REVIEW ARTICLE

Management of Flabby Maxillary Ridge- A Case Report.

Pawar. Sudhir 1,Nirav Rathod2, Rathod C3, Dr. Naitam D4, Gopal Krishna Choudhury 5,
1. Professor & HOD, Department of Prosthodontics and Crown and Bridge, Rungta College of Dental
Sciences & Research.
2. PG student, Department of Prosthodontics and Crown and Bridge, Rungta College of Dental Sciences
& Research.
3. Senior lecturer, Department of Prosthodontics and Crown and Bridge, Rungta College of Dental
Sciences & Research.
4. Reader, Department of Prosthodontics and Crown and Bridge, Rungta College of Dental Sciences &
Research.
5. Reader , Department of Prosthodontics and Crown and Bridge, Institute Of Dental Science,
Bhubaneswar.

Corresponding address :
Dr. Nirav Rathod, Vallabh kunj, H.no. 494, Anupam Nagar, Basantpur Road, Rajnandgaon, CG-491441
email - niravrathod24@gmail.com

Abstract
The Unusually Displaceable denture-bearing tissues often present a difficulty when fabricating complete dentures. Unless
managed appropriately, such ‘flabby ridges’ adversely affect the support, retention and stability of complete dentures. In
particular, problems arise during the procedure of impression making, when forces cause the highly mobile denture
bearing tissues to become distorted leading to loss of peripheral seal and perpetuate tissue inflammation. This paper
presents a case report of one of the impression making technique for edentulous patients with flabby alveolar ridge.

Key words: - flabby ridge, hyperplastic tissue, window technique, mucostatic technique.

Introduction:- Typically these ‘flabby ridges’ are composed of mucosal

A ‘fibrous’ or ‘flabby’ ridge is an area of mobile soft tissue
affecting the maxillary or mandibular alveolar ridges. It
develops when hyperplastic soft tissue replaces the alveolar
bone and is a common finding, particularly in the upper
anterior region of long-term denture wearers. 1
hyperplasia and loosely arranged fibrous connective tissue as
well as more dense collagenised connective tissue. In the soft
tissue, varying amounts of metaplastic cartilage and/or bone
have been reported.
MANAGEMENT

During mastication the force of chewing can displace this The three main approaches to the management of the flabby
mobile denture-bearing tissue, leading to altered denture ridge are:1

positioning and loss of peripheral seal. Distortion of the
mobile tissue can occur by forces exerted during the act of
impression making resulting in poor stability of the denture
and both function and appearance can be heavily
compromised.
Published studies indicate that the prevalence of flabby
ridges can vary, occurring in up to 24% of edentulous
maxillae and in 5% of edentulous mandibles. In the
edentulous patient, it is found in the anterior region more
commonly in both arches. It is often related to the degree of
bone resorption and in severe cases this can be to the level of
the anterior nasal spine.
2
Historically, flabby ridges found in the anterior maxilla were
a feature of the ‘combination syndrome’. In this
‘condition’, the flabby ridge was thought to occur as a result
of a maxillary complete denture opposing mandibular
anterior natural teeth, without proper posterior occlusal
support. Such flabby tissues could also arise as a result of
unplanned or uncontrolled dental extractions.
1. Surgical removal of fibrous tissue prior to conventional
prosthodontics
2. Implant retained prosthesis
• Fixed
• Removable
3. Conventional prosthodontics without surgical
intervention.
Surgical removal of the fibrous tissue
The advantage of this approach is that a firm denture-bearing
area is produced, which enhances the stability of the
prosthesis. As with any surgical treatment option, the health
of the patient must be taken into consideration. Removal is
contraindicated in circumstances where little or no alveolar
bone remains. It can be argued however that the fibrous part
of the ridge has a cushioning effect which reduces trauma to
the underlying bone, which therefore should not be removed.
The removed tissue often requires prosthetic replacement by
denture base material; this can increase the bulk and weight
of the prosthesis. Retention is also adversely affected by the
significant loss of the sulcus depth which is important in

