 2/3rd of the tongue

LONG BUCCAL NERVE

Sensory branch of the mandibular division of the trigeminal nerve Supply skin and mucous membrane of the cheek and the buccal mucosa opposite the mandibular molar region

 INFERIOR ALVEOLAR ARTERY

Enters mandible along with the inferior alveolar nerve Gives off lingual artery before entering the mandibular canal

Coronoid process, condylar process, angle of the mandible

Blood supply is by the arteries that supply the muscles that attach to these sites

Periosteal vessels

 Blood circulation in young adults centrifugal With age direction of blood flow may reverse Inferior alveolar artery is prone to arteriosclerotic changes Reduction in blood flow may be associated with tooth extraction.

 The blood flow may become almost negligible. In such cases the mandibles receives blood from:
Periosteal vessels Mandibular branch of sublingual artery Facial artery Muscular branches of maxillary artery These anastomoses are critical in case of implant dentistry as dehiscence of mucosa at the incision lines during flap reflection have been reported.

 After birth the two segments of the bone become joined at the symphysis, from below upward during the first year but a trace of separation may be visible in the beginning of the second year near the alveolar margin.

Once the teeth erupt, the body becomes elongated in its whole length, but more especially behind the mental foramen, to provide space for the three additional teeth developed in this part.

 The depth of the body increases owing to increased growth of the alveolar part, to afford room for the roots of the teeth, and by thickening of the subdental portion which enables the jaw to withstand the powerful action of the masticatory muscles. The mandibular canal, after the second dentition, is situated just above the level of the mylohyoid line; and the mental foramen occupies the position usual to it in the adult. The angle becomes less obtuse, owing to the separation of the jaws by the teeth. By about the fourth year it is 140.

 In the adult the alveolar and subdental portions of the body are usually of equal depth. The mental foramen opens midway between the upper and lower borders of the bone, and the mandibular canal runs nearly parallel with the mylohyoid line. The ramus is almost vertical in direction, the angle measuring from 110 to 120.

 In old age the bone reduces in size due to the loss of the teeth the and, consequently, the chief part of the bone is below the oblique line.

The mandibular canal, with the mental foramen opening from it, is close to the alveolar border.
The ramus is oblique in direction, the angle measures about 140, and the neck of the condyle is more or less bent backward.

 The bone mass is maximum at during midlife The turnover and metabolism of the bone undergo a change with age, and in older individuals, the resorption surpasses the formation of bone Residual ridge resorption may also be a manifestation of type I or post-menopausal osteoporosis

 Progressive resorption of the ridges makes the mandible wider and the maxilla narrower

The lines A and B represent the centres of the ridges. The distance between them becomes greater as the maxilla and mandible resorb

 Older people take a vast variety of potentially xerostomic drugs for allergies, heart problems etc Sjogrens syndrome and radiation treatment also reduce salivary flow Even though the change in quality of saliva may not be evident on initial clinical examination, it should be suspected as a cause for denture intolerance if a patient is on multiple medications

 Stomatitis and other mild inflammations are the most commonly encountered in older edentulous mouths External carcinogens such as nicotine and alcohol become more damaging to the oral mucosa with age due to atrophy

 The knowledge of oral anatomy, microscopic as well as macroscopic better equips us as prosthodontists to
Decide how to make the impression What material to use How to plan the treatment

All this will result in a successful prosthetic treatment

 Grays Anatomy : The Anatomical Basis Of Clinical Practice, 14th edition. Elsevier ,2008 T.W.sadler : Langmans Medical Embryology, 11th edition. Zarb Bolender, Biological considerations of mandibular impressions. : Bouchers Prosthodontic Treatment For Edentulous Patients, 9th Edition. 174-203 Charles M.Heartwell : Syllabus Of Complete Dentures, 4th Edition. Grays anatomy, The anatomical basis of clinical practice. 455-92 Bocage M, Lehrhaupt J. Lingual flange design in complete dentures. J Prosthet Dent. 1977 May;37(5):499-506.

 Chaurasia B.D. Osteology of head and neck. In Human anatomy dissection and Clinical Volume 3 Head, Neck and Brain 4th Edition. CBS publishing.31-4 Chaurasia B.D. Temporal; and infratemporal fossa. In Human anatomy dissection and Clinical Volume 3 Head, Neck and Brain 4th Edition. CBS publishing. 144-151 Levin B. Related Anatomy, Impressions for Complete Dentures. Quintessence publishing Co.,1984. 35-60 Carl E. Misch, Contemporary Implant Dentistry 3rd edition. Elsevier Roberts, A.C. Full denture impression making. J. Prosthet. Dent. 1:213-228, 1951