ORAL MUCOUS MEMBRANE

contents
 Introduction
 Definition
 Functions
 Classification
 Components
 Age changes
 Prosthodontic considerations
 Mucosal response to Prosthesis
 conclusion
 INTRODUCTION
 The surface of the oral cavity is a mucous membrane.

 The oral mucosa is continuous with the skin of the lip through the
vermilion border, posteriorly continuous with the mucosa of the pharynx.

 Its structures vary in an apparent adaptation to function in different

regions of the oral cavity.

 Areas involved in the mastication of food, such as the gingiva and hard
palate, have a much different structure than the floor of the mouth or the
mucosa of the cheek.
 Definition
 The oral mucosa consists of epithelium and connective tissue
termed lamina propria. The oral mucosa is attached by a
loose connective tissue, termed submucosa, to the underlying
structure that may be bone or muscle. The oral mucosal
epithelium is of stratified squamous type.
Functions
 DEFENSE: It is an effective barrier to the entry of microorganisms, it
is impermeable to bacterial toxins, and also secretes antibodies, and
has an efficient humoral and cell-mediated immunity.

 SENSORY: It is sensitive to temperature, touch, pressure, and pain.

The sensation of taste is unique, felt only in the anterior 2/3rd of the
tongue. Reflexes like swallowing, gagging, and salivation are also
initiated by receptors in oral mucosa.

 ESTHETICS: lips and gingiva enhance facial esthetics

 PROTECTION: The oral mucosa protects the deeper tissues from

mechanical forces resulting from mastication and from the abrasive

nature of foodstuffs.

 LUBRICATION: The secretion of salivary glands keeps the oral cavity

moist and thus prevents the mucosa from drying and cracking thereby
ensuring an intact oral epithelium.

 PERMEABILITY AND ABSORPTION: generally, it is not permeable

except for the floor of the mouth which is the thinnest area. Certain
drugs like nitrates sublingually, buprenorphine – sublingual/buccal, and
estradiol – through the cheek.
 classification
1.BASED ON FUNCTION

MUCOSA

Masticatory Specialized
Lining mucosa
mucosa mucosa

1. Masticatory mucosa (gingiva and hard palate)

2. Lining or reflecting mucosa (lip, cheek, vestibular fornix, alveolar mucosa, floor
of mouth, and soft palate)
3. Specialized mucosa (dorsum of the tongue and taste buds)
2. BASED ON TYPE OF EPITHELIUM:

MUCOSA

NON-
KERATINIZE
KERATINIZE
D
D

ORTHO PARA
KERATINIZED KERATINIZED
KERATINIZED MUCOSA:
1. Gingiva
2. Hard palate

NON-KERATINIZED MUCOSA:
1. Firmly Attached 2. Loosely Attached
a. soft palate a. Floor of the mouth
b. Lip b. Vestibule
c. Cheek c. Alveolar mucosa
d. ventral surface of the tongue

SPECIALIZED MUCOSA: Dorsal surface of Tongue

 Histology
 Consists of 3 components
oral epithelium (stratified squamous epithelium)
basement membrane
connective tissue
 The interface between epithelium
and connective tissue is usually
irregular and upward projections
of connective tissue called the
connective tissue papilla.
 These papillae interdigitate with
epithelial ridges.
 The structural interface between
epithelium and connective tissue
is called the basement membrane
COMPARISON OF ORAL MUCOSA WITH SKIN AND
INTESTINAL MUCOSA:

 The structure of oral mucosa resembles the skin and intestinal

mucosa. Like the skin, it is composed of two layers—epithelium
and connective tissue. These layers are analogous to the
epidermal and dermal layers of the skin. It is also similar to
intestinal mucosa in that it has an epithelium, lamina propria,
and is attached by the submucosa to the underlying muscles.
 The epithelium of the skin is always ortho-keratinized, but the oral
mucosal epithelium depending on the region may be nonkeratinized,
and if keratinized, the keratinization may be ortho- or para-
keratinized. the epithelial tissues of the gingiva and the hard palate
(masticatory mucosa) are keratinized, although in many individuals
the gingival epithelium is para keratinized

 The cheek, faucial, and sublingual tissues are normally

nonkeratinized.
 The epithelium, in turn, is formed into ridges that protrude
toward the lamina propria. These ridges interdigitate with the
papillae and are called epithelial ridges
 When tissue is sectioned and examined under microscope, these
ridges look like pegs as they alternate with the papillae, forming a
serpentine interface.
 The term rete pegs is also used to denote rete ridges.
THE EPITHELIUM :

 The epithelium of the oral mucous membrane is of the stratified

squamous variety.
 Both keratinized and nonkeratinized epithelia consist of
two groups of cells, namely the keratinocytes and non-
keratinocytes.

 Keratinocytes: are epidermal/epithelial cells that

synthesize keratin and their characteristic intermediate
filament protein is cytokeratin.
 Non-keratinocytes: are those cells that do not
synthesize keratin at all, their origins, their structure
and their functions are different
Epithelial maturation

Patterns of maturation

KERATINIZATIO NON-KERATINIZATION
N
KERATINIZED
EPITHELIUM
STRATUM
CORNEUM

STRATUM
GRANULOSUM
STRATUM
SPINOSUM
STRATUM BASALE
STRATUM BASALE :

 The basal layer is made up of a single layer of cuboidal cells.

 The basal layer is made up of cells that synthesize DNA and undergo

mitosis, thus providing new cells new are generated in the basal layer.

 The basal cells and parabasal spinous cells are referred to as the stratum

germinativum.

 The basal cells are made up of two types of cells, one is serrated and

heavily packed with tonofilaments and the other is non serrated slowly

cycling stem cells.

