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Management of Flat Ridge
Management of Flat Ridge
Management of Flat Ridge
Presented by :
MARWA AMER
PREVENTIVE
4-Waxing up
Prosthetic approach:
- Polished surface should
1-Impression:
harmonize with the surrounding
musculature (by neutral zone selective tech , Sectional imp ( window tech),General selective
determination imp tech
- The lower denture should be 2- Jaw relation:
narrow at the premolar region Wax wafer method with easily displaceable recording material
(modiolus) 3- Teeth selection , arrangement:
5- Insertion: Acc to Neutral zone
- Lab, clinical remount: to clear Reduce BL width
any occlusal prematurities Crosslinked acrylic teeth
- Soft liner to decrease trauma 4- periodic check up
- Restricted instruction:
not to were denture at night to Surgical management:
give chance to the tissues to rest. 1- Removal of fibrous tissue:
Type of food: (food doesn’t disadvantages:
require masticatory force exceed Trauma to underlying bone
tissue tolerance Decrease the sulcus depth
6- recall maintenance Increase the bulk of denture material
Unconventional denture: 2- Ridge augmentation by subperiosteal injection of hydroxyapatite
Hollow denture,
Liquid denture
1-Flat ridge
Surgical:
1- Dental Implant
2- zygomatic implant
3-Vestibuloplasty
4-Ridge augmentation
5-Distraction osteogenesis
Prosthodontic:
1-Impression technique:(mucocompressive – butter fly –Dynamic)
2-Jaw relation:
Avoid in VD
Lowering the occlusal plane
3- artificial teeth selection:(Material , size , form)
4- arrangement of teeth : (neutral zone –adequate tongue space)
5- occlusion: bilateral balance (lingualized – flat teeh)
4-Waxing up
- Polished surface should harmonize with the surrounding musculature (by neutral zone
determination
- The lower denture should be narrow at the premolar region (modiolus)
5- Insertion:
- Lab, clinical remount: to clear any occlusal prematurities
- Soft liner to decrease trauma
- Restricted instruction:
not to were denture at night to give chance to the tissues to rest.
Type of food: (food doesn’t require masticatory force exceed tissue tolerance
6- recall maintenance
Unconventional denture:
Hollow denture
Liquid denture
2- Flabby ridge
Def: mobile or extremely resilient ridge due to
displacement of bone by fibrous tissue
Causes: usually seen in anterior maxilla as sequelae of
excessive load of residual ridge and unstable occlusal
condition
Problem: instability of the denture
Management:
Conservative approach (recovery programe):
Tissue rest
Soft tissue massage
Modification of the denture
Tissue conditioning
Prosthetic approach:
1-Impression:
selective tech
Sectional imp ( window tech)
General selective imp tech
2- Jaw relation:
Wax wafer method with easily displaceable recording material
3- Teeth selection , arrangement:
Acc to Neutral zone
Reduce BL width
Crosslinked acrylic teeth
4- periodic check up
Surgical management:
1- Removal of fibrous tissue:
disadvantages:
Trauma to underlying bone
Decrease the sulcus depth
Increase the bulk of denture material
2- Ridge augmentation by subperiosteal injection of
hydroxyapatite
3- Knife edge ridge
Problem : Pain during mastication
Management:
Relief
Resilient liner
alveolplasty
4- Irregular ridge with sharp bony spicules
Problem : Pain during mastication
Management:
Localized relief at regions of bony projections
Resilient liner
alveolplasty
PROSTHODONTIC WITH SURGICAL
INTERVETION
Implant
Vestibuloplasty
Ridge augmentation
Distraction osteogenesis
Osseointegrated implant
Dental implants
Placement of two or more implants anteriorly in the area
between foramina can be of value in improving
horizontal stability and retention of the constructed
implant supported overdentures
Advantages of implant
prosthesis
Maintenance of alveolar bone
Restoration& Maintenance of occlusal vertical dimension
Maintain facial esthetics improved phonetics
Improved occlusion
Improved psychological health
Regained propioception
Increased stability, retention
Improved masticatory performance
There is 20 fold decrease in the loss of structure with implants when
compared with resorption that occurs with removable prosthesis
Transosseous implant
Subperiosteal implant
Zygomatic implants:
When there is substantial amount of bone lost from the
upper jaw , and ordinary implants cannot be used
Longer than ordinary implants , engage bulk of
zygomatic bone
Can be used as an alternative to complex bone grafting
procedures
VESTIBULOPLASTY
Def:
Lowering muscle attachment, unattached mucosa into
deeper position into the sulcus.
Indication:
- Moderate bone resorption
- When vertical height of 12-15mm in mandible
Techniques of vestibuloplasty
1. Mucosal advancement
2. Secondary epithelialization
3. Epithelial graft
Removal of genial tubercles: This is done to provide
for an extension in the sublingual fold space.
