Soft Tissue abnormalities

Soft Tissue Abnormalities

Maxillary Tuberosity reduction (soft Tissue) Mandibular retromolar pad reduction Unsupported Hypermobile tissue Lateral Soft tissue excess Inflammatory fibrous hyperplasia Labial frenectomy Lingual frenectomy

Cross-section of the Mandible

With age, loss of teeth, the bone melts away yet the muscle attachments remain in place Most common cause of unstable denture

General considerations
When to commence impressions
Soft Tissue procedure 3 to 4 weeks Osseous procedures 6 to 8 weeks

Maxillary Tuberosity reduction (soft Tissue)

Aim: Provide adequate interarch space Diagnostic aids:
Panoramic radiograph sharp probe

Technique
Incision
Elliptical

Width~ depth of tissue Secondary undermining cuts

Allows tension free closure Removes excessive tissue Use digital pressure to approximate tissues

Mandibular retromolar pad reduction

Rare Elliptical incision More tissue excised from the buccal/labial aspect Avoid excising lingual tissue

Unsupported Hypermobile tissue

Causes:
Resorption of underlying bone Ill fitting dentures Both

Diagnose the cause:

bony deficiency- Augment the underlying bone adequate bone height exists-excise soft tissue

Hypermobile tissue
Maxillary Anterior
Parallel horizontal incisions Undermine Excise

Mandibular Anterior
Simple scissor incision

Disadvantages
Loss of vestibular height eliminates keratinized mucosa

Flabby Ridge
This occurs when you have natural teeth occluding against denture teeth Bone disappears and the body fills the space with flabby tissue

Inflammatory Papillary Hyperplasia

PAPILLARY HYPERPLASIA: the body attempts to make the denture more stable
1. Epulis Fissuratum 2. Papillary Hyperplasia

As patients wear dentures for a long time the bone wears away the denture become loose it wobbles the bone resorbs more the body fills up the space with granulation tissue

Epulis Fissuratum
Forms around the periphery of the denture Soft, movable, poor base for denture Appearance
single or multiple fold of tissue that grows in excess around the alveolar vestibule

The edge of the denture rests in between two of the folds The excess tissue is firm and fibrous in nature Ulcerations may be present

Epulis fissuratum
Etiology- Ill fitting dentures Problem
Underlying connective tissue hyperplasia and NOT that of the epithelium

Small lesions
Tissue conditioner

Larger lesions
Surgical excision

Epulis fissuratum
Total Excision/Secondary epithelialization From crest of ridge to vestibular depth Hyperplastic soft tissue is excised superficial to periosteum from the alveolar ridge area Unaffected mucosal margin is sutured to most superior aspect of vestibular periosteum with interrupted sutures Surgical stent with tissue conditioner/denture Worn for 5-7days continuously

Epulis fissuratum

Send tissue for biopsy Disadvantages Shrinkage of vestibule Can be avoided by grafting

Papillary Hyperplasia
Causes:
Seen beneath ill-fitting dentures of long use Overnight denture wearers

Clinical Presentation:
Combination of chronic, mild trauma and low-grade infection by bacteria or candida yeast. Patients with high palatal vaults Mouth breathers

Papillary Hyperplasia -Treatment

Early stage
Tissue conditioning Relining of dentures

Late stage
Surgical excision
Electrosurgical loop Scalpel or loop blade High speed diamond, acrylic or bone bur

Papillary Hyperplasia
Complications of Deep excision
Bone necrosis Atrophic, non elastic, fixed mucosa Denture irritation ulcers

Papillary Hyperplasia- Use of Electrosurgery

Labial Frenectomy
Anatomy Level Problems Types of Techniques
The simple excision Z-plasty Localized vestibuloplasty with secondary epithelization Laser assisted frenectomy

Simple Frenectomy
Indications : Narrow frenum Local Anesthesia- Avoid excessive infiltration Incision Narrow elliptical incision Incision is made down to the periosteum Sharp dissection of underlying periosteum Dissect fibrous frenum Suture placement Advantages-reduces hematoma formation

Z-plasty technique
Similar to simple frenectomy Two oblique incision are made in a Z fashion Undermine two pointed ends Rotate to close vertical incision Advantages
Less chances of Vestibular obliteration

Use of laser in frenectomy

No sutures Fewer post operative complains
Less Swelling Little or no pain

Lingual Frenectomy
Anatomy Mucosa Dense fibrous tissue Superior fibers of genioglossus muscle Binds tip of the tongue to posterior surface of mandibular ridge

Lingual Frenectomy
Affect Speech Interfere with denture stability Technique
Stabilize tongue with traction suture Transverse incision of fibrous connective tissue at the base o the tongue Hemostat is placed across the frenal attachment at the base of the tongue Undermine tissues Sutures placed parallel to midline of tongue

Lingual Frenectomy
Structures to be careful of
Blood vessel Whartons duct

Lingual Frenectomy

Localized vestibuloplasty with secondary epithelialization

Indication: Base of the frenal attachment is extremely wide eg. Manibular anterior frenum Local anesthesia:
Infilterate the supraperiosteal areas along the frenal attachments

Incision:
Mucosa, underlying submucosal tissue SPARE the periostium

Technique
Supraperiosteal dissection Edge of the mucosal flap is sutured to the periosteum at the maximal depth of the vestibule Exposed periosteum heals through secondary epithelization Surgical splint or denture with tissue liner is very useful for initial healing period

Immediate Dentures
Most commonly performed by GP (Prosthetics/surgery done by GP) Surgery to be done by OMFS depending on certain factors:
Complexity Length of case
The older the patient, the more dense the bone, the longer it takes to get the teeth out.

Anxiety level
To many women, this is a sign of aging which will cause them to become more anxious, thus requiring i.v. sedation

Immediate Dentures
Preoperative stage
Models- undercuts, tuberosity occluding with retromandibular pad Mounted models are not required anymore

Operative stage
Phase1
1. Posterior extractions Phase22. Anterior extractions 3.recontouring 4. surgical guide 5.suture 6.Insertion

Postoperative stage (after 24hours)

Adjustments
More adjustments on an immediate denture The bone will remodel itself

Immediate Dentures
Advantages:
Immediate psychologic & esthetic benefits Functions as a splint Improves tissue adaptation Vertical dimension can easily be reproduced

Disadvantages
Frequent alterations Cost

Overdenture Surgery
Maintenance of Alveolar bone An overdenture technique attempts to maintain teeth in alveolus by transferring force directly to the bone and improving masticatory function with prosthetic reconstruction
Peterson

Indications
Several teeth with adequate bone support Good periodontal health Teeth are restorable Bilateral canines

Overdenture
Advantages
Improves propriception during function Improves Retention (retentive attachments)