STRATUM SPINOSUM:(PRICKLE CELL LAYER)

 Cells are large elliptical or spherical.

 The cells frequently shrink away from each other remaining in

contact only at points known as intercellular bridges. This
point of attachment resembles a spine ending at
desmosomes.

 This layer is active in protein synthesis

STRATUM GRANULOSUM:(GRANULAR CELL LAYER)

 This layer contains flatter and wider cells.

 These cells are larger than the spinous cells.

 Cells are flat and have a thickness of about three to five cell layers.

 Prominent in keratinized epithelium (absent in non-keratinized)

 The presence of keratohyaline granules in the cytoplasm helps in the

formation of keratin fibers that are found in the superficial layer.
STRATUM CORNEUM:(KERATINIZED LAYER,CORNIFIED
LAYER)

 stratum corneum is made up of keratinized squamae, which

are larger and flatter than the granular cells.

 Thickness of stratum corneum varies at different sites in the

oral cavity and is thicker than most areas of the skin.

 Here all of the nuclei and other organelles, such as

ribosomes and mitochondria, keratohyalin granules have
disappeared .

 These cells appear compact, dehydrated and cover a greater

surface area than the basal cell from which it developed.
 In orthokeratinized there is no retention of nuclei and in
parakeratinized epithelium, the cells retain pyknotic nuclei
 NON KERATINIZED
EPITHELIUM
STRATUM
BASLAE
STRATUM
INTERMEDIUM

STRATUM
SUPERFICIAL /
DISTENDUM

STRATUM BASALE :
 Similar to that of keratinized.
 The only difference is that cells are larger than keratinized
epithelium.
 Intercellular bridges are less conspicuous.
STRATUM INTERMEDIUM :
 Glycogen is present.
 rarely keratohyaline granules are also visible at this level ,
but are not associated with tonofilaments.
STRATUM SUPERFICIALE :
 Cells appear slightly more flatten than others.

 They contain dispersed tonofilaments and nuclei and dehydrated

cells.
 The surface is flexible and tolerant to compression and
distension.
KERATINIZED NON-KERATINIZED
EPITHELIUM EPITHELIUM
KERATINOCYTES:

 constitute the major part of epithelial cells.

 Arranged in different layers.

 During maturation they either change to keratin or share

in keratin formation & have the following criteria:

• Always present in sheets and attached by one or more

types of cellular junctions.

• Cytoplasm is stained with H & E.

• Cytoplasm contains the tonofilaments.

NON KERATINOCYTES:

 Present in both keratinized and non-keratinized epithelium & have the

following criteria:

 Appear as clear cells by ordinary H&E stain, they need special

stains.

• Scattered cells not in sheets.

• A clear hallow around their nuclei.

• Cytoplasm is free of tonofilaments.

• No cellular junctions.

• Do not play any role in the synthesis of keratohyaline granules or

keratin.
LANGERHANS CELLS:

 Found in stratum spinosum & occasionally in stratum Basale.

 Cells have thin, long extensions of cytoplasmic membrane called

dendrites.

 Distinguished from keratinocytes by the absence of desmosomes &

tonofilaments.

 Can be distinguished from the melanocytes by the absence of

premelanosomes
 Contains rod shaped or racquet shaped birbeck’s granules ,
which allows positive identification at ultrastructural level.
 Are antigen presenting cells.They engulf antigens & intracellular
lysosomes split the antigens into peptide components.
 These fragments are then transferred to T-Lymphocytes.
 MERKEL CELLS:
 Situated in the basal layer of gingival epithelium. Possess
occasional desmosomes & tonofilaments.
 Usually associated with an axon terminal.
 Merkel cell & associated axon terminal forms a complex that
serves as touch receptors.
 Found in groups or clusters.
MELANOCYTES:

 These cells are melanin-producing cells located in the basal layer of

the gingival epithelium.

 These cells arise from neural crest.

 Lack of tonofilaments, desmosomes, and hemidesmosomes. Highly

dendritic in nature. Characteristic feature- melanosome granule.

 A more heavily pigmented gingiva is due to the production of

melanin & subsequent uptake by the epithelial cells.
 There is great variability in location & distribution of melanin in
oral cavity.
 LYMPHOCYTES:
 Present variably.
 Contains large circular nucleus
 Cytoplasm is scanty with few organelles.
 No desmosomes and tonofilaments
present.
 Associated with inflammatory response
in oral mucosa.
BASEMENT MEMBRANE AND BASAL LAMINA:

 Ultra structurally, the basement membrane is called the basal

lamina, which is not just a membrane but is a basal complex
consisting of lamina and Fibers.
 The basal lamina is made up of a clear zone (lamina lucida) just
below the epithelial cells and a dark zone (lamina densa)
beyond the lamina lucida and adjacent to the connective tissue.

LAMINA PROPRIA

Found below the epithelium.

Has 2 parts
1. PAPILLARY
2. RETICULAR
Papillary portion : close to epithelial ridges with loosely arranged
cells
 Increase in length of papilla is seen in areas
where additional mechanical adhesion is
required between epithelium and connective
tissue.
Eg - masticatory mucosa
 Reticular portion is located parallel to epithelum
with thick fibers. Contains
 Cells: Fibroblast, histiocytes, mast cells,
macrophages, PMNs, lymphocytes, plasma
cells, endothelial cells
 Blood vessels and neural elements
 Fibres , Ground substance
 SUBMUCOSA

 It is connective tissue of variable thickness.

 Serves as primary attachment for lamina propria to the underlying

bone and muscle.