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AYUSH
aiding border seal. For conventional prosthodontics, it is
argued that although the flabby ridge may provide
substandard retention for the denture base, it may be more
desirable than no ridge at all.
Implant retained prostheses
a) Fixed prosthesis
b) Implant retained overdenture.
Fixed and removable implant retained prostheses offer
potential benefits too many of the problems encountered
with conventional prosthodontics. These may be an
attractive alternative due to the enhanced stability, retention
and oral function. An implant retained overdenture, in
comparison to a fixed prosthesis, is initially economic and
the surgery is often more straightforward as usually fewer
implants are required. However, the recurrent cost due to
maintenance can be considerable. Implants in the maxilla,
which has a higher prevalence of flabby ridge, are not as
successful as in the mandible. The success rates for
maxillary implants have been shown to be as low as 78.7%.
It is thought that this could be due to the placement of shorter
implants into highly vascular, poor volume, low-density
bone. The diminished alveolar bone volume in this subject
group may result in restrictions on suitable implant sites or
the need for bone augmentation. In terms of both time and
finance, the initial cost and long-term maintenance costs of
these restorations can be high. Other factors that must be
considered include: surgery, discomfort and inconvenience,
general health of the patient and risk of surgical
complications or implant failure .2
Conventional prosthetic management
All impressions for complete dentures could be categorized
in three ways:
1. The mucostatic technique (nondisplacive) 3
2. The mucocompressive technique (displacive) 4, 5
3. The selective pressure impression technique — where
some denture bearing tissues are displaced, and others are
not. 6
A mucostatic impression technique records the un-displaced
denture bearing areas at rest. As the resultant denture is more
closely adapted to the underlying tissues at rest, it is
theoretically more retentive. However, occlusal forces will
not be evenly distributed across the underlying denture
bearing area.
In contrast, a mucocompressive impression technique
compresses the underlying tissues in a manner similar to the
way in which the resultant denture will compress the
underlying tissues. In this fashion, the resultant occlusal
forces will be more evenly distributed across the denture
bearing tissues. While there is much speculation in the
dental literature regarding the most suitable impression
technique for a complete denture, there is no evidence to
indicate that one technique produces better long-term
results than the other.
In practice, most impression techniques for conventional
dentures could effectively be considered ‘selective pressure’
techniques. If close-fitting custom trays and high viscosity
impression materials are used, the soft tissues at the
vibrating line on the palate are compressed, while the tightly
bound mucosa on the hard palate is not.
A particular problem is encountered if a flabby ridge is
present within an otherwise ‘normal’ denture bearing area.
84
If the flabby tissue is compressed during conventional
impression making, it will later tend to recoil and dislodge the
resulting overlying denture. Clearly, an impression technique
is required which will compress the nonflabby tissues to
obtain optimal support, and, at the same time, will not
displace the flabby tissues.
Review of literature
Liddlelow described a technique whereby two separate
7
impression materials are used in a custom tray (using ‘plaster
of Paris’ over the flabby tissues, and zinc oxide and eugenol
over the ‘normal’ tissues).
Osborne described a technique whereby two separate
8
impression trays and materials are used to separately record
the ‘flabby’ and ‘normal’ tissues, and then related intra-orally.
Watson described the ‘window’ impression technique where
9
a custom tray is made with a window or opening over the
(usually anterior) flabby tissues. A mucocompressive
impression is first made of the normal tissues using the
custom tray and zinc oxide and eugenol. Once set, it is
removed, trimmed, and re-seated in the mouth. A low
viscosity mix of ‘plaster of Paris’ is then painted onto the
flabby tissues through the window. Once set, the entire
impression is removed.
Watt and McGregor — recently revisited by Lynch and Allen 10
— described a technique where impression compound is
applied to a modified custom tray. The thermoplastic
properties of this material are then manipulated to
simultaneously compress the ‘normal tissues’, while
avoiding displacement of the ‘flabby tissues’ using the same
material and impression tray. Over this manipulated
impression compound, a wash impression with zinc-oxide
and eugenol is made.
Case report
A 52 year old male patient reported to department of
Prosthodontics, Rungta College of Dental Sciences and
Research, Bhilai, to get his missing teeth to be replaced.
History revealed that he had complete denture for 3 years
which was loose. On examination, the patient was completely
edentulous with an extensive area of flabby ridge on the
maxillary anterior region (Fig: 1). All treatment modalities
was discussed with the patient like surgical management and
implant supported denture but patient was not ready for
surgical modality and he was not economically sound to
afford implant prosthesis. So it was decided to provide him a
new denture with appropriate impression technique and
occlusion. To treat the abused tissue patient was advised to
discontinue the use of old denture for a week. Once the tissue
comes to a healthy state the impression procedure was started.
Fig: 1- Flabby tissue in maxillary anterior region
 Management of Flabby Maxillary Ridge- A Case Report.

