2. Outline
Flabby Ridges
Introduction to management of patients with flabby ridges
Etiology of flabby ridges
Management of patients with Flabby ridges
Highly resorbed Ridges
Introduction
Etiology
Management
3. Introduction
• Flabby ridge is mobile or extremely resilient alveolar ridge
• Is due to replacement of bone by fibrous tissue. (Carlson GE
1998)
• It 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 sequel of excessive load on the
residual ridge and unstable occlusal condition.
(Kelly E. et al 1972)
4. Cont..
• Flabby ridge gives rise to complaints of pain or
looseness relating to a complete denture that rests on
them.
• Published studies indicate that the prevalence of
flabby ridges can vary, occurring in up to 24% of
edentate maxillae and in 5% of edentate mandibles
(Fenlon MR etal 1999)
5. Cont..
• In this ‘condition’, the flabby ridge was thought to
occur as a result of a maxillary complete denture
opposing mandibular anterior natural teeth, without
proper posterior occlusal support.
• Such flabby tissues could also arise as a result of
unplanned or uncontrolled dental extractions. (Kelly E.
et al 1972)
6. ETIOLOGY
1. Chronic irritation , this could be from ill fitting dentures ,
occlusal disharmony and traumatic denture fitting
surface.
2. Load concentration on the anterior segment of the
ridge. Such as Anterior masticatory habits or anterior
interference causes load concentration on the anterior
segment of the ridge also dentures constructed with
anterior porcelain teeth and posterior resin teeth.
3. Rapid ridge resorption on the lingual and labial on the
lower alveolar ridge frequently results in a narrow knife-
edge ridge.
4. (COMBINATION SYNDROME) Complete maxillary denture
opposing natural mandibular anterior teeth.
(CD LYNCH, F ALLEN 2006)
7. Etiology continued
5 .Not removing the dentures during night time to allow
oral mucosa to regain its resting form
6. Anterior over-erupted natural teeth against edentulous
ridge.
7. Denture Instability due to under extended flange.
(CD LYNCH, F ALLEN 2006)
8. Management of flabby ridges
Management of a flabby ridge is mainly by three approaches:
1.Conservative approach. (Recovery program)
2.Prosthetic approach.
3.Surgical.
(Umesh YP 2014)
9. Management
Conservative Approach
1.Tissue rest.
The dentures should be removed from the mouth for at
least 8 hours every 24 hours for few a days before making
new impressions to allow the inflammation to subside.
2.Soft tissue massage.
Massage of the soft tissues two or three times a day to
stimulate the blood supply and aid recovery.
Instruct the patient to rinse vigorously using a mouth wash
or Warm salty water vigorously twice daily (Umesh YP 2014)
10. Conservative management continued
Modification of the denture by flange and occlusal adjustment.
•Detect and remove any pressure areas or sore spots using
pressure-indicating paste.
•Correction of occlusal disharmonies by clinical remounting
and Restoring (VDO) the occlusal vertical dimension
•Elimination of any contact between natural anterior teeth
and opposing artificial teeth.
(Umesh YP 2014)
11. Conservative management continued
Tissue conditioning.
•Relining the old dentures with soft tissue conditioning materials
is to aid recovery before constructing new dentures.
•For tissue conditioning, the material is applied a few days to the
f i t t i n g surface of a denture when the mucosa is traumatized
and inflamed.
•The tissue conditioner acts as a cushion absorbing the occlusal
loads, improving their distribution to the supporting tissues and
encouraging healing of the inflamed mucosa.
•It shouId be changed every 72 hours. (Umesh YP 2014)
12. Prosthetic approach
If the condition persists then the prosthetic
approach employed:
1. Impression techniques
2. Centric Occluding record.
3. Occlusal form and posterior teeth
arrangement
( C. D. Lynch and P. F. Allen, 2006)
14. Impression techniques
• A multitude of impression techniques have been suggested in the
past to help record a suitable impression of a flabby denture-bearing
area.
• All impressions for complete dentures can be categorised in three
ways:
• The mucostatic technique (nondisplacive),
• The mucocompressive technique (displacive).