 Sub mucosa contains glands, adipose tissue, vascular and neural

components.
KERATINIZED MUCOSA (MASTICATORY MUCOSA)

 During mastication , parts of oral mucosa are subjected to

forces & pressure
GINGIVA
HARD PALATE
 GINGIVA

 Gingiva is that part of oral mucosa that covers the alveolar

processes jaw and surrounds the neck of teeth.

 Gingiva consists of either keratinized or para-keratinized

epithelium with no sub-mucosal layer.

 Develops from the union of oral epithelium and reduced

enamel epithelium.
 Types of gingiva
The gingiva is divided into three types:

 Free or Unattached or Marginal gingiva

 Attached gingiva

 Interdental papilla

Free or Unattached or Marginal gingiva:

 Part of oral mucosa that surrounds the teeth in collar like fashion
 It is differentiated apically from the attached gingiva by free gingival
groove.
  It is 1mm wide and forms soft tissue wall of gingival

Sulcus

 Free marginal mucosa is composed of stratified

squamous epithelium that may be keratinized ,

parakeratinized or sometimes non keratinizied.

ATTACHED GINGIVA
 Attached gingiva is continuous with the marginal gingiva
 It is firm ,resilient and bound to the underlying periosteum of alveolar
bone
 The junction of the attached gingiva and alveolar mucosa is called
mucogingival junction.
 In healthy mouth attached gingiva shows
stippling (orange-peel appearance) which is
characteristic feature of attached gingiva.

INTERDENTAL PAPILLA
 Part which extends between two teeth up to contact point is called
‘interdental gingiva’
 It has facial and lingual side.
 Margins are concave.

Due to inflammation , interdental papilla

loses its concavity.
COL:
 Connects the facial and lingual side of the interdental papilla (on
the proximal side).
 Concavity indicated healthy gingiva.
 It becomes dome-shaped, in gingival recession and inflammation
 The epithelium of col is non keratinized .
GINGIVAL FIBERS
 Bind attached gingiva to the alveolar bone & tooth
 4 groups :
1.Dentogingival fibers : from cervical cementum to
lamina propria , most numerous
2.Alveologingival fibers : from alveolar crest into
lamina propria

3.Circular fibers : circles the tooth

4.Dentoperiosteal fibers : from cementum into
periosteum of alveolar crest & surface of alveolar
bone.
 VERMILION ZONE:
 The transitional zone between the skin of the lip and the
mucous membrane of the lip is the red zone or the vermilion
zone
 The skin on the outer surface of the lip is covered by a
moderately thick, keratinized epithelium with a rather thick
stratum corneum.
 The papillae of the connective tissue are few and short. Many
sebaceous glands are found in connection with the hair
follicles. Sweat glands occur between them.
 HARD PALATE:

 Keratinized masticatory mucosa

 Pink in color and firmly attached to underlying structures.

 Lamina propria –a layer of dense connective tissue,is thicker in

the anterior than in the posterior parts of the palate and has
numerous long papillae.

 Various regions in the hard palate differ because of varying

structure of the submucous layer. The following zones can be
distinguished.
1. Gingival region, adjacent to the teeth

2. Palatine raphe, also known as the

median area, extending from the
incisive or palatine papilla posteriorly

3. Anterolateral area or fatty zone

between the raphe and gingiva

4. Posterolateral area or glandular zone

between the raphe and gingiva
INCISIVE PAPILLA:

 The oral incisive (palatine) papilla is formed of dense connective tissue.

 It contains the oral parts of the vestigial nasopalatine ducts.
 They are blind ducts of varying lengths lined by simple or
pseudostratified columnar epithelium, rich in goblet cells
 Small mucous glands open into the lumen of the ducts.
PALATINE RUGAE (TRANSVERSE PALATINE RIDGES):
 The palatine rugae, irregular and often asymmetric in humans, are
ridges of mucous membrane extending laterally from the incisive papilla
and the anterior part of the raphe.
MID PALATINE SUTURE
 Extends from incisive papilla to posterior region of hard
palate.
 Sub mucosa is very thin.
 The mucosal layer is practically in contact with the underlying
bone.

 Tissue covering the structure is non-resilient.

ANTERO-LATERAL AREA (FATTY
POSTERO-LATERAL AREA
ZONE) (GLANDULAR ZONE)
 Present posteriorly to fatty zone
 Area present between the raphae
 This submucosa contains pure
& the gingiva anteriorly. mucous glands
 Lamina propria is fixed to the
periosteum by bands of
connective tissue dividing the
submucosa into compartments
containing fat cells
• The fatty and glandular zones acts as cushion.
• The connective tissue of hard palate is thick anteriorly than posteriorly,
Epithelial pearls.

In the midline, especially in the region of the incisive papilla,

epithelial pearls may be found in the lamina propria.
 They consist of concentrically arranged epithelial cells that are
frequently keratinized. They are remnants of the epithelium
formed in the line of fusion between the palatine process
 NON-KERATINIZED MUCOSA(LINING MUCOSA)

 All zones of lining mucosa are characterized by a relatively

thick non-keratinized epithelium and a thin lamina propria.
1. FIRMLY ATTACHED 2.LOOSELY ATTACHED

• SOFT PALATE • FLOOR OF THE

• LIP MOUTH
• CHEEK • VESTIBULE
• VENTRAL SURFACE • ALVEOLAR
OF TONGUE MUCOSA
 SPECIALIZED MUCOSA

 Dorsal surface of tongue and Taste buds

 The connective tissue binds the epithelium to underlying skeletal

muscle.
 The epithelium is modified stratified keratinized covered with
papillae
 Different papilla on dorsal surface of tongue are:

 FILLIFORM PAPILLAE

 FUNGIFORM PAPILLAE

 CIRCUMVALLATE PAPILLAE
 2 parts :

• Anterior 2/3 : 1st pharyngeal arch

called as body

trigeminal nerve innervation (V)

papillary portion

• Posterior 1/3: 3rd pharyngeal arch

called as base

glossopharyngeal nerve innervation (IX)

lymphatic portion (lingual tonsil )

• Separated by V shaped groove called as sulcus terminalis.