Procedure:

The primary impression of maxillary denture bearing area

was made with alginate (Zelgan, Dentsply, India) to
minimize distortion and record the flabby tissue in
undisplaced manner. The impression was poured in dental
plaster. Relief wax was given in incisive papilla and the mid-
palatine raphe area, and a special tray was fabricated with
auto-polymerizing acrylic resin and a small handle was
attached in flat portion of palate. Border molding was done
with green stick compound (pinnacle, DPI, India). Final
impression was made with zinc oxide eugenol then the
displaceable tissue was marked intraorally and transferred
on the impression(Fig:2,3), the marked area was cut to
create a window taking care not to damage the adjacent
impression area(Fig:4). The impression of displaceable
mucosa was recorded by applying impression plaster over it Fig: 4- creation of window in the region of flabby tissue
(Fig: 5). Once set, the impression was removed from the
mouth and inspected. Any excess material was removed.
The impression was re-inserted to ensure that it was
retentive and did not rock when pressure was applied over
the displaceable areas. Thus in this way the flabby tissue was
recorded by mucostatic technique in undisplaced manner
and rest firm tissue is recorded by mucocompressive
technique.

Fig: 5- completed final impression; flabby tissue is recorded

by plaster.

The impression was cast in dental stone, paying

Fig: 2- Marking of flabby tissue with indelible pencil
careful attention to preserving the bordered moulded sulcus
area. A heat-cured acrylic resin baseplate was fabricated for
proper fit. Denture fabrication then continued in the usual
manner. The denture was delivered, and the patient was
happy with it (Fig:-6, 7, 8). at subsequent review
appointments the patient reported satisfaction with stability,
aesthetics and function.

Fig: 3- Transfer of marking in final impression Fig: 6- finished and polished complete denture

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AYUSH
Fig: 7- Preoperative photograph
Fig: 8-Postoperative photograph
Discussion
The life expectancy of patient has increased now days than
it was 30 years ago, as a result of advances in dental
techniques and dental treatment philosophies, more patients
retain some, or all, of their natural teeth until later in life.
Sometimes, unusual arrangements of remaining natural
teeth can lead to unfavorable distribution of occlusal forces
on residual alveolar ridges, resulting in bone resorption and
development of flabby tissues. As a result of accompanying
medical conditions or medical treatments such elderly
patients may be unsuited for surgical procedures such as
removal of flabby ridges, bone grafting, or placement of
dental implants. The description of this impression
technique is therefore important. It describes how the
management of poor denture-bearing areas can be
86
accomplished by expanding on the basic principles of
complete denture construction without recourse to surgically
invasive procedures .3
The design of this modified special tray can vary
from a completely uncovered section of the arch to a window
overlying the unsupported mucosa. In the fibrous anterior
maxilla, modification of the handle position is often
required. The advantage of a window design means that the
appropriate border correction can be undertaken and checked
around the entire sulcus before the second stage of the
impression is completed.
Conclusion
An accurate impression is mandatory for good prosthetic
service. However, making of a good impression is not a
mechanical job, but involves a sound knowledge of oral
anatomy, physiology and dental material sciences. The
dentist’s ability in these three aspects is severely tested while
dealing with compromised situations.
No doubt presence of highly displaceable denture bearing
tissue presents a difficulty in complete denture fabrication;
with modified impression techniques these ridges can be
managed effectively by conventional prosthodontics without
any additional clinical visits like the patients with normal
edentulous ridges.
References :
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using contemporary materials to solve an old problem.
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4. Fournet S C, Tuller C S. A revolutionary mechanical
principle utilized to produce full lower dentures
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