Biomechanics of the Edentulous State

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Biomechanics of the Edentulous State

Support mechanism for natural teeth. Support mechanism for complete denture.

Functional and parafunctional considerations

Changes in Morphological face height and the TMJ. Esthetic,Behavioural,and Adaptive responses.

Functions and parafunctions

PDL support mechanism

Mucosal support mechanism

Morphological face height &TMJ

Behavioral &adaptive responses

Support mechanism for natural teeth

The principal functions of the periodontium are support and positional adjustment of teeth together with secondary and dependent function of sensory perception.

Soft tissue=PDL

Periodontium as a supporting element

Hard tissue= bone+cementum Cementum hardly to resorb. Bone well vascularized. Normally they receive tensile loads. Provide excellent medium for PDL attachment.

Highly organized and oriented. Highly vascularized (three sources). Highly innervated( touch, pain &pressure). Contain elastic fibers. Approximately uniform thickness.

Support mechanism for complete denture

Alveolar mucosa Uneven thickness. Uneven attachment &resiliency. Less vasularization &innervations. Diminished proprioceptive nerve endings. Reduced elasticity.

Variable thickness & attachments

A section through the edentulous mandible in the molar region. Arrow length indicate thickness ,and the width for attachment of the mucosa. -The mucosa (a) over the buccal (B) shelf of bone is mobile, resilient, and fairly thick. -The mucosa (b) is firmly attached to the underlying bone, and less resilient. -The lingual (L) mucosa (c), is very thin and mobile. -Over some areas it is resilient, but over sharp ridges of bone (d) there is no resilience.

Viscoelastic behavior of the alveolar mucosa

oral mucosa is displaced under load about 10 times more than the periodontium. mucosa has less elasticity than the PDL. A slower recovery rate to sustained loads. Recovery rate increased with age.

Support mechanism for complete denture

Alveolar bone Receive vertical, diagonal& horizontal loads. Their quality differ according to location. Undesirable and irreversible bone loss.

Concepts of bone loss

As a normal sequala of loss of PD structure. Not necessary a consequence of tooth removal but depends on a series of poorly understood factors. (e.g.; RAP)

Factors influences mucosal support

Total surface area: 22.96 cm2 edentulous maxilla
12.25 cm2 edentulous mandible 45 cm2 PDL

Tolerance and adaptability: reduced by systemic

and metabolic disease.

Masticatory loads: 44Ib(20 kg) natural teeth

13 to 16 Ib(6 to 8) complete denture.

Functional and parafunctional considerations

Functional: occlusion mastication& swallowing mandibular movements Parafunctional: previously found denture induced

Occlusion
The primary components of human dental occlusion:
1- the dentition. 2- the neuromuscular system. 3- the craniofacial structures.

Developing dentition

Healthy adult dentition

1- extensive sensory input 2-development of motor skills& neuromuscular learning. 3- dental , alveolar, craniofacial adaptability 1-dental adaptation (wear, drift, extrusion) 2-bone adaptation is reparative. 3-learned protective reflexes.

Deteriorating adult dentition

1-partial edentulism. 2-periodontal disease. 3-diminished dental reflex adaptation. 1-residual ridge reduction.. 2-compromised reflex. 3-increase in parafunctional movements.

The edentulous state

Adaptive mechanisms of mechanoreceptors

Tactile sensibility. 10 micron for natural Load sensibility. 1:8 ant. To post. Sudden disocclusion. Silent period initiation. (muscle pausing) Modification of the mandibular closure. Modify swallowing patterns, habits and speech

Mastication & other mandibular movements

Mastication consists of a rhythmic separation and apposition of the jaws and involves biophysical and biochemical processes including lips, teeth, tongue ,palate and all the oral structure to prepare food for swallowing.

Mastication
duration per stroke 0.3 sec.
1800 stroke/ day occur during meals stress transmitted through bolus of food increase steadily , abruptly to zero directed principally perpendicular to occ.plane with some horizontal component

Deglutition duration is 1 sec.

500 times/day occur at meals & in-between ( daytime 400sec, sleep 80 sec) direct tooth contact , fixed level with different rhythm through out day mainly vertical in direction with slight horizontal component by surrounding musculature

Important facts on Mastication

25% masticatory efficiency is adequate for complete digestion of food. Maximal biting force for complete denture wearers is 5-6 times less than natural. Biting force for complete denture ( 100N at molar region and 40 anteriorly. Tendency to chew at premolar-molar region even with remaining anterior teeth.

Parafunctions
Parafunctions related to complete denture
Tongue thrusting against denture. Tendency to occlude teeth frequently. Strong response of the lower lip and mentalis to lower labial flange

The main problem that the parafunctions are prolonged ,excessive, both diurnal and nocturnal and with an undesirable direction.

Change in morphological face height &TMJ

The skeletal growth terminated 20-25y of age. Other investigator recognized that growth and remodeling continues accompanied with increase in the morphological face height (MFH). Any changes in (MFH) as result of teeth loss are inevitably transmitted to TMJs. Longitudinal studies support the hypothesis that the vertical dimension of rest change throughout life.

Centric relation
The occlusion of complete denture is designed to harmonized with the primitive unconditioned reflex of swallowing, that is mandatory to prevent disharmonious occlusal contacts. Centric occlusion position is the most functional and physiologic position for occlusion however it could not recorded accurately in edentulous subjects. The coincidence of CR &CO is the proper solution as well. CR is subjected to change with alteration in face height, and morphological change in theTMJs.

TMJ changes
Most of edentulous patients experienced a spectrum variation as a result of mutilated dentition. In the course of such periods, pathological and/or adaptive structural alterations may take place. Appearance of cartilage cells and GAG occur as response of additional forces to TMJ by teeth loss. Continued loading beyond adaptive capability of the articular tissues may lead to osteoarthritis. TMJ could undergo degenerative joint disease, however other investigators consider it as a process rather than disease entity.

Esthetic, Behavioral &Adaptive responses

Esthetic changes : Deepening of the nasolabial sulcus. Loss of labiodental angle. Narrowing the lip. Increase in columella philtral angle. Prognathic appearance. Decrease in horizontal labial angle.

Adaptability
Acceptance and usage of dentures require adaptation of learning, muscular skills and motivation. Learning mean the acquisition of a new activity or change of an existing one. Muscular skill refers to the capacity to coordinate muscular activity to execute movement. As a result habituation process occurred.

 Habituation is the gradual diminution of responses to continued or repeated stimuli. The oral cavity is richly innervated which receive various stimuli from the prosthesis as a foreign body. After repeated stimuli ,the tissue response decrease due to information storage. The habituation process reduced with advancing in age due to progressive atrophy of elements in the cerebral cortex.

 The tactile stimuli should be specific and identical to achieve habituation. Patient motivation dictates the speed with which adaptation to denture takes place. Emotional and psychological factors also should not be neglected.