FILIFORM PAPILLAE :

 Anterior tongue

 Cone shaped

 Connective tissue core is covered with thick

keratinized epithelium – the velvety
appearance of the tongue.

 Touch abrasive surface so functions as

masticatory mucosa.

 Increased keratinization leads to a hairy

FUNGIFORM PAPILLAE :

 Scattered between numerous filiform papillae at the tip of the

tongue.

 Smooth, round structures, mushroom-shaped.

 Red-high vascular connective tissues core & thin non-

keratinized epithelium.

 Taste buds present on the superior surface.

CIRCUMVALLATE PAPILLAE :

 8-12 in number.

 Adjacent & anterior to sulcus terminalis.

 Surrounded by deep circular groove in to which

ducts of VON EBNER salivary glands open.

 Connective tissue core covered by keratinized

epithelium superiorly.

 Lateral walls are non- keratinized & are taste buds.

FOLIATE PAPILLAE :

 Foliate papillae are located in the furrows along the posterior sides of
tongue.

 They may be lined with taste buds.

 They are not prominent in humans.

Papillae are mainly concerned with different sensations :
VALLATE PAPILLAE – BITTER
FUGIFORM PAPILLAE – SWEET AND SALT
FOLIATE PAPILLAE-SOUR
TASTE BUDS

 They are barrel shaped-intra epithelial organs

 Consisting of outer supporting cells arranged like staves of
barrel and inner spindle shaped cells
 Between inner spindle shaped cells neuroepithelial cells are
present
 Taste buds are seen in :
• vallete papillae
• Folds of foliate papillae
• Posterior surface of epiglottis
• occasionally in fungiform papillae
AGE CHANGES IN ORAL MUCOSA

 The epithelial layers are less in number and the mucosa and
submucosa show a decrease in thickness.
 This actual thinning of tissues, coupled with its depleted repair
potential renders the denture-bearing mucosa of basal seat
friable and easily traumatized.
 The oral mucosa of an elderly patient has a smoother and
drier surface than young patients due to any systemic
diseases.
 Flattening of epithelial ridges.
 Reduction in number of the filiform papilla.

 Langerhans cells become fewer with age, leading to a

decrease in cell-mediated immunity.
 Decrease in cellularity in lamina propria with an
increase in collagen.
 Sebaceous glands (Fordyce’s spots) of lips and cheek
increases with age.
 Elderly post-menopausal women, have symptoms such
as dryness of mouth, burning sensations, and abnormal
taste.
 CLINICAL EXAMINATION

 Mucosa is checked for inflammation ,the conditions where inflammation can be

seen :
 Prosthetic reason:
i. Over extension
ii. Ill fitting denture
iii. Continious wearing of denture
iv. Faulty occlusion
v. Traumatic
vi. Alveolar bone spicules
 Common oral conditions :
i. Apthous ulcers
ii. Vesiculo bullous lesions
iii. Precancerous and cancerous conditions
 CLINICAL EXAMINATION OF MUCOSA :
 The masticatory mucosa covers the alveolar ridge and the attached
gingiva and hard palate
 It is exposed normally to masticatory forces, it has a characteristic
thickness, degree of keratinization, density, lamina propria firmness, and
immovable attachment to underlying structures.
 Palpation of the masticatory mucosa with an instrument or finger is
indicated.
 The degree of stability of the prosthesis that might be expected as well
as the capacity of soft tissue for adaptation to the prosthesis.
COLOR OF THE MUCOSA :
 It indicates mucosal health
 The color of the mucosa may range from healthy pink to red.
 The redness is an indication of inflammation and can be of
varying degrees.

MUCOSAL THICKNESS:
 According to Dr.M.M.HOUSE mucosal thickness is classified into
CLASS 1: Tissue can be displaced approximately 2mm,cushion-like
yet will not permit gross positional displacement
CLASS 2:
a) Tissues thinner than 2mm, usually unyielding, often atrophic with
smooth surface and poor for developing good adhesion and marginal
seal
b) Tissues thicker than 2mm, easily displaced, and poor stress-bearing,
usually occur as flabby redundancy in regions of excessive bone
resorption under ill-fitting or maloccluded prosthesis. Also may present
as anteroposterior folds over resorbed posterior ridges or fibrous
ridges where bony resorption has occurred lately.
CLASS 3: Excessive flabby to the degree that surgical excision is
indicated.
EVALUATION:
Thickness can be evaluated by firmly pressing with a ball end of
the burnisher
Thin mucosa-Blanching is seen
Thick mucosa- Blanching is not seen
MUCOSA CONDITION
According to Dr.M.M.House it is classified as follows :
CLASS 1: Healthy mucosa
CLASS 2:irritated mucosa
CLASS 3:Pathologic mucosa
SIGNIFICANCE :
 Mucosa condition is important in providing retention ,stability and
support
 Consequently have direct bearing on comfort and efficiency of the
denture
 PROSTHODONTIC CONSIDERATIONS

 The oral mucosa shows adaptation to function. the area of mucosa

to receive load in CD in the maxilla and mandible is about 22.9 cm2
&12.25 cm2.
 Support areas of denture – should have keratinized mucosa with
lamina propria tightly bound to the bone composed of dense
collagen to withstand stresses.

