Tissue changes/ fixed orthodontics courses

INDIAN DENTAL ACADEMY

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CONTENTS

Introduction

Microscopic anatomy of the mucous membrane in oral cavity

Sequelae of wearing complete denture




Microscopic anatomy of the mucous membrane in oral cavity Has thinner horny layer than skin. Sigmund and Weber et.al.: claimed that mucosa

has no horny layer. Spreng(1945) : demonstrated horny layer in

palatine mucosa and claimed that hornification is a reaction to the wear and tear produced by the denture.

Orban(1953) : first to state positively that oral mucosa has horny layer.


EPITHELIUM

Its thickness is not more than 0.20mm

Consists of several differentiated cells covered by stratum corneum

Important as a protective mechanism


Stratum corneum It has a mean thickness of

13.2micron Appears as homogenous band

stained red Consists of closely packed

cells which appear to have no nuclei.

Scrapings from palatal mucosa shows cells appearing as fried egg with nucleus in centre as yolk


Stratum granulosum Characterized by

granulation in cytoplasm

Kerato-hyaline granule: located in basal

parts of the layer as single granules

Number of cells increase as they approach the surface


Stratum spinosum cells are polygonal/rounded

connected to each other by protoplasm in the form of fibrillar structure called tonofibrils

In the mesh b/w the fibrils, tissue fluid facilitate the metabolism of the cells

Metabolism is facilitated by extension of the papillae of connective tissue into the epithelium


Stratum basale Formed by thin layers of

amorphous materials and of reticular fibers

Demonstrated using PAS

Under EM : seems to have 1. basal lamina

2.reticular lamina


Functions Provide adhesion on one side to epithelial cells and

other side to connective tissue Act as barriers to the diffusion of molecules Play role in cell organization May influence the regeneration of peripheral nerves

after injury May play a role in re- establishing of neuro- muscular

junctions


Lamina propria Characterized by

collagenic and elastic fibers

Fibers run parallel to the surface of epithelium and extend in papillae perpendicular to their main course

This wavy course provides the tissue with high degree of elasticity


sub mucosa Constitutes major bulk of

the mucous membrane Contains :

Other components (blood vessels, lymphatic vessels and nerves)

Fatty tissues Glands Muscles fibers


SEQUELAE OF WEARING COMPLETE DENTURES DIRECT SEQUELAE

Denture stomatitis Flabby ridge Denture irritation hyperplasia Traumatic ulcers Oral cancer Burning mouth syndrome Gagging Residual ridge reduction Caries and periodontal disease


Indirect sequelae

Atrophy of masticatory muscles

Nutritional deficiencies


Denture stomatitis Prevalence: 50% among

the complete denture wearers

Synonyms : denture sore mouth, denture-induced stomatitis, inflammatory hyperplasia, and chronic atrophic candidosis

Classification: 3 types By –Newton's


Newton’s classification Type I :

localized simple inflammation or pinpoint hyperemia

Cause: trauma

induced


Type II :

Diffuse erythema involving a part or entire denture covered mucosa


Type III :

Granular type of inflammatory hyperplasia

Cause: Presence of microbial

plaque ( bacteria/yeasts)


Candida associated denture stomatitis


Colonization of the fitting denture surface by Candida species depends on several factors Adherence of yeast cells

Interaction with oral commensal bacteria

Redox potential of the site

Surface properties of the denture resin


Predisposing factors Systemic factors Local factors Denture properties Environmental factors Oral hygiene


Systemic factors Age Diabetes mellitus Nutritional deficiencies Malignancies Immune disorders


Local factors Denture properties favoring Candida growth

Surface irregularities Micro porosity Improper Design of prosthesis Mechanical irritation Texture


Environmental factors Health of adjacent mucosa Composition of saliva Salivary secretion rate xerostomia sjogrens syndrome High carbohydrate diet Broad spectrum antibiotics


Smoking tobacco Oral hygiene maintenance Denture wearing habits


Associated with Angular chelitis

Diffuse atrophic glossitis


Median rhomboid glossitis

Erythema of the soft palate


Diagnosis

Confirmed by finding of mycelia/pseudohyphae in a direct smear or the isolation of Candida in high numbers from the lesions.


HISTOLOGICAL FINDINGS

Thinning of stratum corneum or absence of keratinization.Epithelial atrophy & hyperplasiaIntraepithelial infiltration by leucocytes.Lymphocytic infiltration in underlying connective tissue.


