4. • Abused tissues
• Types of abused tissues
• Management of abused tissues
• Tissue conditioners
• Uses
• Resilient liners
• Relining and rebasing
• Diet and nutrition
• Lasers
• Discussion
• References
4
5. INTRODUCTION
• DEVANS PRINCIPLE-PRESERVATION OF WHAT ALREADY EXISTS
THAN THE MERE REPLACEMENT OF WHAT IS MISSING.
• Ridge atrophy poses a clinical challenge towards the fabrication of a
successful prosthesis.
• Extreme resorption of the maxillary and mandibular denture bearing
areas results in sunken appearance of cheeks, unstable and non
retentive dentures with associated pain and discomfort.
5
7. • The success of a denture depends on its proper
management techniques especially in the case of
compromised ridges.
• This involves proper impression making procedures.
7
9. • Rudd,Morrow and Rhoads
A full wax spacer 2 mm short of the
resin special tray border all over. Then
they recommend placement of three
tissue stops (4 x 4 mm)
9
10. Sharrys spacer design
• Adaptation of a layer of base-plate
wax over the whole area outlined
for tray (even in PPS area).
• Four tissue stops (2 mm in width
located in molar and cuspid regions
which should extend from palatal
aspect of the ridge to the
mucobuccal fold) .
10
11. Roy Mac Gregor spacer design
• Placement of a sheet of metal foil in
the region of incisive papilla and
midpalatine raphe.
• Other areas that may require relief
are maxillary rugae, areas of mucosal
damage, and buccal surface of the
prominent tuberosities.
11
12. • T-spacer covers the anterior residual
alveolar ridge in maxilla when it is
resorbed and flabby.
• It is based on selective-pressure
technique; it also covers the
prominent incisive papilla, rugae and
midpalatine raphe, and the exposed
areas act as stoppers.
12
13. • I-spacer in maxillary arch, based on
selective-pressure technique, covers
the incisive papilla and midpalatine
raphe when it is prominent
13
16. Severe ridge atrophy results
• Increased inter-arch space.
• Unstable and non retentive dentures with inability
to withstand the masticatory forces
16
17. Residual ridge resorption
• Residual ridge resorption is a complex, multifactorial,
biomechanical process and a common occurrence
following extraction of teeth.
• Ridge atrophy is most dramatic during the first year
after tooth loss followed by a slower but more
progressive rate of resorption thereafter.
17
19. Anatomic factors
• RRR is directly proportion to the anatomic factors.
• The more the bone there is higher will be the rate of resorption.
• Evaluate the present state of the ridge to determine what has gone on before.
19
20. Metabolic factors
• RRR- directly proportional to bone resorption factors
- indirectly proportional to bone formation factors.
• One of the main factors-endotoxins from dental plaque.
(OAF,prostaglandins,gingival bone resorption stimulating factor)
20
21. DENTAL PLAQUE
21
IMPROPER HYGIENE MICROPOROSITIES IN
THE DENTURE
TEXTURE OF
THE DENTURE
CANDIDA RELATED
STOMATITIS
WHICH IS FURTHER AGGRAVATED BY TOBACCO,SYSTEMIC FACTORS,NUTRITIONAL
DEFIECIENCIES,IMMUNE DEFECTS
22. MECHANICAL FACTORS
a) Functional factors
• Frequency, direction and strength of forces acting on bone
• Bruxism
b) Prosthetic factors
• Type and fit of prosthesis
• Duration of prosthodontic treatment
• Hours of prosthesis wearing per day
• Occlusal disharmony
• Lack of prosthodontic treatment
22
23. Management of atrophic ridges
• As the residual ridges resorb the tissues become unsupported and displaceable;
the use of conventional impression techniques will result in a distorted
impression . Therefore, the impression technique needs to be modified.
23
25. Advantages:
• Easily controlled to gain maximum coverage
• Corrected readily
• Used to accurately determine the extent of the mucobuccal reflections
• Used to direct pressure toward the load-bearing areas, specifically, the buccal
shelf and the slopes of residual ridges in the mandible
25
27. Mc Cord and Tysons admixed technique
• Impression compound and green
stick in the ratio 3:7
• Water temperature-60 degree celsius
• Working time - 90 seconds
• Wax spacer is removed-homogenous
mass is loaded and patient is asked to
do various tongue movements.
27
28. Green all compound technique
• The custom tray is adjusted optimally in the
patients mouth.