 Complete denture support is the resistance to vertical movement of

the denture base toward the ridge.
 It counteracts those forces directed toward the ridge at right angles
to the occlusal surfaces.
 Support involves a consideration of the relationship between the
intaglio of the denture base and the underlying tissue surface
under varying degrees and types of function
NATURE OF SUPPORTING TISSUE:
 Ideally, the soft tissues should be firmly bound to underlying
cortical bone, contain a resilient layer of submucosa, and be
covered by keratinized mucosa.
 The underlying bone should be resistant to pressure-induced
remodeling.
 These characteristics minimize base movement, decrease soft
tissue trauma, and reduce long-term resorptive changes
 Supporting soft tissues: must be capable of withstanding the
pressures induced through normal function of the prosthesis.
 The presence of keratinized, firmly bound mucosa permits the
tissues to better resist stress.
 Nonkeratinized alveolar mucosa is not well adapted to tolerate the
functionally generated stresses of a denture base. Excessive trauma
to the mucosa beneath a denture base can lead to abnormal tissue
changes such as the development of parakeratin, localized
hyperkeratosis, and epithelial ulceration or necrosis.
 The fatty and glandular submucosa acts as a “hydraulic cushion”.
 Those regions, that possess a thin and/or less keratinized mucosa
over bone without an intervening layer of submucosa, should be
relieved or recorded without displacement. This eliminates the
impingement of soft tissues between the denture base and bony
foundation during occlusal loading, thereby minimizing soft tissue
trauma and reducing pressure-induced bony remodeling.

 SUPPORTING HARD TISSUES: The rate and amount of bone loss

and remodeling that occur in the anterior maxilla and mandible are of
serious concern.
 Minimizing the pressures in those regions most susceptible
and directing the forces toward those regions relatively
resistant to resorption can help to maintain healthy residual
ridges.

 ANATOMICAL CONSIDERATIONS OF DENTURE-BEARING

AREA
1.MAXILLA:
 In the maxillae the horizontal portion of the hard palate lateral to
the midline raphe should provide primary support for complete
dentures.
 the horizontal hard palate resists resorption and is covered by
keratinized mucosa and resilient submucosa. These properties
dictate its essential function as a primary denture-support area.
 Keratinized masticatory mucosa overlies a distinct submucous
layer everywhere but at the midline suture.
 The submucosa contains fatty tissue anterolaterally and
glandular tissue posterolaterally. This resilient layer acts as a
cushion for the functional stresses transmitted to the mucosa.
 Dense bands of connective tissue traverse the submucosa,
firmly binding the lamina propria of the epithelium to the
underlying periosteum.
 Over the midline raphe the mucosa is unyielding, has little
or no submucosa, and must be relieved to avoid tissue
impingement between the denture base and bone.
However, the relief should be minimal to permit light contact
of this tissue with the denture base under a masticatory
load.
 Various anatomic regions of maxilla in
providing support.:
 Primary support areas (1) should include
horizontal support Anteroand
posterolateral hard palate.
 The ridge crest should function at best as
a secondary area (2).
 Midline suture normally requires slight
relief ® while the denture border is
noncontributing (N/C).
 2.MANDIBLE:

 The primary stress-bearing regions on the mandible must include the

pear-shaped pad and the buccal shelf.
 The pear-shaped pad is the most distal extent of the keratinized
masticatory mucosa of the mandibular ridge.
 The deep and superficial tendons of the temporal muscles are inserted
medially and laterally in the mandible at the posterior border of the
pear-shaped pad. Such muscle attachments and the overlying, firmly
bound masticatory mucosa provide a stress-bearing region that is
relatively resistant to resorptive changes.
 If the mandibular denture is short of this region, there will be
more rapid resorption of the distal alveolar ridge and a resulting
settling of the denture base posteriorly

The relative importance of various anatomic regions

of the mandible in providing denture support.:
 Primary support areas must include a
buccal shelf and pear-shaped pad (2).
 The ridge crest and area of genial
tubercles may be treated as secondary
support areas (2).
 Lingual and labial ridge inclines are
either relieved (R) or non-contributing
(N/C).
 Relief areas – areas of the submucosa, with adipose tissue
glandular tissue neurovascular bundles, or extreme thinness.
 Relief regions fall into three categories:
1. First, tissues that are susceptible to resorption should not be
subjected to functional pressures. These would include some
maxillary and most mandibular ridge crests.
2. Second are those regions that have thin mucosa directly over
hard cortical bone. These include the mid-palatine raphe, tori, and
exostoses, and the lingual surface of the mandible, especially the
mylohyoid ridge.
3.A third category involves the regions of mucosa overlying
neurovascular bundles such as the incisive papilla and, in some
cases, the mental foramen.
 The oral mucosa is not only displaceable but also
compressible.
 Tissues take hours to recover,

more resilient tissues > deformity

longer the load > deformity

 Hence in clinical procedures care should be taken to avoid

tissue compression and deformation.
PRACTICAL CONSIDERATION:

 One generally accepted principle of impression procedures is

that the maximal allowable denture-bearing surface area
should be incorporated.
 The need to record the different anatomic regions under
varying degrees of pressure, depending on the nature of the
tissues the rationale behind these techniques is that certain
tissues require slight placement while others must be recorded
at rest or relieved.
 A truly mucostatic or pressure-free impression is virtually
impossible to achieve. The fluid impression material contained in a
rigid tray inevitably causes some tissue compression
 Even if it were possible to obtain a pressure-free impression of the
tissues at rest, the mucostatic theory is based on the belief that
oral tissues of the denture-bearing area behave as a confined fluid
following Pascal’s laws of hydrostatics.
 These laws state that pressure exerted on a confined fluid will
transmit evenly throughout the fluid.
 But, the fluid in oral tissues is not confined. The tissue fluids can move
through the interstitial spaces in response to stresses placed on them.
They also vary in their ability to tolerate or transmit pressures
according to their anatomic location and histologic makeup.
 For these reasons, it would seem that the most desirable impression
techniques would attempt to provide mild displacement of the more
resilient tissues, which are capable of providing denture support and
resisting resorption
 Ideally, the tissues beneath the denture base should be recorded in
the shape and contour that they assume under a loading force.

