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Prevention and Treatment
of
Abused Tissue
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacad...
CONTENTS
• Introduction
• Terminologies
• Abused Tissue
– Denture irritation hyperplasia
– Traumatic Ulcer
– Flabby Ridge
...
• Treatment modalities
– Surgical removal
– Correction of occlusal disharmony
– Massage of the soft tissue
– Correction of...
Sympathy & Pity
www.indiandentalacademy.com
Terminologies
• Abuse (v) : to make bad use of something or to
use so much of something that it harms your
health
(n) : th...
Abused Tissue = Mucosal Reaction
Bony spicules
Faulty Occlusion
Traumatic Injuries
Continuous wearing
Dirty ill-fitting de...
• Denture Irritation Hyperplasia
– Papillary hyperplasia
• Pressure changes with relief chamber
• Early Stage – reversible...
Epulis Fissuratum
• Hyperplastic tissue repair –
response
• Association with immediate
or interim denture
• Settling of de...
Traumatic Ulcer Flabby Ridge
• Occurs within 1-2 days
• Over extended Flanges
• Unbalanced Occlusion
• Systemically non co...
DENTURE STOMATITIS
Found in about 50% of the Denture wearers
Prevalent in women
Predisposing factors
Systemic
• Old age
• ...
Etiology and Pathogenesis
• Etiological changes caused by dentures
• Plaque accumulation and presence of saliva
• Aspartyl...
TYPE II TYPE III
•Lower denture mucosa
•Erythema is restricted to denture bearing areas
•No symptoms
DIAGNOSIS
MANAGEMENT
...
Burning mouth syndrome / oral
dysaesthesia / Stomatodynia
• Medically unexplained symptoms
• Affects 5 persons per 100000 ...
Type Pattern of
symptom of
burning
Frequency
I waking
day
Unremitting
II On waking
Day
Unremitting
III No regular
pattern
...
Angular Cheilitis
• One of the commonest
fungal lesions
• Overclosed VDO
• Coexistant denture
stomatitis in 80% of the
cas...
Preventive Measures
Evaluating the tissue side
• For undercut areas and accuracy of tissue
contact
• Relieved by grinding ...
Evaluating the Borders
• For compatible
extension and contour
• Frenum attachments
and hamular notch
areas
• Stability dur...
Clinical Errors
Registering the jaw relation
• Ill fitting record bases
• Shifting of record bases
• Exertion of excessive...
Incorrect arrangement of posterior teeth
Changes in supporting structures
Processing errors
• Failure to close the flasks ...
Checking for occlusal errors
• Error exists and one has to work to find it
• How to observe the error – first “feather tou...
Intra Oral Methods
Central bearing device
• Central bearing pin works on a spring
• Metal plate
• Dentures do not shift on...
Patient Remount
Interocclusal records
Advantages
• Easy to visualize locate and correct
• Stable denture bases
• Easily ma...
Interocclusal Record Of Centric
Relation
www.indiandentalacademy.com
Remounting the mandibular denture
• Remounting the maxillary
denture by remount occlusal
index
• No need of face bow or
pr...
Selective Grinding Procedure
• Realeff – Hanau
•Forces Exerted on teeth when Pt Closes the jaw
•Change in Vertical Dimensi...
Selective Grinding of Anatomic teeth
• Alteration of Cusp form teeth
• Occlusal balance in lateral direction
Working side ...
6. Right side as a working side
• Excessive contact on one side- No contacts on other side
• Working side teeth too long –...
8. Balanced Gliding occlusion
• Working side – BULL
• Balancing side – Mandibular buccal cusps
Elimination of Centric cusp...
Selective Grinding of Non-Anatomic teeth
• Articulating paper tape
• Tapping the teeth together
• Simultaneous even contac...
Occlusal equilibration of
Zero degree teeth
• Dr Gronas 1970 – Corborundum stripping technique
• Maintain flat occlusal sc...