• It is fabricated without a spacer.
• Low fusing compound is then heated in a
water bath at 55 degree.The borders are
shaped with fingers to mimic the borders of
the final denture.
• Once done,scrape the areas which need
relief,the crest of the ridge,sharp mylohyoid
ridge.
• A final impression is made with light
viscosity poly vinyl siloxane.
28
29. Closed mouth functional impression technique-Winkler
• Denture bases with rims were fabricated on
the primary cast.
• Jaw relations were recorded.
• Tissue conditioning material was applied on
the tissue surface of mandibular denture base
and patient was asked to close the mouth in
the prerecorded vertical dimension and do
various functional movements such as
puffing, blowing, whistling, and smiling
29
30. • Three applications of tissue conditioner material were done at an interval of 8–10
minutes and functional movements were made by the patients.
• Final impression was made with light body addition silicone material with
closed mouth technique.
30
31. Cocktail impression technique
• A tray with 1mm wax spacer and
cylindrical mandibular rests in the
posterior region is made at increased
vertical height.
• Patient is advised to close his mouth
so that the mandibular rests fit
against the maxillary alveolar ridge.
• This helps to stabilize the tray in
position by preventing
anteroposterior and mediolateral
displacement of the tray during
definitive impression.
31
32. • Lingual surfaces of mandibular rests are made concave to provide space for the
tongue to move freely during functional movements.
• McCord and Tyson’s technique for flat mandibular ridges is followed for definitive
impression.
• For recording the functional state,patient was instructed to run his tongue along his
lips, suck in his cheeks, pull in his lips, and swallow by keeping his mouth closed, as
in closed mouth impression technique, till the impression material hardens.
32
33. Elastomeric impression technique
• The special tray is placed in the mouth and
is border molded; the patient is asked to
move the tongue according to standard
impression procedures.
• The light body is loaded in the impression
and inserted in the mouth.
• The patient is instructed to repeat the
tongue movements, more vigorously,
while the light-body impression material is
border molded along the buccal and labial
flange areas.
33
37. Flabby ridges
Kelly in 1972
• Edentulous maxilla opposed by natural mandibular anterior teeth
• Loss of bone from anterior maxillary region
• Overgrowth of tuberosities
• Papillary hyperplasia
• Loss of alveolar bone and ridge height beneath mandibular RPD
37
38. According to tissue character
1. Coarse and fibrotic
2. Average
3. Thin and fragile
According to mobility
1. Attached, low mobility, low displacement
2. Average
3. High mobility, high displacement
38
Massad J. Building the edentulous impression--a layering technique using multiple
viscosities of impression material. Compend Contin Educ Dent. 2006 Aug;27(8):446-51
39. Unless managed appropriately, such ‘flabby ridges’
adversely affect the support,retention and stability of
complete dentures. Many impression techniques have
been proposed to help overcome this difficulty
39
41. One part impression technique
• Primary impressions are made in stock
trays using low-viscosity alginate.
• A special tray is fabricated and
impressions are made with a low viscosity
impression material, such as impression
plaster, low-viscosity silicone .
• Pressure on the unsupported,displaceable
soft tissue can be minimized further by
the use of perforations in the tray
overlying these areas.
41
42. Controlled lateral pressure technique(McCord,Grant ,Allen)
• Mainly for hyperplastic posterior mandibular ridge.
• A low fusing impression compound is used to record the denture bearing area using a
correctly extended special tray.
• A heated instrument is then used to remove the low fusing impression compound
related to the fibrous crestal tissues and the tray is perforated in this region.
• Light bodied silicone impression material is then syringed onto the buccal and lingual
aspects of the greenstick and the impression gently inserted.The excess material is
extruded through the perforations and theoretically the fibrous ridge will assume a
resting central position having been subjected to even lateral pressures.
42
43. Hobkirk technique
• The maxillary preliminary impression was made using irreversible
hydrocolloid in perforated edentulous tray and the primary cast was
poured.
• Special tray was fabricated using double spacer over the flabby tissue
area and in the region of mid palatine raphe.
• After checking the proper tray extensions, border molding was done in
conventional manner using green stick
43
45. • Spacer wax was removed and impression was made with medium body
elastomeric impression material (Elite Glass medium body, Zhermack,
Germany).
• The tray was then removed from the mouth and impression material was
removed in the region of flabby tissue using a scalpel.