Management and preventive measures


Because of diverse possible origin, several treatment procedures are used like:

Antifungal therapy

Correction of ill-fitting dentures

Efficient plaque control

Surgical care


Antifungal therapy Local therapy > nystatin, amphotericin B, miconazole,

clotrimazole Systemic therapy > ketoconazole , fluconazole

Used mainly in following patients: After the clinical diagnosis has been confirmed by a mycological

examination Associated with burning sensation in oral mucosa When infection has spread to other sites of oral cavity or the

pharynx Patients with high risk of systemic infections


Precautions to reduce the risk of relapse

Treatment should continue for 4 weeks


When lozenges are prescribed > patient is instructed to take out the denture during sucking

Meticulous oral and denture hygiene instructions


Correction of ill-fitting dentures

Rough surface > smoothened and polished

Relining > soft tissue conditionerclassification:1) short term a) tissue conditioner

b) functional impression materials 2) long term heat cure silicone cold cure


B) acrylic based resins heat cure cold cure 3) others: polyvinyl chloride polyvinyl acetate polyurethane hydrophilic acrylates


COMPOSITION

In general they are supplied in powder and liquid form.

POWDER – poly (ethyl methacrylate) LIQUID – A mixture of aromatic ester and

ethyl alcohol. The ester behaves as a plasticizer and the

alcohol is penetrated which speeds up the process.


On mixing the two together a slurry is formed. The liquid then penetrates between the molecules of the powder, a process accelerated by the ethyl alcohol present and the whole material becomes stiffer until a gel is formed, the setting therefore is a physical process, there being no chemical reaction involved.


PREFORMED SHEETS OF ACRYLIC GEL ARE ALSO AVAILABLE WHICH CAN BE ADAPTED TO THE SURFACES OF THE DENTURE.




Method to condition the tissues traumatized by ill-fitting dentures Ask the patient not to

wear the dentures for days – week period

Stimulate the diseased tissue with a gauze dipped in warm saline > 3 times a day

Tissue side of the denture should be clean


Adjust and perfect the occlusion and the vertical dimension

Adjust the periphery


Relieve the tissue side of the denture > about 11/2 mm of relief is given

Coat the denture base with tissue conditioning material and insert.


BEFORE CONDITIONING


AFTER CONDITIONING


Effective plaque control

Oral hygiene instructions

Denture and partial clasp brushes

Denture cleansing solutions


Surgical care Deep crypt formations in type III :

electro surgery / cryosurgery


DETURRENCE / PREVENTION

> Educating the patient about the oral health care.

> Instructing the patient to take their dentures out atleast 8hrs a day.

> Mechanical plague control & appropriate denture wearing habits are important measures.


Angular chelitisa painful inflammation at the corners of the mouth.

Synonyms: angular stomatitis, perleche, angular cheilosis


Predisposing factors Reduced vertical

dimension

Secondary to denture stomatitis

Riboflavin and thiamine deficiency


CLINICAL FEATURES

epithelium at the corner of the mouth appears wrinkled, macerated, one or more deep fissures, cracks which appear ulcerated & tends to bleed.


Treatment

Elimination of the primary cause.

Antifungal treatment & supplement antifungal ointment at the lesion site


FLABBY RIDGE It is due to the

replacement of bone by fibrous tissue

Common in maxillary anterior region (when mandibular anteriors are remaining)

They offer poor support to the denture


Mechanism

Direction of applied force of mastication causes slight rotation of the denture around the anterior maxillary alveolus.Pressure of the distally rotating anterior flange against the labial plate of bone causes resorbtion.


The shearing force applied to the periosteum by friction with the base during rotation results in fibrous hyperplasia .When the patient incises the pad, fibrous tissue is compressed & upward movement of the maxillary denture causes downward displacement posteriorly ,with loss of retention in the post dam area & development of fibrous maxillary tuberosity.


TREATMENT SURGICAL:

i) surgical removal to improve stability of denture

ii) Augment the alveolar ridge with biocompatible bone substitutes

iii) In extreme atrophic condition, flabby ridges should not be totally removed because the vestibular area will be limited.


Conservative :

judicious selection of impression materials and technique.