Patient Instructions
Albino J E et al 1984 – expectation of the patient can
profoundly influence treatment outcomes
Mainta...
Treatment Modalities
1. Surgical excision
• Hyperplastic , Hypertrophied & Pendulous tissue
• Alteration of bony support
•...
Denture lining material
Materials used to refit the surfaces of complete dentures and
to help condition traumatized tissue...
Soft Liners ( O”Brien )
Silicones Others
Heat cure RTV
• Molloplast B
Gamma methacryloxy
propyl trimethoxy silane
 Less p...
Indications
1. Treatment and conditioning
2. Provisional or Diagnostic purpose- VD
3. Temporary reline-Immediate dentures ...
Long term Soft Liners
Requirements
1. Permanent softness
2. Good bond to denture base
3. Adequate abrasion and tear resist...
Plasticized acrylics
Powder
Liquid
PEMA &
Benzoyl peroxide
Higher methacrylate monomer+ plasticizer
Ethyl ,n-butyl, 2ethox...
Silicone soft liners
Heat activation Room temperature
vulcanization (RTV)
polydimethyl siloxane
+
Silica
+
Benzoyl peroxid...
Self administered soft liners ( HOME liners )
• Simple tool to improve a clinically acceptable prosthesis
-diff components...
Relining and Rebasing
Reline –to resurface tissue side o f the denture with new base material
Rebase - to replace entire d...
Diet and Nutrition
Abuse of tissue – complicated by a weakened host response or repair
Poor nutrition – Reduce tissue reco...
Drugs and Medication
Local management
Topical local anesthetic in an emolient base
Tincture of benzoin – ulcerated area
...
LASER
Light Amplification by Stimulated Emission of Radiation
• Alternative to Conventional surgical technique
• Selection...
Low level LASER therapy ( Therapeutic lasers )
Soft , Cold, Low intensity laser therapy unlike surgical lasers
Wound Heali...
LIST OF REFERENCES:-
•Prosthodontic treatment of edentulous patients; Zarb & Bolender;12th
ed.
•Essentials of complete den...
Irritation & discomfort..!!!
Warmth & Comfort…!!!
www.indiandentalacademy.com
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Prevention and Treatment of Abused Tissue /cosmetic dentistry courses

The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit 
www.indiandentalacademy.com

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Prevention and Treatment of Abused Tissue /cosmetic dentistry courses

  1. 1. Prevention and Treatment of Abused Tissue INDIAN DENTAL ACADEMY Leader in continuing Dental Education www.indiandentalacademy.com
  2. 2. CONTENTS • Introduction • Terminologies • Abused Tissue – Denture irritation hyperplasia – Traumatic Ulcer – Flabby Ridge – Denture Stomatitis – Burning Mouth Syndrome – Angular Cheilitis • Preventive Measures – Evaluation of Tissue Side – Evaluation of Borders – Clinical and processing errors – Correcting Occlusal Disharmony • Patient remount and selective grinding – Instructions for patients www.indiandentalacademy.com
  3. 3. • Treatment modalities – Surgical removal – Correction of occlusal disharmony – Massage of the soft tissue – Correction of pressure areas – Denture lining materials • Short term soft liners • Long term soft liners • Home liners • Relining and rebasing – Diet and nutrition – Drug and medication – Psychological counseling – Use of lasers in soft tissue lesions – Low level laser therapy • Conclusion • References www.indiandentalacademy.com
  4. 4. Sympathy & Pity www.indiandentalacademy.com
  5. 5. Terminologies • Abuse (v) : to make bad use of something or to use so much of something that it harms your health (n) : the use of something in a way that is wrong or harmful (Oxford dictionary) • Tissue : an aggregation of similarly specialized cells united in the performance of a particular function (GPT - 7) www.indiandentalacademy.com
  6. 6. Abused Tissue = Mucosal Reaction Bony spicules Faulty Occlusion Traumatic Injuries Continuous wearing Dirty ill-fitting dentures Over extension Inflammation Hyperkeratosis www.indiandentalacademy.com