• Relief holes were made and tray was loaded in this region with light body
elastomeric impression material (Elite HD+ light body, Zhermack, Germany) to
record the flabby tissue.
45
47. Watsons technique/window technique
• The maxillary preliminary impression was made using irreversible hydrocolloid
in perforated edentulous tray and primary cast was poured.
• Spacer was adapted over the primary cast except in the region of flabby tissue.
• Special tray was fabricated providing a window in the region of flabby tissue.
• Border molding was done using green stick compound .
• Spacer wax was removed and impression was made with zinc oxide eugenol
impression material.
47
49. • With the zinc oxide eugenol impression
(DPI Impression Paste) in the mouth,
flabby tissue was painted with
impression plaster.
• Impression plaster was allowed to set
and tray was removed from the mouth.
• Master cast was poured after applying
soap solution as separator over
impression plaster.
49
50. Massads technique
• The impression tray was selected in accordance with the size and shape of
patient’s ridge.
• Using heavy viscosity impression material (Aquasil, Dentsply, Delhi, India)
tissue stops were created in both maxillary and mandibular tray.
50
51. • Spherical pieces of material were placed in each tray- one in anterior region, one
in each posterior region, and one in palatal area (maxillary tray).
• The tray was then placed in patient mouth allowing for 2-3 mm of space.
• The stops were allowed to set in patient mouth.
• Border molding of the impression was now done using heavy viscosity
impression material
51
53. • Final impression of maxillary ridge was then made using medium body
impression material in tuberosity region and light body in the remaining region.
• Final impression of mandibular ridge was made using light body impression
material.
• Different viscosities of impression material were selected so as to record the load
bearing area in the functional state and the other areas that is flabby tissue and
relief areas, under minimal displacement .
53
55. Modified window technique
• A Primary impression was made with alginate.
• A maxillary cast was poured and the flabby ridge area was marked, followed by
fabrication of custom tray [spaced (2 mm), tissue stops] (Triad, Tru tray,
Denstsply) with two posterior handles .
55
56. • The anterior window in the marked
area was outlined using sharp knife
before curing the tray material to
facilitate removal of the window at a
later stage
56
57. • A vacuum heat pressed polyethylene
sheet of 0.5 mm thickness was
adapted on the tray after curing
57
58. • The window was removed and three
holes on the polyethylene sheet were
made in the window area.
58
59. • Border molding was done and a
maxillary impression with regular
body polyvinylsiloxane impression
material was made.
59
60. • The excess materials on the periphery
and the opening area were removed
away using scalpel blade.
60
61. • The impression was re-seated in the
patient mouth and a light body PVS
impression material was injected
starting from one of the side holes
passing through the middle of the
polyethylene sheet until some excess
material poured from the holes.
61
62. ABUSED TISSUES
• Traumatized oral mucosa because of ill fitting
dentures
• Poor occlusion
• Bruxism
• Papillary hyperplasia
• Nutritional disorders
• General debilitating patients
62
63. Papillary hyperplasia
• Seen mostly along the palatal vault.
Due to
• Local irritation
• Low grade infections
• Poor oral hygiene
Mainly associated with a relief chamber in the palatal vault
area of the denture-pressure changes causes a pumping motion
that excites mucosal tissues-hence proliferates.
63
64. Manifests in several forms from small isolated
projections to multiple papillary modular projections
with fissures covering the palate.
64
65. • Early isolated hyperplasia may be reversible following removal of the denture or
tissue conditioning.
• Smaller lesions may be removed surgically with sharp curettes or by
microabrasion with rotary instruments.
• Larger lesions-split thickness supraperiosteal excision, following removal the
denture should be lined with a tissue conditioning agent.
65
66. Denture stomatitis
Systemic factors
• Old age
• Diabetes
• Nutritional deficiency
• Malignancy
• Immunosuppression
due to drugs or steroids
Local factors
• Dentures
• Xerostomia
• High carbohydrate diet
• Broad spectrum
antibiotics
• smoking
66
68. Features
• Chronic inflammation of the denture bearing mucosa that may be localized or
generalized.Lesion is asymptomatic.
• Patient may complaint of itching or burning sensation along the palatal or glossal
mucosa.
• Occurs more frequently in the upper arch than in the lower arch.
68
69. Management
• Effective oral and dental hygiene
• Correction of ill fitting dentures
• Rough areas on the fitting surface are smoothed or relined with tissue
conditioner.