3 technique has been advocated as follow :


A

Special tray made with a window cut in the region of displaceable tissue


Border molding done


Wash impression made with ZOE paste


Tray re-inserted, impression plaster syringed over displaceable tissue


Completed impression


Technique – B


Special tray with window cut


Medium- bodied / monophase elastomer is loaded


Light body material is syringed in the cut window and then stabilized by syringing the plaster over the set elastomer


Technique – c


Special tray with no window and border molding done


Impression made using ZOE / Monophase elastomer When set , impression material corresponding to the

displaceable tissue is removed Tray is perforated


Impression plaster / light body elastomer syringed over displaceable tissue

Tray is reinserted and the impression is complete


Denture irritation hyperplasia


cause Chronic irritation by ill-

fitting dentures

Overextended flanges


Lesions may be single or numerous

Composed of flaps of hyper plastic connective tissue

Severe inflammation and ulceration in deep fissures

Asymptomatic


HISTOLOGICAL FINDINGS Excessive bulk of fibrous

connective tissue covered by a layer of stratified squamous epithelium

Connective tissue shows coarse bundle of collagen fibers with few fibroblast & blood vessels.


Management Correction of over extended flanges

Surgical excision if its fibro tic or if the hyperplasia does not fully subside on correction of over extended flanges.


Traumatic ulcers Commonly develop within

1 to 2 days after placement 0f new dentures

Lesions are painful, small, and ulcerated

Lesion is covered by a grey necrotic membrane , surrounded by inflammatory halo with firm and elevated borders


Direct cause

Overextended denture flanges Unbalanced occlusion

Predisposing factors Diabetes mellitus Nutritional deficiency Radiation therapy/xerostomia


HISTOLOGICAL FINDINGS Loss of continuity of the

surface epithelium with the fibrous exudates covering exposed connective tissue.

Infiltration of leucocytes into the connective tissue


Treatment Management includes correction of local irritant factors

in the denture.

Not treated > subsequently may develop into denture irritation hyperplasia


Oral cancer in denture wearers Associated with chronic

irritation of the mucosa by the dentures

Case reports > detailed development of oral carcinomas in patients who wear ill-fitting dentures


Predisposing factors Heavy alcohol and tobacco use Lower socioeconomic status Less education

Prevention

regular recall visits > 6 months – 1 year interval for comprehensive oral examinations


Burning mouth syndrome Characterized by a burning sensation in one or several oral

structures in contact with the dentures

Commonly seen at the age of 50 years

Females are affected more

The oral mucosa appears clinically healthy

Clinical signs: absent

Symptoms : gradual in onset associated with pain


Characters of the painGradual in onset

Often present in morning

Aggravated during the day / absent at night


Quality of pain Burning sensation associated dry mouth and persistent

altered taste sensation

Associated symptoms : headache, insomnia, decreased libido, irritability , depression

Aggravating factors : tension, fatigue, hot or spicy food

Reducing factors : sleeping, eating, distraction


Site of occurrence Anterior two third of the tongue

Anterior hard palate

Mucosa of the lower lip


Etiology


Management Systematic approach is necessary to identify the possible causes. symptomatic treatment should be given.

- Mucosal disease -diagnosis & treat the mucosal condition.

-Dry mouth - high fluid intake & sialagogueAny systemic disease present should be identified & treated.

-Menopause-hormonal replacement -Nutritional deficiency -oral supplementation.


if no organic basis is found, proper counseling of the patient, help the patient to understand the benign nature of the problem & with subsequent elimination of fears.comprehensive prosthetic treatment should be carried out as collaborative effort of psychiatrist & prosthodontist


Gagging

Normal , healthy defense mechanism

Functions to prevent the entry of foreign bodies in to the trachea


Gagging problem in prosthodontic treatment. Part I : Description and causes, JPD ; 1983:49 FAIGENBLUM’S CLASSIFICATION

Mild : Experiences nausea with mild stimulus Will be able to control the stimulus

Severe : > responds in an exaggerated

manner to physical or psychological stimuli


Five trigger zones identified producing gag reflex Fauces ( tonsils )

Base of the tongue

Palate

Uvula

Posterior pharyngeal wall


Clinical behavior ( by khan ) - Intraoral Puckering of the lips or attempting to close the jaws Elevating and furrowing the tongue Elevation of the soft palate and hyoid bone Fixation of the hyoid bone Contraction of anterior and posterior pillars of the fauces (tonsils) Elevation, contraction and retraction of larynx and closure of the

glottis Simultaneous and uncoordinated respiratory muscle spasm vomiting


Extra oral Excessive salivation

Lacrimation

Coughing

sweating


Causes of gagging SYSTEMIC FACTORS

Psychological FACTORS

PHYSIOLOGIC FACTORS

IATROGENIC FACTORS


SYSTEMIC FACTORS Deviated septum Nasal polyps or sinusitis Inflammation of pharynx Chronic gastritis Carcinoma of stomach Peptic ulcer

Psychological FACTORS Active passive


PHYSIOLOGIC FACTORS Extra oral stimuli

Visual Auditory Olfactory

Intraoral stimuli Inadequate post-dam Over-extended posterior borders Disharmonious occlusion Poor retention Surface finish of acrylic resin Inadequate free-way space