• The selective pressure impression technique.
( C. D. Lynch and P. F. Allen, 2006)
15. Cont,,
• Retention, support and stability of complete dentures is
compromised by flabby ridges unless the tissue is
appropriately managed and manipulated by special
impression techniques.
• A particular problem is encountered in the conventional
impression making if a flabby ridge is present within an
otherwise “normal” denture bearing area.
• Nawaf L, 2017
16. Cont..
• If the flabby tissue is compressed during conventional
impression making it will later tend to recoil and
dislodge the overlying denture
• Thus, over the years, several impression techniques
have been suggested for the impression of a flabby
tissue ridge which will support the flabby tissue but at
the same time will not displace it.
(Jayaprakash MB etal, 2014)
17. Cont..
•Liddlelow described a technique whereby two
separate impression materials are used in a
custom tray (using ‘plaster of Paris’ over the
flabby tissues, and zinc oxide and eugenol over
the ‘normal’ tissues).
(Jayaprakash MB etal, 2014)
18. • A technique using PVS heavy body and light wash impression has also
been described by Lynch.
• A custom tray is fabricated with perforations in the area of
displaceable tissues. 3 layers of wax is placed here and 1 layer of wax
in normal tissues.
• An impression is then taken with the heavy body in only the normal
tissue then in the displaceable tissues. A light wash is then taken for
all tissues.
• ( C. D. Lynch and P. F. Allen, 2006)
19. SECTIONAL IMPRESSION TECHNIQUE (WINDOW
TECHNIQUE).
• As described by Watson , a primary impression is taken in
alginate loaded in a stock tray. The impression is then
poured and a special tray is constructed on the model.
• The special tray is close fitting and has a hole or "window"
over the area corresponding to the flabby ridge.
• An impression is taken in impression paste
(mucodisplacive). Once this has set it is left in place and
impression plaster (or any light body impression material -
mucostatic) is painted over the flabby ridge and allowed to
set and removed as one impression. (C. D. Lynch and P. F. Allen,
2006)
20. • The impression is removed as one, cast and the denture
constructed on the resulting model. (C. D. Lynch and P. F.
Allen, 2006)
22. Surgical management
• This technique involves surgical excision of the flabby tissue, with or
without ridge augmentation using bine grafts followed almost always by
vestibuloplasty .
• The advantage of the surgical technique is that it provides a firm denture
bearing area.
• Its limitations include chances of decrease in vestibular height requiring an
additional surgery or vestibuloplasty.
• Also resultant formation of fibrous tissue and also resorption
• Sometimes the flabby ridge might recur.
• It is contraindicated in patients who are unwilling to undergo a surgical
treatment.
(Umesh YP 2014)
23. Implant retained prostheses
• Implant retained prosthesis take the support from the underlying
bone hence minimal or no support is needed from the tissue area.
• Disadvantages: expense time taken for the completion of procedure.
• Other factors that must be considered include surgery, discomfort
and inconvenience, general health of the patient, and risk of surgical
complications or implant failure
(Umesh YP 2014)
25. Residual ridge resorption
•A term used for thediminishing quantity and quality of the
residual ridge after teeth are removed. (GPT 8)
• It is a chronic, progressive, irreversible, multifactorial
and cumulative disease of bone reconstruction.
• In aprosthetic sense, bone is considered to be the base
which provides support for dentures.
26. ETIOLOGY
It is a complex biophysical process involving;
1 Anatomical factors
A.Ridge form (square, ovoid, wiry) and muscle attachment. The broad
ridge is more resistant to atrophy and bone resorption than narrower arch
B.Nature of bone (compact vs cancellous) cancellous bone is more prone to
resorption.
C.Facial skeleton morphology Individuals with longer faces and obtuse
gonial angle are more likely to have atrophy of their ridges than those with
short faces and right angle gonial angle.
2 Biologic metabolic factors
A.Age (old age more affected due to increasing the osteoclastic activity of
cells over the osteogenesis.
B.Sex, female more than male due to hormonal imbalance (such as
menopause) which causes demineralization and osteoporosis of the bone.