 The tissues beneath the denture base should be recorded in the

shape and contour that they assume under a loading force. In this
way, the more resilient tissues would be more displaced than those
tissues that are unyielding, such as the maxillary midline raphe.
 MUCOSAL RESPONSE TO ORAL PROSTHESIS

DUE TO REMOVABLE DUE TO FIXED

PROSTHESIS PROSTHESIS

1. MUCOSAL LESIONS 1. SECONDARY CARIES

2. BURNING MOUTH SYNDROME 2. PULP AND
3. ALLERGIC RESPONSE PERIODONTAL
4. RESIDUAL RIDGE INFECTIONS
RESORPTION 3. OCCLUSAL RELATED
5. TRAUMA(METALLIC CLASPS) DISORDERS
6. PERIODONTAL DISEASE 4. PERIIMPLANTITIS
7. GAGGING
DENTURE IN ORAL CAVITY
 INTERACTION OF PROSTHESIS WITH ORAL
ENVIRONMENT

 The results of prosthetic material to the mucosa are influenced by:

 Surface properties – adhesiveness, texture, microporosity, hardness

 Chemical properties – corrosion, toxic and allergic reactions

 Physical properties - mechanical irritation, plaque accumulation

 Changes in oral environment – plaque microbiology

 DIRECT SEQUELAE CAUSED BY WEARING DENTURES

1.DENTURE STOMATITIS(DENTURE SORE MOUTH)

2. FLABBY RIDGE

 Flabby ridge (i.e. mobile or extremely resilient alveolar ridge) occurs

due to replacement of bone by fibrous tissue.

 In 1972, Kelly and his colleagues first described “combination

syndrome” caused by the presence of opposing natural teeth to an
edentulous area.

 Flabby ridge is seen most commonly in the anterior part of the

maxilla, particularly when there are remaining anterior teeth in the
mandible, and is probably a sequela of excessive load on the
residual ridge and unstable occlusal conditions.
The bone may be grossly resorbed often up to level of
anterior nasal spine.
ETIOLOGY :
 The etiology of flabby ridge must be considered as
speculative. It could be related to age, lack of
nourishment, disease, action of toxins, pressure, and
interference with neural innervations, but old age and
pressure are the most commonly encountered factors.
Histologically:
 There is marked fibrosis, inflammation, and resorption
of the underlying bone.
MANAGEMENT:
 The methods to overcome this problem are either by the surgical
removal of the fibrous ridge or modification of impression
techniques.
 The removal of fibrous ridge surgically will leave a firm ridge as well
as lead to elimination of vestibular area.
 These problems can be solved to some extent by fabricating a
denture over a flabby ridge using impression technique specific for
this condition.
 The three main approaches to the management of the flabby ridge are:
1. Surgical removal of fibrous tissue before conventional procedures.
2. Implant retained prosthesis.
3. Conventional prosthodontics without surgical intervention.

1.surgical approach
 The advantage of the surgical technique is that it provides a firm
denture bearing area. which enhances the stability of the prosthesis.
 Its limitations include chances of decrease in vestibular height requiring
an additional surgery of vestibuloplasty.
 It is contraindicated in circumstances where little or no alveolar bone
remains.
2. Implant Retained Prostheses
 Implant prosthesis takes the support from the underlying bone hence
minimal or no support is needed from the tissue area.
 In terms of patient economics and time taken for the completion of the
procedure, the implant-supported prosthesis has its drawbacks.
 Other factors that must be considered include surgery, discomfort and
inconvenience, general health of the patient, and risk of surgical
complications or implant failure
3.Conventional Prosthetic Management
Different impression techniques used for recording flabby tissue are
• Window Impression Technique (minimally displacive impression
technique)
• The Selective Pressure Impression Technique with Relief Areas
And Pinholes
• Selective Perforation Tray Technique
• The modified open window technique with PVS
• Zafrulla and Hobkrik Combination Impression Technique
Window Impression Technique (minimally displacive impression
technique)
 In this technique, A preliminary impression of the maxillary
edentulous arch is made using an irreversible hydrocolloid
impression material
 Extension of the flabby area was marked on the maxillary primary
cast.
 After that, proper wax spacer was adapted such that there were four
tissue stops to stabilize the tray in maxillary arch
 Over it, a special tray was fabricated and the
borders were reduced to 2 mm short of the
sulcus and border molding is done
 Window was prepared in the custom tray in
the area of flabby tissue.
 After this, the spacer was removed and the
definitive impression was made with ZoE
impression paste.
 The excess material over the window and
the flabby area was recorded using an
impression plaster
 Impression plaster was applied with a painting brush in proper
consistency so that it wouldn’t run out of the area.
 Apply a separating medium over the plaster part of the impression before
pouring it. If elastomeric impression material is available, then tray
adhesive can be applied on the borders and on the tissue surface of the
tray.
 Allow the tray adhesive to dry for 10 minutes before loading the tray with
elastomeric material to obtain a chemical bond between the tray and the
material.
 The definitive impression can be made with monophase polyvinyl siloxane
impression material and the excess over the window opening can be
trimmed
 The flabby area can be recorded with light body polyvinyl siloxane. This can be injected
with a syringe on to the flabby area exposed through the window made in the special
tray
 After adequate disinfection of the impressions and beading/boxing procedures, the
impression can be poured in type III dental stone to obtain the master cast
 In this technique the flabby ridge is recorded in minimally displaced form and the rest of
the tissue in functional form.
The Selective Pressure Impression Technique with Relief Areas And
Pinholes