Management – Daniel J. conny and Lisa A. 1983; 49

Clinical techniques

Prosthodontic management

Pharmacologic measures

Psycho logic intervention


Clinical techniques Surgical ( Leslie ):

Removal of uvula Shortening of soft palate

Prosthodontic Impression technique > BORKIN

Provides greater control of setting time

Discrepancies can be easily corrected


Technique Primary impression > stock tray and red modeling

compound

Secondary impression > by pouring “Kerr impression wax”

Flexible nature of the wax allows reseating of the tray and border molding until desirable results are obtained


Marble technique > SINGER First visit :

Patient asked to place 5 marbles in his/her mouth > 1 at time at leisure

Further instructed to keep the marbles continuously for 1 week, except while sleeping and eating

Second visit : Patients ability to tolerate the marbles was evaluated Reassured that patient would be able to tolerate the

denture


Third visit : Primary impression made Special tray fabricated

Fourth visit : Lower tray was inserted with 3 marbles in the

mouth Training bead placed on the lingual aspect of the

tray to maintain proper tongue position Fifth visit :

Use of marbles discontinued


Sixth visit : Fabrication of bite rims Jaw relation

Seventh visit : Wax – try in made

Eighth visit : Final denture insertion

This technique admits patient motivation Has definite risk in aspiration of marbles by the

patient during the procedure


Radiographic > RICHARD’S use of high – speed film Preset the timer Moisten the film pack Ask the patient to rinse in cool water

Psycho logic > LANDA Engage the patient in conversation Make the patient count rapidly from 50 – 100 Have the patient to read aloud


Prosthodontic management Obtaining proper post – dam Correcting over – extended borders Correcting the occlusion Proper retention Mattel surface finish Increasing the free – way space


Pharmacologic measures Approached when clinical and prosthodontic measures

are ineffective Their efficacy, however is not universally accepted

Classification

peripherally acting drugs centrally acting


peripherally acting drugs Topical and local anesthetics

Centrally acting drugs Antihistamines Sedatives and tranquilizers Parasympathocytics Central nervous system depressants

Psycho logic intervention• Hypnosis• Behavioral therapy


RESIDUAL RIDGE REDUCTION A term used for the

diminished quality & quantity of the residual ridge after the teeth are removed.(GPT-7)

A continuous loss of the bone tissue after tooth extraction & placement of the complete denture

the reduction is the sequelae of alveolar remodeling due to altered functional stimulus of the bone tissue.


Follows a chronic progressive & irreversible course that often results in severe impairment of prosthetic restoration & oral function.

First year after tooth extraction ,the reduction of the residual ridge in the midsagittal plane

maxilla:2-3mm mandible:4-5mm

After healing remodeling takes place in decreased intensity


Etiological factors of reduction of residual ridges Anatomical factors :

Short and square face associated with elevated masticatory forces

Alveoloplasty Prosthodontic factors :

Intensive denture wearing Unstable occlusal conditions

Metabolic and systemic factors : Osteoporosis Calcium and vitamin D deficiency


CONSEQUENCE OF RR REDUCTION Apparent loss of sulcus width

& depth

Displacement of muscle attachment

closer to the crest of the ridge

Loss of vertical dimension of occlusion


reduction of lower facial height

Anterior rotation of mandible & increase in relative prognathism

Sharp, spiny, uneven residual ridge & location of mental foramina closer to the ridge


Treatment

Preprosthetic surgical initiation such as vestibuloplasties

Severe situations > ridge augmentation procedures


PREVENTVE MEASURES Dietary / nutrition intervention, estrogen therapy when

indicated, maintenance of teeth & placements of implants. Supplement of calcium & vit D to reduce the rate of post

extraction remodeling of RR in immediate denture wearers (Wical & Bruser 1979)

Retaining the tooth as for the over denture abutments.RRR was found to be 0.6mm in over denture wearers compared with 5mm in complete denture wearers( Crum & looney,1978).

Osseo integrated implants as abutment, reduces rate of resoption of RR than conventional complete denture( Sennerby et al 1988)


OVERDENTURE ABUTMENTS: CARIES & PERIODONTAL DISEASE

Wearing of over denture are often associated with high risk of caries & periodontal disease of the abutments when oral hygiene measures are not adequate.