C.Nutritional (proteins, minerals, alcohol, smoking, and (vitD,
aIcium /phosphorous diet deficiency)) (TALLGREN A1983)
27. Systemic health
1. Calcium / phosphat e metabolism diseases.
2.Hormonal; endocrinal (hyperthyroidism,
hyperparathyroidism, oestrogen deficiency or
postmenopausal and diabetes
3. Renal and bone diseases
E.Treatment of certain systemic disease (drugs, radiation
and surgery management may affect the resorption rate)
F.Loss of natural teeth or local bone resorping factor (such
as sever periodontal diseases).(TALLGREN A1983)
28. 3-Functional factors
•The intensity and duration of applied forces (24-hour use
of dentures has a particularly bad influence on the residual
ridge)
Parafunctional habits (such as bruxism and clenching
habits).(TALLGREN A1983)
29. Prosthodontic factors
A. Long term wearing of dentures (night wearing)
B. Improper constructed denture
1. Improper vertical dimension
2. Incorrect centric relation
3. Non-balanced occlusion
4. Incomplete basal seat coverage.
C.Porcelain teeth or anatomic teeth with high clasp angle
(high vertical and lateral forces) . (TALLGREN A1983)
30. •Poor denture hygiene (stomatitiss,
candida infections, sore mouth, ulcers,
all these diseases can influence the
bone resorption
•Flabby ridges (unstable denture).
Denture wearing habits.
• (TALLGREN A1983)
32. l - SURGICAL MANAGEM ENT.
Vestibuloplasty : A surgical procedure to restore
alveolar ridge height by lowering muscles attaching
to the buccal, labial, and lingual aspects of the jaws.
Types:
1- secondary epithelialization .
Secondary epithelialization is ineffective because
the postoperative vestibular depth often decreased
over time as a result of wound contraction but with
grafting increases the sulcus depth and the amount
of stable attached tissue. (PF ALLEN 2014)
34. II- Surgical removal of any prominent bony or high
muscle attachment, such as removal of genial tubercles
and mylohyoid ridge
Ill- Ridge augmentation.
Any surgical procedure employed to alter the contour of
the residual alveolar ridge.
The augmentation itself is to increase in size beyond the
existing size. In alveolar ridge augmentation, bone grafts
or alloplastic materials are used to increase the size of an
atrophic alveolar ridge. It can be: (PF ALLEN 2014)
35. 1- Autogenous (a graft taken from
the patient's own body) Autografts or
allograft (ramus of mandible.-
symphesial, iliac crest.- ribs)
2.Heterogeneous (Xenografts a graft
taken from a donor of another species)
Hydroxyapatite (artificial bone
substitute), Granular or blocks. (PF
ALLEN 2014)
37. IV- Distraction ost eogenesis : a procedure whereby a segment of
the jaw is sectioned by osteotomy and gradually displaced by a
controlled movement.
Alveolar ridge distraction has become a useful technique for ridge
augmentation. This technique produces new bone by local guided
bone regeneration without the necessity of bone transplants.
38. It enables heightening of the alveolar
ridge up to 6mm. The prosthetic super
structure is loaded 4 to 6 months after
distraction (needs long time). The
advantage of distraction is that there is
no need for donor site, simultaneous
lengthening of the surrounding soft
tissues as skin, muscles, blood vessels
and nerves. (CD LYNCH 2005)
39. V- DentalImplants
It is a prosthetic devices of alloplastic material implanted to provide
retention and support for fixed or removable prosthesis.
Pioneered by prof. Per-lngvar Branemark in 1 952 (Swedish orthopedics'
surgeon) Made of various biomaterial. Most commonly made of titanium
(most compatible with human biology)
)
The placement of two or more implants anteriorly in the area between
the two mental foramina can be of value in improving horizontal
supported
stability and retention of the constructed implant
overdenture.
40. 2- PROSTHETIC MANAGEMENT
Factors need to be considered;
1-
2-
3-
4-
5-
6-
7-
Muscular control.
Vertical dimension of occlusion.
Area of the impression surface of the denture.