 In this technique, A primary impression of the upper and lower arches

were taken with alginate and poured with dental stone and the
displaceable tissues were identified on the cast.
 The stress bearing areas in the maxillary denture were relieved with
modeling wax relief was done on the anterior flabby tissue region
from canine to canine
 The mandibular cast was first adapted with a layer of wax to
provide extra relief in the flabby region followed by addition of
one more layer of wax covering the ridge except the buccal
shelf area. Then, the custom tray was fabricated covering the
tissues except the area that was flabby. Over the “open” area of
the tray another “supporting tray” of clear acrylic was made thus
covering the flabby ridge
 For the final impression of the lower ridge; the buccal shelf area was
recorded by using mucocompressive impression material like
impression compound which in this case is the primary stress-
bearing area and it also acts as a stopper for the tray in the final
impression procedure.
 The remaining borders of impression were recorded by selective
pressure technique using green stick compound.
 Finally, the spacer wax was then removed and multiple holes were
drilled in the region of the flabby tissue. Tray adhesive was applied.
A final impression with monophase (medium Body addition silicone)
was made
Edentulous mandibular arch showing areas of flabby tissue.

1.Relief wax placed over the mandibular flabby ridge

region

2.Mandibular custom tray fabricated with clear

acrylic resin

1.Custom tray with complete mandibular

border moulding.

2.Completed mandibular impression with

monophase polyvinylsiloxane material.
Final Impression of the Upper Ridge: The maxillary borders were
recorded by selective pressure impression technique using green stick
compound. Placement of multiple relief holes was done to ensure
prevention of pressure buildup in the flabby area thereby leading to
inadvertent tissue compression. Tray adhesive was applied. Similar to
the lower impression a monophase impression of addition silicone was
made
1.Relief wax placed over the maxillary arch.

2. Clear acrylic custom “open”

tray.
 1.Maxillary custom tray with
“supporting” tray covering areas of
flabby tissue with the handle placed
at the center of the palatal area.

2.Maxillary custom tray with

multiple relief holes.

1.Completed secondary impression

with monophase PVS material

2.Fabricated prosthesis.
Selective Perforation Tray Technique
 It has been suggested that if the degree of mucosal displacement is
minimal, then this modified conventional technique may be considered.
 Preliminary impressions are taken in stock trays using low-viscosity
alginate after appropriate border correction.
 A spaced special tray is fabricated from the primary cast for use with a low
viscosity impression material, such as impression plaster, low-viscosity
silicone or alginate.
 Pressure on the unsupported, displaceable soft tissue can be minimised
further by the use of perforations in the tray overlying these areas.
 The modified open window technique with PVS:

 This technique involves the greater use of the mobile anterior tissue for
denture support. Primary impressions are made and cast is poured
 light-body PVS is used to record the flabby tissue, alongside a muco-
compressive record of the ‘normal’ tissue with ZOE, and functional
record of the sulcus, tuberosities and post-dam with impression
compound
Maxillary modified window technique impression
with lightbody PVS (light green), ZOE (pink) and
impression compound (peripheral border)
 To accurately assess the uniformity of pressure distribution over the
fibrous tissue, minimizing the risk of displacement. The wax rims can
be subsequently molded onto the acrylic resin base to prescribe the
desired vertical and horizontal dimensions.

Maxillary wax registration block with clear acrylic

resin base
Zafrulla and Hobkrik Combination Impression Technique

 Zafrulla and Hobkrik modified the technique where a custom tray is

made with a window or opening over the (usually anterior) flabby
tissue.
 A muco-compressive impression is first made of the normal tissues
using the custom tray and zinc oxide and eugenol. Once set, it is
removed, trimmed, and re-seated in the mouth.
 A light body elastomeric impression is then used in the flabby tissues
through the window. Once set, the entire impression is removed.
 A primary impression of upper edentulous arch was made with a
low viscosity irreversible hydrocolloid material (Alginate) to
ensure minimal distortion of the displaceable ('flabby') tissues.
 The impression was poured in dental stone. Two uniform
thicknesses of dental wax were placed as a spacer. The custom
tray was fabricated

Customized impression tray for final Impression

 the custom tray was inserted into the mouth and any over-
extended areas of the periphery were reduced. The master
impression was then made as follows: Border molding is done
with green stick and then impression was made with zinc oxide
eugenol impression material.

Border moulding with zinc oxide wash

impression
 The flabby region was marked intraorally with an indelible pencil.
The custom tray was perforated over the areas of the primary cast
representing the flabby tissues. The area of the custom tray
associated with the 'flabby' tissues was then filled with light-
bodied polyvinylsiloxane impression material.

removal of material from the flabby

light body Impression was made
ridge area and perforation were made
  Once set, the impression was removed from the mouth and
inspected. Any excess material was removed.
 The impression was poured in dental stone and then the
Denture is fabricated.

3.DENTURE IRRITATION HYPERPLASIA

ETIOLOGY:
 A common sequela of wearing ill-fitting dentures is
the occurrence of hyperplasia of the mucosa in
contact with the denture border.
 CLINICAL PRESENTATION

 The lesions may be single or quite numerous and are composed of

flaps of hyperplastic connective tissue.
 It is characterized by the development of elongated rolls of tissue in
the mucolabial or mucobuccal fold area into which the denture flange
conveniently fits. It is less commonly seen along the lingual sulcus.