• Antifungal therapy-nystatin,amphotericin B,fluconazole
• Surgical treatment to eliminate crypts and ensure proper mucosal hygiene.
69
70. Burning mouth syndrome
Local factors
• Friction on mucosa from
dentures
• Instability of dentures
• Parafunctional tongue
activity
• Myofascial pain
• Infection and allergic
reactions
Systemic factors
• Menopause
• Vitamin B12 and iron
deficiencies
• Xerostomia
• Diabetes
• Depression
• Anxiety
70
71. Features
• Female predilection higher-postmenopausal women
• Symptoms generally appear for the first time after placement of new dentures
• Patients complain of a burning sensation associated with dry mouth and altered
taste sensation.
• Aggravating factors are-tension,fatigue,hot or spicy foods
71
72. Management
• Denture should be checked thoroughly.
• Patients need to be counselled to help them understand that their problems are
benign and that dentures are not the cause of their psychiatric disorders.
72
73. Management of abused tissues
• Step I – Relieving the pressure areas and over extension
in the dentures (pressure indicating pastes).
• Step II – Correcting occlusal discrepancies.
• Step III – Massage of soft tissue 2-3 times a day to
increase blood supply for better healing.
73
74. In case of candida infections
• Counseling for efficient oral and denture hygiene.
• Rough areas should be removed. Micro-organisms can
penetrate about 1mm of the fitting surface of the denture.
This should be removed and relined with soft tissue
conditioners.
• Anti fungal drugs
• Disinfectant solution – 0.2% to 2.0% chlorhexidine.
74
75. • Step V – To wear the dentures as seldom as possible
• Step VI – Soft liners can be used as they act as a cushion over the tissues
preventing excessive transmission of forces allowing tissue recover.
• Step VIII – Surgical removal of excessively flabby / hyperplastic tissue.
• Step VIII – Relining the denture preferably using resilient liner till the healing is
complete.
75
76. Tissue conditioners
• Soft resilient materials which function as short term reline materials by restoring
fit and stability of the denture.
• They flow under pressure and act as a cushion helping in equalization of force
over the mucosa.
• They form an intervening cushion between the denture base and basal seat tissues.
• Hence-transmission of masticatory forces to the mucosa is equalized .
76
77. • Occlusal disharmonies and improperly extended
borders should be corrected before initiating tissue
conditioning.
• As long as material remains soft-rehabilitating
effect,prolonged use-can cause trauma
77
79. Composition
• Powder-poly (ethylmethacrylate)
• Liquid- mixture of aromatic ester and ethyl alcohol.
• When mixed,they form a cohesive ,resilient gel.
• It does not adhere to the wet mucosa but readily adheres to dry acrylic resin.
• Continue to flow under pressure for several days.
79
80. Uses of tissue conditioners
• Conditioning the tissues during fabrication of new complete denture
• After occlusal corrections lining the old dentures with a tissue conditioner
improves stability,relieves and equalizes pressure almost immediately and thereby
allows tissues to recover and prevent further breakdown.
• If new dentures are to be in proper occlusion ,maxillomandibular jaw records must
be made with recording bases supported by normal healthy tissues.Tissue
conditioners are useful here because they preserve the form of the tissues.
80
81. • To use these materials effectively-a thickness of
1mm or more is needed.
• A new application of the material is necessary every
3 to 4 days until the tissues have recovered.
81
82. Temporary obturators
• They can be added to an obturator following
surgery.
• Temporary obturation is accomplished 7 to 10 days
after surgery
• Protects the tissues and enhances the healing
process.
82
83. Stabilize baseplates, surgical splints or stents
• When undercuts are present on an edentulous cast,conditioners of a stiffer
consistency may be used to stabilize recording bases and breakage of the cast.
• This procedure also enhances the stability, retention and comfort of the recording
bases , this will minimize errors during this procedure.
• Tissue conditioners may be used to line surgical stents or splints after maxillary
or mandibular vestibuloplasty or resections-Close adaptation to the tissues and
prevent trauma.
83
84. Technique to use conditioner
Ensure the following
• Adequate extension
• No occlusal discrepancy
• Correct horizontal and vertical relations
84
85. Manipulation and placement
• Remove from denture base all undercuts and area immediately on the ridge-1mm
• If both maxillary and mandibular arches need to be treated-do separately-arch
with most stable denture is used as a guide and other is treated first.