Size or area of the occlusal table .
Morphology of the occlusal table.
Occlusal balance.
Impression
technique
(PF ALLEN 2014
41. l -Muscular control
The polished surfaces should harmonize with the
musculature (tongue, lips and cheeks). Mold the periphery
of the polished surfaces to be convex in harmony with the
buccinator muscles
(i)The cheeks can impart a downward component to the
denture, assisting retention.
(ii)By filling in this space, it helps prevent 'dead space'
where food debris may gather.
42. 2- Vertical dimensi1
on of occllusion
The static measurements of OVD is established by recording
the resting facial height and subtracting the proposed freeway
space, by using a Willis gauge, dividers or any vertical
measuring tool.
Guidelines suggest 2-4 mm for freeway space, however, this
may need to be increased in older patients or for those patients
with atrophic mucosa overlying the residual ridges (to
decreases the occlusal load and force on the tissues and
supporting bone). (PF ALLEN 2014)
The lower denture usually becomes intolerable Such a
complaint is usually of insufficient freeway space, occlusal
modification or reset a teeth is indicated.
If sufficient freeway space is present and there is pain on
eating, consideration should be given to either increasing the
denture bearing area and / or reducing the size of the occlusal
table.
43. 3 Area of the impression surface of the denture
The major factor influencing the pressure on
mucosa du ring function is the denture-base. The
smaller the fitting surface is the greater the
mucosal loading.
4 Size or area of the occlusal table
The greater the area of the occlusal table is the
greater will be the effort to drive the denture teeth
through a bolus of food. (PF ALLEN 2014)
44. 5-Morphology of the occlusal table
Anatomical-shaped teeth with cusps provide a balanced
articulation, however, cuspless teeth avoid occlusal locl<ing
cases of flat ridge and
(and this is more favorable in
reduced denture stability).
The choice of posterior teeth must take into consideration
the masticatory characteristics of the patient:
1(CHOPPER) Patient with purely vertical mandibular
movements not require denture teeth with cusps.
2(GRINDER) Patient with ruminatory mandibular
movements a balanced articulation is required to maintain
denture stabiIity.
45. 6-0cclusal balance
When it is vertical movements, 'choppers', it needs even contact
(balanced occlusion) in the retruded contact position (centric
occlusion). While, in 'grinders', with their mixture of vertical,
balanced
lateral and protrusive movements, they need
articulation.
7- lmpressiion technique An ideal impression taking for;
1- Maximum extension without muscle impingement.
2- Intimate contact with tissue covered area.
3 Proper form of border molding.
4 Proper relief of hard and sensitive area.
According to the condition of the supporting tissue , different
impression techniques used;
1- Closed mouth technique (muco-compressive) impression.
2 SubIi ngual crescent recording technique butterfly impression.
3 Neutral zone impression technique dynamic impression
46. 1- CLOSED MOUTHTECHNIQUE
It requires
1-
2-
3-
well-fitting record base.
Accurate occlusal rim.
Acceptable vertical dimension.
Procedure
Primary impression with compound in suitable stock tray is made
A tray made on the primary cast with occlusion rims upper and
1-
2-
lower.
3- Border molding of the periphery is carried out in the usual manner
4Final impression is made using zinc oxide and eugenol impression paste
(light body silicone impression material can be used) while the patient is
closing on the occluding rims (closed mouth technique).
5Patient was asked to close the mouth and make various functional
movements like puffing, blowing, whistling and smiling, etc.
48. •
•
•
•
•
•
•
3- NEUTRAL ZONE IMPRESSION TECHNIQUE
DYNAMIC IMPRESSION
►The loose and unstable lower complete denture is one of the most
common problems faced by denture patients. One of the methods used
to solve this problem is the neutral zone technique.
►The neutral zone is the area where the displacing forces of the lips
cheeks and tongue are in balance.
►It is in this zone that the natural dentition lies and this is where the
artificial teeth should be positioned.
►This area of minimal conflict may be located by using the neutral zone
technique.
►The artificial teeth can then be set up in the correct positions. This
technique is described below.
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