  7. 7. • Denture Irritation Hyperplasia – Papillary hyperplasia • Pressure changes with relief chamber • Early Stage – reversible Well Establised Local irritation Poor oral hygiene Candida Small lesion •Sharp curettes •Mucoabrasion • Electrosurgery 0 Large lesion •Split thickness supra periosteal excision www.indiandentalacademy.com
  8. 8. Epulis Fissuratum • Hyperplastic tissue repair – response • Association with immediate or interim denture • Settling of dentures • FEMALES • MANDIBLE • Varies from small single fold to multiple folds • Excessive amount of Post Dam www.indiandentalacademy.com
  9. 9. Traumatic Ulcer Flabby Ridge • Occurs within 1-2 days • Over extended Flanges • Unbalanced Occlusion • Systemically non compromised host • Anterior part of maxilla • Remaining Mandibular anteriors • Poor support • Extreme resorption cases www.indiandentalacademy.com
  10. 10. DENTURE STOMATITIS Found in about 50% of the Denture wearers Prevalent in women Predisposing factors Systemic • Old age • Diabetes Mellitus • Nutrition Deficiencies • Malignancies • Immune Defects Local • Denture • Xerostomia • High Carbohydrate diet • Broad Spectrum Antibiotic • Smoking www.indiandentalacademy.com
  11. 11. Etiology and Pathogenesis • Etiological changes caused by dentures • Plaque accumulation and presence of saliva • Aspartyl Proteinase production • Candida isolated in up to 90% of cases • 66% of Denture wearers harbor them • Staph. Aureus • Migration inhibition factor, Overactive suppressor T cells Newton’s Classification • Type I – Pinpoint Hyperemia – Trauma Induced • Type II – Generalized Erythema • Type III – Granular type Microbial Plaque Accumulation www.indiandentalacademy.com
  12. 12. TYPE II TYPE III •Lower denture mucosa •Erythema is restricted to denture bearing areas •No symptoms DIAGNOSIS MANAGEMENT www.indiandentalacademy.com
  13. 13. Burning mouth syndrome / oral dysaesthesia / Stomatodynia • Medically unexplained symptoms • Affects 5 persons per 100000 population • FEMALES 3:1 ratio • Appears to follow – Dental intervention – URTI – ACE or Protease inhibitor • No specific hormonal changes Clinical features • Tongue > Palate > Lips > Lower Alveolus • Burning sensation – Chronic, Bilateral • Relieved by drinking or eating O/E • no detectable sign www.indiandentalacademy.com
  14. 14. Type Pattern of symptom of burning Frequency I waking day Unremitting II On waking Day Unremitting III No regular pattern May remit Diagnosis of exclusion Management • 50% of patients remit spontaneously • Avoid citrus drinks and spices • Patient education and cognitive behavioral therapy • Antidepressants www.indiandentalacademy.com
  15. 15. Angular Cheilitis • One of the commonest fungal lesions • Overclosed VDO • Coexistant denture stomatitis in 80% of the cases • Rare in natural dentition • Restoring correct VDO and topical steroid preparation • Perleche www.indiandentalacademy.com
  16. 16. Preventive Measures Evaluating the tissue side • For undercut areas and accuracy of tissue contact • Relieved by grinding in dentures • Areas of exostosis and mid palatine suture • Not to relieve any pressure areas until occlusal harmony is obtained • Displaced paste does not necessarily reflect a pressure area. www.indiandentalacademy.com
  17. 17. Evaluating the Borders • For compatible extension and contour • Frenum attachments and hamular notch areas • Stability during speech and swallowing • Disclosing wax instead of softened impression compoundwww.indiandentalacademy.com
  18. 18. Clinical Errors Registering the jaw relation • Ill fitting record bases • Shifting of record bases • Exertion of excessive pressure • Unequal distribution of stress • Soft tissue deformation • Systemic factors • Errors in transfer Mounting the cast •Occlusal rims not being definitely locked or keyed •Interference of the casts •Error in articulator •Improperly seated record bases •Changes in the dental plaster www.indiandentalacademy.com