Prominent mylohyoid ridge: It is some times
trimmed to allow proper extension of the lingual
flange of the mandibular denture
Ridge augmentation
DEF: Restore mandibular bulk by placing onlay bone graft
INDICATION
Severe bone resorption
Vertical height less than 1mm
Disadvantages:
1. Long time
2. Danger of infection need for suitable distractors
Prosthodontic treatment
Aim : Preservation of remaining tissues
Factors to be considered:
1. Maximum tissue coverage
2. Correct vertical dimension
3. Occlusal balance
4. decrease occlusal table
5. Control amount & direction of force
6. Improve stability &retention of complete denture
The cause of degenerative ridge will determine the type of
treatment
So a detailed examination must be performed
Complete mouth and panographic radiographs are essential
Dietary analysis: Their ability to chew will frequently dictate
their selection of food, and this will usually generate a diet high
in refined carbohydrates and lo in protein, vitamins and
minerals- just the opposite of what is needed to help stop bone
destruction
Medical history
Record previous and existing systemic condition that may
contribute to mandibular atrophy
Comprehensive dental history:
1. Cause of extraction
2. Past denture experience, number of old dentures made
3. Frequency of denture rebasing should be appreciated to
estimate both the apparent rate of resorption & capability of
the individual to cope up with previous denture
4. Examination of the existing denture
Intraoral Examination
Visual :
1. Saliva (quality, quantity,
7. Interfering structure
viscosity)
(frenum)
2. Mucosa color
8. Size position of
3. Health of ridge tongue
,surrounding structure
9. Sulcus depth
4. Size ,shape of hard palate
10. Lip position
5. Size, shape of the arch
11. Interarch space
6. Remaining root or bony
12. Patient profile
spicules
s
Digital
1. Firmness of the ridge 7. External oblique
2. Type of mucosa ridge
3. Pattern of bone 8. Undercut area
resorption 9. Lingual pouch
4. Irregularities of the ridge 10. Painful area nature
5. Bone exostosis of muscles
6. Tuberosities ,tori 11. Buccal shelf
Radiographic examination:
1. Assess degree of bone resorption, inadequate bone
thickness (risk of spontaneous fracture)
2. Position of the mental foramen, mandibular canal
dehiscence of the canal
AIM:
1. Maximum extension without muscle impingement
2. Intimate contact with the tissue covered
3. Proper form of the border including the posterior border of
the maxillary denture
4. Proper relief of sensitive, hard area
Impression materials
1. Adequate flow during impression to avoid uneven
pressure……….result in rebounding of compressed
tissues and /or sore spots
2. Should provide adequate reproduction of surface
detail
NB:
Accurate impression can only be recorded in their
healthy, full recovered state
Patients not allowed to wear their dentures for min 48
h before the impression
Different impression techniques
Primary impression :
Alginate or compound in properly selected stock tray
Secondary impression:
1. Mucocompressive imp.
2. Butterfly imp.
3. Dynamic imp.
4. Admixed Imp.
5. Selective pressure imp.
Mucocompressive
(Closed mouth technique)
I ry impression : compound
Acrylic special tray with occlusion rims on upper
,lower trays at acceptable VD.
Border molding using green stick compound
Final imp using ZOE while the patient is closing on
the occlusal rims
1896 by Greene
Butterfly imp technique
Indication:
In cases of advanced resorbed ridge with projecting sublingual glands
Suitable stock tray with lingual border is made nearly flat to cover the
sublingual crescent area, 1ry imp with alginate
Acrylic special tray with butterfly extension over the sublingual
crescent area, occlusion rims is added
3 application of tissue conditioning mat. Are used in closed mouth
technique
- 2 application of viscous tissue conditioning material, each application is
allowed to remain in mouth for 8-10 min, pressure areas corrected after
each application
- 3rd wash is made using either a soft TC mat. or light body rubber base
imp mat
Result : imp has tissue placing effect, very thick buccal border,
relatively thick lingual and sublingual crescent areas, covering the
max possible basal seat area with in functional limits of adjacent
tissues
Dynamic impression
The impression material is shaped by the function of the
muscles and muscle attachments
Steps:
1. Special tray of acrylic resin
2. Three stops of impression compound are added to the fitting
surface ( one at the anterior,2 posteriorly in the 1 st molar
region) to allow space for 2mm for the imp material
3. Mandibular rests of imp compound are placed bilateral on the
occlusal surface of the tray in the molar region ( should be
concave to allow tongue movement) & compound tongue rest
is added in the anterior region to secure correct tongue
position during imp making
Dynamic impression
1. Final impression using a thin mix of alginate impression.
2. The patient is asked to close slowly until the mandibular
rests firmly contact the maxillary arch , keep the tongue in
contact with the maxillary rest
3. The patient is instructed to swallow 3-5 times, forcefully
protrude the lips forward
J. F. McCord and K. W. Tyson, “A conservative prosthodontic option for the treatment of edentulous
patients with atrophic (flat) mandibular ridges,” British Dental Journal, vol. 182, no. 12, pp. 469–472, 1997.
Tanvir H, et al. An innovative Wire Impression Technique of Highly
Resorbed Mandibular Ridge . Periodontics and Prosthodontics Vol.3 No.1:5
2017
Jaw relation
Determination of proper vertical dimension:
Avoid increasing the VD to avoid excessive forces on the ridge
Level of occlusal plane:
lowering the level of occl. plane toward the flatter ridge will decrease lateral
forces
lingualize Linear
Flat teeth
d occlusion
Lingualized occlusion
prominent maxillary lingual cusps articulate with the
mandibular occlusal surfaces in centric, working and
balancing mandibular positions
Advantages:
1. Centralization of vertical forces
2. Minimize tipping forces
3. Facilitate bolus penetration
(Mortar and pestle effect)
Linear occlusion
Flat teeth opposed by
bladed teeth ,
Mandibular teeth are set to flat occlusal plane
No anterior interference in protrusive or lateral
movements
Provide consistent vertical seating force in both
centric and eccentric, hence the transverse vectors
area eliminated
Balanced occlusion with cupless teeth can be achieved
by several ways:
inclination of the lower second molar
balancing ramps placed posterior to the most distal
molar.
steep compensatory curves
Determination of Neutral zone
Aim:
-record the range of muscle action , spaces into which the
denture can be extended without displacement,
Aggarwal H et al, Lost salt technique for severely resorbed alveolar ridges: An innovative approach