Soft Tissue abnormalities

1. Soft Tissue abnormalities

2. 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

3. With age, loss of teeth, the bone melts away yet the muscle attachments remain in place Most common cause of unstable denture Cross-section of the Mandible

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

5. Maxillary Tuberosity reduction (soft Tissue) • Aim: Provide adequate interarch space • Diagnostic aids: • Panoramic radiograph • sharp probe

6. Technique • Incision • Elliptical • Width~ depth of tissue • Secondary undermining cuts • Allows tension free closure • Removes excessive tissue • Use digital pressure to approximate tissues

10. Mandibular retromolar pad reduction • Rare • Elliptical incision • More tissue excised from the buccal/labial aspect • Avoid excising lingual tissue

11. 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

12. Hypermobile tissue • Maxillary Anterior • Parallel horizontal incisions • Undermine • Excise • Mandibular Anterior • Simple scissor incision • Disadvantages • Loss of vestibular height • eliminates keratinized mucosa

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

14. Inflammatory Papillary Hyperplasia • PAPILLARY HYPERPLASIA: the body attempts to make the denture more stable • 1. EpulisFissuratum • 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

15. 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

16. 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

17. Epulisfissuratum • 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

18. Epulis fissuratum • Send tissue for biopsy • Disadvantages • Shrinkage of vestibule • Can be avoided by grafting

20. 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

21. 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

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

23. Papillary Hyperplasia- Use of Electrosurgery

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

25. 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

26. 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

27. Use of laser in frenectomy • No sutures • Fewer post operative complains • Less Swelling • Little or no pain

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

29. 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

30. Lingual Frenectomy • Structures to be careful of • Blood vessel • Wharton’s duct

31. Lingual Frenectomy

32. 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

33. 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

34. 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

35. Immediate Dentures • Preoperative stage • Models- undercuts, tuberosity occluding with retromandibular pad • Mounted models are not required anymore • Operative stage • Phase1 • 1. Posterior extractions • Phase2- • 2. 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

36. Immediate Dentures • Advantages: • Immediate psychologic & esthetic benefits • Functions as a splint • Improves tissue adaptation • Vertical dimension can easily be reproduced • Disadvantages • Frequent alterations • Cost

37. 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

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

39. Overdenture • Advantages • Improves propriception during function • Improves Retention (retentive attachments)