• Lubricant-applied to areas where conditioning material is not supposed to contact
• Powder and liquid are mixed as per manufacturers guidelines
85
86. • Once it is creamy and fluid-cover the entire denture
base.
• Once it stops flowing and reaches dough stage –
insert in patients mouth –close in centric relation,for
5 to 7 minutes.
• Denture removed and excess is trimmed
86
89. Recall and maintenance
• Avoid hard food for the first 8 hours-tendency to squeeze the conditioner out of
shape.
• Ask the patient to return the following day for inspection and correction of
pressure areas and this has to be repeated every 3 to 4 days till the traumatized
tissues have healed.
89
90. Resilient liners
• Used in the prevention of chronic soreness from dentures and preservation of
supporting structures.
• Soft liners or permanent liners
• Usage- 6 months to 5 years
• They prevent denture soreness,while conditioners treat denture soreness
90
92. Composition
• 2 categories are used as resilient soft liners-
• Acrylics (plasticized acrylics)
• Silicones (siloxane polymers)
Acrylics are referred to as temporary reline material and are used as tissue
conditioners.
Silicones-permanent soft liners,long term use-Molloplast B
92
94. Long term soft liners
• Requirements
• Permanent softness
• Good bond to denture base
• Adequate abrasion and tear resistance
• Inhibit colonization of fungi
• Easy to clean
• Low water sorption and solubility
94
95. Indications
• Patients who cannot tolerate stress
• Chronic pain,soreness or discomfort
• Sharp thin heavily resorbed ridges or severe bony
undercuts
95
97. Uses
• Atrophied or resorbed ridges-(esp knife edged ridges ,surgically excised soft or
bony tissues)-excellent protection
• Patients who cannot afford surgery for removal of bilateral undercuts(facilitate
removal and insertion without compromising retention)
• In cases of bruxism-protect tissues from excessive stress.
• In obturators-restore congenital or acquired defects
97
98. Drawbacks
• Plasticizer leaches out over a period of time –hard and discolored
• Silicone elastomers donot adhere well with acrylic resin denture base-gets
discolored, difficult to finish and polish, dimensionally unstable,affected by
candida albicans
98
99. Relining and rebasing
• Reline-to resurface the tissue side of the denture
with new base material
• Rebase-to replace the entire denture base material
on an existing prosthesis
99
100. Treatment rationale
Adversely changing denture foundation
Variable changes in VD and occlusal relationship
Induces more adverse stresses
Magnitude of the observed changes
100
101. Diet and nutrition
• Abuse of tissue-complicated by weakened host response or repair
• Poor nutrition-reduces tissue recovery
• Deterioration of supporting tissues
• Xerostomia,burning,sore tongue,angular cheilitis
• Diet-As prescribed by the dentist
101
102. LASER(Light amplification by stimulated emission of
radiation)
• Alternative to conventional surgical technique
• Selection of the wavelength is best absorbed by the target tissue
• Each wavelength has different absorption coefficient based on the composition of oral structures
(erbium laser)
• Treatment of-
• hyperplastic tissue
• Nicotinic stomatitis
• Denture stomatitis
• Epulis etc
102
103. Journal references
• Kumar, et al.: Impression techniques for hypermobile alveolar mucosa. Int J Health Allied Sci
2012;1:255-67
• Salinas T. J. Treatment of edentulism: optimizing outcomes with tissue
management and impression techniques.J Prosthodont. 2009; 18(2) :
97–105
• Lytle RB. The management of abused oral tissues in complete denture
construction. J Prosthet Dent 1957;7:27-42.
• Lynch CD, Allen PF. Management of the flabby ridge: Using contemporary materials to solve an
old problem. Br Dent J 2006;200:258-61
103
104. • Hobkirk JA. Complete Dentures Dental Practitioner Handbook. Bristol: Wright;
1986:44-5.
• Kelly E. Changes caused by a mandibular removable partial denture opposing a
maxillary complete denture. J Prosthet Dent 1972;27:140-50
104
105. Text references
•Prosthodontic treatment of edentulous patients; Zarb & Bolender;12th edition
•Essentials of complete denture prosthodontics: Sheldon winkler;3rd edition
•Textbook of complete dentures;Heartwell;5th edition
• Textbook of Prosthodontics;Rnagarajan,2013
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