Etiology Bacterial colonization beneath the close fitting denture

due to poor oral hygiene

Streptococcus and actinomyces > gingivitis and periodontitis

streptococcus mutans and lactobacilli > caries


Treatment Maintain good oral hygiene Motivate the patient with

regular recall visits at 3 – 6 months intervals

Superficial caries > application of fluoride- chlorhexidine gel and polishing

Deep caries > placement of copings

Periodontal pockets greater than 4 to 5 mm > surgically eliminated


Indirect sequelae


Atrophy of masticatory muscles Computed tomography study > masseter and medial

pterygoid muscle demonstrated greater atrophy in complete denture wearers

Maximal bite forces tend to decrease in the old age.

Chewing efficiency decreases as the number of natural teeth is reduced.

Reduced bite force & chewing efficiency are sequelae caused by wearing the complete denture , resulting in impaired masticatory function


Diagnosis Capacity to reduce the test food particles

It has been verified > chewing efficiency as the number of natural teeth is reduced

Worse for subjects wearing complete denture

Complete denture wearers need approximately 7 times more chewing strokes than subjects with natural dentition


Management Retention of small number of teeth used as over denture

abutments > role in maintaining the oral function

Completely edentulous patients > placement of implants


Nutritional deficiencies Nutrition the science of how the body utilizes food to

meet requirements for development, growth, repair and maintenance

Essential nutrients to maintain good health are

Carbohydrates Fat Protein Vitamins Minerals Water


Nutritional deficiencies

Primary > faulty selection of food Lack of knowledge what to eat Fat diets Poor food habits Food like n dislikes Poverty Physical incapacities Emotional prejudices


Secondary > systemic disorders

Factors that interfere with food intake

Conditions that interfere with digestion

conditions that interfere with absorption

Factors that interfere with metabolism

Conditions that interfere with utilization

Factors that increases nutrition requirements

Factors that cause excessive excretion


Risk factors for malnutrition in patients with dentures Eating less than two meals/day. Difficult chewing and swallowing Unplanned weight gain or loss of more than 10lb

in the last 6 months. Undergoing chemotherapy or radiation therapy. Loose denture or sore spots under denture Oral lesions(glossitis,cheliosis,or burning tongue) Severely resorbed mandible Alcohol or drug abuse


NUTRITION & THE DENTURE BEARING TISSUE

Nutritional deficiency (Proteins, vitamin C & D, Ca)

Alveolar ridge resorption Thin friable mucosa

ILL-Fitting denture Poor force tolerances


ALCOHOLISM, SMOKING & DENTURE

Decrease in food intake

Multiple nutrient def Dehydration (Vit B & C)

Thinning of oral mucosa Friable oral mucosa

Abrasion of the denture bearing mucosa


NUTRITION & OVER DENTURE

Cariogenic diet Ca++ deficiency Vit A & C def

Caries of abutment Ridge resorption Poor periodontal health Failure of abutment FAILURE OF OVER DENTURE


Providing nutrition care for denture wearing patients Obtain a nutrition history and an accurate record of food intake over

a 3-5 day period or complete a food frequency form

Evaluate the diet: assess nutritional risk

Teach about the components of a diet that will support the oral musosa,bone health, and total body health

Help patient establish goals to improve the diet

Follow-up to support patient in efforts to change food behaviors.


Dietary counseling for Denture wearers

Diet for the first day after denture insertion :

liquid diet


Diet for the 2nd and 3rd day after denture insertion:

Pureed diet to soft diet

Diet for the fourth day and later:

Soft diet to regular diet as tolerated


CONTROL OF SEQUELAE WITH USE OF COMPLETE DENTURES Every effort should be made to retain some teeth in good positions

to serve as over denture abutments. Proper patient education & good oral hygiene practices. Patient should be motivated to practice proper denture wearing

habits. Patients wearing complete dentures should follow a regular control

schedule at yearly intervals so that acceptable fit & stable occlusal condition to be maintained.

Patients wearing over dentures should follow a program of recall & maintenance for continuous monitoring of the denture and the oral tissues


REFERENCE Prosthodontic treatment for edentulous patients-BOUCHER. Essentials of complete denture prosthodontics-WINKLER. Textbook of complete denture-HEARTWELL. Complete denture-sharry. Problems & solution in complete denture prosthodontics-DAVID J.LAMB. Clinical dental prosthetics-FENN. Principles & practise of complete denture-IWAO. Prosthodontics for elderly-BUDTZ-JORGENSEN. Txtbook of oral pathology-SHAFER. Oral lesions of interest to prosthodontics JPD1961. Oral conditions associated with dentures JPD 1958. Trouble shooting in CD prosthesis JPD 1960. Candida associated denture stomatitis Aus DJ 1998.


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