  19. 19. Incorrect arrangement of posterior teeth Changes in supporting structures Processing errors • Failure to close the flasks or Too much pressure in closing • Changes in denture base material – High coefficient of thermal expansion – Greatest amount of change on removal from the cast “OCCLUSAL DISHARMONY” •Processing errors – Lab remount •Clinical errors – clinical remount •Small errors in occlusion will correct themselves •Errors may not be apparent •Prosthesis should be maintained in water before the final occlusal refinement www.indiandentalacademy.com
  20. 20. Checking for occlusal errors • Error exists and one has to work to find it • How to observe the error – first “feather touch” is felt • Stopping the instant tooth contact is felt and then close tight • Amount of occlusal errors and location of deflective contacts. • Articulating paper – Shifting of denture bases – Tissue distortion – Eccentric closure by patient – Presence of saliva • Selective grinding done in the mouth increases the amount of errors • Accurate mounting in the articulator – Idealwww.indiandentalacademy.com
  21. 21. Intra Oral Methods Central bearing device • Central bearing pin works on a spring • Metal plate • Dentures do not shift on premature contact Occlusal wax • Excellent method for correcting occlusion in centric position only • False markings in eccentric jaw positions Abrasive paste • Shifting of bases • Not selective www.indiandentalacademy.com
  22. 22. Patient Remount Interocclusal records Advantages • Easy to visualize locate and correct • Stable denture bases • Easily made articulating paper marks on dry teeth • Avoids misconception Remounting the mandibular denture Verifying the centric relation www.indiandentalacademy.com
  23. 23. Interocclusal Record Of Centric Relation www.indiandentalacademy.com
  24. 24. Remounting the mandibular denture • Remounting the maxillary denture by remount occlusal index • No need of face bow or protrusive records • Raise the upper member of the articulator about a mm dropping the incisal pin Verifying the centric relationwww.indiandentalacademy.com
  25. 25. Selective Grinding Procedure • Realeff – Hanau •Forces Exerted on teeth when Pt Closes the jaw •Change in Vertical Dimension •Development of premature contacts Multiple remount procedure - Hanau •No displacement of mucosa •Displacement of mucosa Selective Grinding Unstrained J R Strained J R Long Centric occlusion Short protrusive www.indiandentalacademy.com
  26. 26. Selective Grinding of Anatomic teeth • Alteration of Cusp form teeth • Occlusal balance in lateral direction Working side – All posterior teeth and canine Balancing side – only Posterior • Protrusive balance – Incisal edge contact at the same time Posterior teeth contact Procedure 1. Adjust horizontal and lateral condylar inclinations 2. Raise the incisal pin 3. Evaluate areas of tooth contact and functional cusps 4. Record the areas of premature contacts 5. Evaluation in eccentric positions- before starting grindingwww.indiandentalacademy.com
  27. 27. 6. Right side as a working side • Excessive contact on one side- No contacts on other side • Working side teeth too long – No contacts on balancing side • Single tooth at higher level – No contacts on balancing& working 7. Left side as a working side Note: Avoid wrinkling or doubling of articulating paper Cover all occlusal and incisal surfaces Rules • If cusp is high in centric and eccentric – Reduce • If cusp is high in centric only – deepen the fossa / marginal ridge • Not to reduce any more www.indiandentalacademy.com
  28. 28. 8. Balanced Gliding occlusion • Working side – BULL • Balancing side – Mandibular buccal cusps Elimination of Centric cusp - Mandibular buccal cusp  Maxillary lingual cusps - better direct the forces of mastication - necessary for protrusive balance • Balance in protrusive excursions Distal inclines – Maxillary Mesial inclines - Mandibular 9. Refining the Occlusal anatomy & Polishing www.indiandentalacademy.com