 Inflammation is variable; however, in the bottom of deep fissures,

severe inflammation and ulceration may occur.
 .
TREATMENT:
 After replacement or adjustment of the dentures, the inflammation and
edema may subside and produce some clinical improvement of the
condition.
 After surgical excision of the tissue and replacement of the denture, the
lesions are unlikely to recur.
4.TRAUMATIC ULCERS
CLINICAL PRESENTATION
 Sore spots appear after one to three days after new dentures.
 Ulcers-small, painful, covered with gray necrotic membrane,
surrounded by inflammatory halo with firm & elevated borders.
  When no treatment is instituted, the patient will often
adapt to the painful situation, which subsequently may
develop into a denture irritation hyperplasia.
CAUSES
 The dierect cause is usually overextended denture
flanges or unbalanced occlusion.
 The predisposing conditions that suppress resistance of
the mucosa to mechanical irritation include diabetes
mellitus, nutritional deficiencies, radiation therapy, and
xerostomia.

5.ANGULAR CHELITIS(Angular Cheilosis, Perlèche)

 Angular cheilitis is a multifactorial disease affecting the commissure
of the lips and is commonly seen in denture wearers.
5.ANGULAR CHELITIS
6.BURNING MOUTH SYNDROME
 Could be a sequela of denture wearing and
characterized by one or many areas in contact with
denture.
 Seen around 5-7% of denture wearers.
ETIOLOGY
 Local factors – ill fitting dentures, undue friction on
mucosa, parafunctional activity of tongue.
 systemic – vitamin b12 deficiency, iron deficiency,
xerostomia, menopause, diabetes, Parkinson’s
disease.
 Psychogenic – anxiety, depression
 In edentulous patient wearing CD, burning sensations from
upper denture bearing tissues and the tongue are common
complaints particularly in postmenopausal women.

MANAGEMENT

 Identifying and removing causative factor.

 Vitamin therapy

 Counselling in case of psychogenic patients and tranquillizers

if needed.
7.ORAL CANCER IN DENTURE WEARERS
8.GAGGING:

• The gag reflex is a normal and healthy defense mechanism. Its

function is to prevent foreign bodies from entering the trachea.
• Gagging can be triggered by tactile stimulation of the soft palate,
the posterior part of the tongue, and the fauces.
• Usually, this may be due to a denture that is too loose, too thick, or
extended too far posteriorly onto the soft palate.
9. RESIDUAL RIDGE RESORPTION:

• The residual ridge provides vital support to the dentures, and the quality
of residual bone is critical to the stability and functionality of a denture.

• It is supposed that the alveolar bone begins to atrophy following

extraction of teeth or with edentulous aging, due to lack of stimulus to
maintain the local bone quality.
• However, the stimulus-induced by the denture base surface may not
necessarily positively stimulate bone growth, and on the contrary may
cause RRR. The residual ridge changes its shape and progressively
reduces in size at varying rates.
INDIRECT SEQUEL
1.PERI IMPLANTITIS
 Peri-implant mucosa is composed of well keratinized oral epithelium,
sulcular epithelium and junctional epithelium, as well as underlying
connective tissue.
 While peri-implant mucosa differs from gingiva in its vascularity, collagen
content, and connective tissue fiber arrangement, the inflammatory response
to plaque is similar.
 Peri-implant disease which is commenced by bacteria has two subtypes:
peri-implant mucositis and peri-implantitis.
 The term peri-implant mucositis is used for reversible inflammation of the soft
tissues surrounding implants in function.
 Clinical signs include redness of adjacent mucosa, swelling,
bleeding on gentle probing, and suppuration.

 Peri-implantits been defined as an inflammatory lesion of the

mucosa surrounding an endosseous implant and with progressive
loss of supporting peri‐implant bone.

 It is generally perceived that following implant installation and initial

loading, some crestal bone height is lost (between 0.5 and 2 mm)
in the healing process.
 The distinctive difference between a diagnosis of peri‐implant mucositis
and peri‐implantitis is the presence of bone loss in peri‐implantitis, as
identified from dental radiographs.

TREATMENT

 Mechanical debridement of biofilm and calculus.

 Occlusal therapy: Prosthesis design changes, improvement in implant

number and occlusal equilibration can contribute to the arrest of peri-
implant tissue breakdown progression.

 Regenerative approach: the bone defect is filled with bone graft after
debridement.
 2.ATROPY OF MASTICATORY MUSCLES:
 Individuals rehabilitated with complete dentures have a poor
masticatory function, reduced by 50–84% in relation to the
masticatory function of dentate individuals.
 Furthermore, computed tomography (CT) studies of the masseter
and the medial pterygoid muscles have demonstrated a greater
atrophy in complete-denture wearers, particularly in women.
 This indicates that reduced bite force and chewing efficiency are
sequelae caused by wearing complete dentures, resulting in
impaired masticatory function.
 CONCLUSION

 The oral mucous membrane plays a crucial role in prosthodontics. It is

essentially that all the treatment is performed and the results depend upon
the condition of the mucosa.

 A thorough knowledge of the oral mucosa aids in proper prosthesis

designing and successful treatment.

 The patient should be motivated to practice proper denture-wearing habits

and maintenance of oral hygiene and follow a program of recall and
maintenance for continuous monitoring of dentures and oral tissues.
 REFERENCES

 BOUCHER 12th ed; Sequalae of complete denture .

 Shafer; Textbook of oral pathology ed 7th ; Mucosal response to

oral prostheses.
 Orban’s, oral histology and embryology. 11th Edition, Mosby:
1998; p – 345-385.
 A contemporary review of the factors involved in complete
dentures. Part III: Support T. E. Jacobson, D.D.S.,
 Carranza F.A., Michael G. Newman. Clinical periodontology 10th
edition.
 Impression techniques for flappy tissue –university of Baghdad