  29. 29. Selective Grinding of Non-Anatomic teeth • Articulating paper tape • Tapping the teeth together • Simultaneous even contact areas on Rt & Lt • Do not allow anteriors to contact • Distal of the premolars and first molar and Mesial of the second molar • Polishing www.indiandentalacademy.com
  30. 30. Occlusal equilibration of Zero degree teeth • Dr Gronas 1970 – Corborundum stripping technique • Maintain flat occlusal scheme on Grinding • water proof Corborundum abrasive paper 220 Grit – Porcelain 320 Grit - Acrylic • Avoid rotary instrument • Premature contacts in Centric & eccentric • Put the strip on occlusal surface Gently close the articulator • Apply pressure to upper member Pull the strip • Avoid rounding of bucco-occlusal angle • Stripping an equal number of times www.indiandentalacademy.com
  31. 31. Patient Instructions Albino J E et al 1984 – expectation of the patient can profoundly influence treatment outcomes Maintaining tissue health Tissue rest Denture Hygiene Cleansing of tissues • Cleansers • Brushing • Sonic action Cleansers Myers & Krol • Gentle rubbing ( wash cloth ) • Removing dentures at night www.indiandentalacademy.com
  32. 32. Treatment Modalities 1. Surgical excision • Hyperplastic , Hypertrophied & Pendulous tissue • Alteration of bony support • Repositioning of sulci 2. Correction of Occlusal Disharmony 3. Massage • 2-3 times a day • warm salt water rinse • washing with moist cotton balls, normal saline rinses- Boos • Chewing gums • Chewing inflated balloons Plastic bags 4. Correcting the Pressure areas www.indiandentalacademy.com
  33. 33. Denture lining material Materials used to refit the surfaces of complete dentures and to help condition traumatized tissues , providing an interim or permanent cushion like effect • Hard Liners • Soft Liners Soft Liners ( ISO 10139 ) Short term Long term • Upto 30 days • Tissue conditioners > 30 days – 1 Yr / more www.indiandentalacademy.com
  34. 34. Soft Liners ( O”Brien ) Silicones Others Heat cure RTV • Molloplast B Gamma methacryloxy propyl trimethoxy silane  Less prone to Candida  Retains Resiliency Limited shelf life Less tear resistance Acrylic • Tissue conditioner PEMA + Phthalate +25% ethanol Poly(fluoroalkoxy) Phosphazime elastomeric system Gettleman et al www.indiandentalacademy.com
  35. 35. Indications 1. Treatment and conditioning 2. Provisional or Diagnostic purpose- VD 3. Temporary reline-Immediate dentures / surgical splints 4. Relining Cleft palate speech aids 5. Tissue conditioning during implant healing 6. Functional impression material • Available in P:L form or Acrylic gel sheets • When mixed forms gel- cushioning effect • With time plasticizer and alcohol leaches out • Deterioration ,Contamination and fouling • Replacement- 3 days for 2weeks or longer www.indiandentalacademy.com
  36. 36. Long term Soft Liners Requirements 1. Permanent softness 2. Good bond to denture base 3. Adequate abrasion and tear resistance 4. Inhibit colonization of fungi 5. Easy to clean 6. Low water sorption and solubility Indications • Pts who cannot tolerate stresses • Chronic pain ,soreness, discomfort • sharp thin heavily resorbed ridges or severe bony undercut Examples: 1. Plasticized acrylics 2. Silicone rubbers 3. Plasticized vinyl polymer 4. Fluoroethylene 5. Polyvinysiloxane 6. Polyphospazine fluoropolymerswww.indiandentalacademy.com
  37. 37. Plasticized acrylics Powder Liquid PEMA & Benzoyl peroxide Higher methacrylate monomer+ plasticizer Ethyl ,n-butyl, 2ethoxy ethyl  If chemically activated – peroxide tertiary amine system  Chair side relining Tendency to foul and Debond Prescence of free monomer www.indiandentalacademy.com
  38. 38. Silicone soft liners Heat activation Room temperature vulcanization (RTV) polydimethyl siloxane + Silica + Benzoyl peroxide • Single paste Good durable bond More resistant to candida growth Acceptable tear strength Better abrasion resistance Less resilient Hardens by time • Paste & liquid Condensation reaction catalyzed by organo tin compound Low bond strength Less resistant to candida growth Low tear strength Low abrasion resistance Highly resilient Retains softness & elasticity www.indiandentalacademy.com
  39. 39. Self administered soft liners ( HOME liners ) • Simple tool to improve a clinically acceptable prosthesis -diff components of soft liners affect the growth ,acid production & colonization of Candida -amount of ethyl alcohol content and type of plasticizer used made a significant difference Nikawa et al 1995 S Parker & M Braden 1982 -Formulated a soft liner using 1. polymerizable plasticizer system 2. powder elastomers - There was no extractable plasticizer Braden et al- -allows uniform distribution of stress but does not necessarily reduce the transmitted forces www.indiandentalacademy.com
  40. 40. Relining and Rebasing Reline –to resurface tissue side o f the denture with new base material Rebase - to replace entire denture base material on an existing prosthesis Treatment rationale Adversely changing denture foundation Variable change in VD & Occlusal relationship Induces more adverse Stresses Magnitude of the observed changes Reline Rebase Remakewww.indiandentalacademy.com
  41. 41. Diet and Nutrition Abuse of tissue – complicated by a weakened host response or repair Poor nutrition – Reduce tissue recovery Deterioration of supporting tissues Xerostomia,burning and sore tongue,RRR, angular stomatitis,thin & friable mucosa Diet – Prescribed by the dentist- discussed with the patient www.indiandentalacademy.com
  42. 42. Drugs and Medication Local management Topical local anesthetic in an emolient base Tincture of benzoin – ulcerated area 30% Trichloro acetic acid – granulation tissue Topical steroids – generalized inflammatory response Warm saline solution – most therapeutic ,effective & economic rinse Psychologic Counseling Patient who had considerable denture prosthesis experience without apparent success Appropriate mental preparation of the patient can be as significant as physical conditioning of the supportive tissueswww.indiandentalacademy.com
  43. 43. LASER Light Amplification by Stimulated Emission of Radiation • Alternative to Conventional surgical technique • Selection of wavelength best absorbed by the target tissue • Each wave length has different absorption coefficient based on composition of oral structures • water – erbium and carbon dioxide wavelengths • oral mucosa – extremely high water content • Treatment of – Hyperplastic tissue Nicotinic stomatitis Denture stomatitis Epuli and other problems www.indiandentalacademy.com
  44. 44. Low level LASER therapy ( Therapeutic lasers ) Soft , Cold, Low intensity laser therapy unlike surgical lasers Wound Healing Reduced Pain ATP production - Mitochondria Synthesis of Endorphins C – fiber activity Bradykinin Altered pain threshold www.indiandentalacademy.com
  45. 45. LIST OF REFERENCES:- •Prosthodontic treatment of edentulous patients; Zarb & Bolender;12th ed. •Essentials of complete denture prosthodontics: Sheldon winkler;2th ed. •Textbook of complete dentures;Heartwell;5th ed. •Complete prosthodontics – problems , diagnosis & management: Grant •Diagnosis &treatment of prosthodontics ; William.R.Laney •Atlas of diseases of oral mucosa; J.J.Pindborg •Burkets oral medicine- diagnosis & treatment ;10 th ed. •Diseases of oral mucosa & lips; Bork et al •DCNA jul 2004;48:3 Removable prosthodontics •DCNA Oct 2004;48:4 LASERs in clinical dentistrywww.indiandentalacademy.com
  46. 46. Irritation & discomfort..!!! Warmth & Comfort…!!! www.indiandentalacademy.com

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