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1. Pre-prosthetic Methods surgery

1.1. Hard tissue

1.1.1. Retained dentition Retained Roots Should be removed in case of pathologic conditions Unerupted Teeth Majority of cases should be removed to prevent transition Maybe retained when the tooth has been asymptomatic for years

1.1.2. Sharp irregular residual ridges

1.1.3. Prominent Mylohyoid ridges Mylohyoid ridge is an oblique ridge on the lingual surface of the lower jaw when the gum ridge is sharp and denture pressure can cause significant pain in this area.

1.1.4. Prominent Maxillary Tuberosity Results from overerupted teeth procedure aims to create a normal interarch space. Indicated for removal if Pendulous, bulbous and fibrous Too large vertically interfering with the placement of teeth If excess tissue elliptical incision, the mucosa is undermined then removal of fibrous tissue If excess bone elliptical incision, mucoperiousteum is reflected, rotary bur or rongeur is used to removed the bone. Smoothing of bone surface with a bone file.

1.1.5. Undercut area Undesirable if interferes path insertion. all undercut areas need not to be reduced If bilateral one side can be left intact Protrusion of alveolar bone

1.1.6. Reduce residual ridge Ridge augmentation implants

1.1.7. Discrepancies in jaw size

1.1.8. Tori&exostoses Benign , slowly growing hyperostoses maximum growth at the age of 30 Torus Palatinus Junction of palatine process in the midline of palate Removed when : Tours Mandibularis bilaterally on the lingual cortical surface of the mandible in canine- premolar area Removal is always indicated Exostoses Bony nodules located on the alveolar process on the buccal sides of posterior maxillary and molar area of the mandible. Present undercuts to the path of placement

1.1.9. Alveoloplasty surgical smoothing and shaping of the alveolar ridge Indications Sharp spinous edges Extreme irregularities of the alveolar crest Exostoses Opposing undercuts Lacking of intermaxillary space Esthetically unfavorable alveolar bone formation Protrusion alveolar bone Supraeruption of maxillary teeth dragging

1.1.10. Reduced Residual Ridge Can cause problems in denture support , retention and stability Mand augmented more than Max Treatment Augmentation

1.2. Soft tissue

1.2.1. Hypermobile (flabby, fibrous) Common on upper anterior ridge Presence of natural anterior lower teeth Detectable thru palapation Flabby ridge is better than no ridge at all. If removed – leaves a low flat ridge Conservative treatment

1.2.2. Prominent frena Susceptible to irritation Intefere with denture border treatment Frenectomy Ankyloglossia as a result of a short frenum

1.2.3. Shallow sulci Reduction of alveolar bone ridge Lead to encroachment muscle attachment Instability of denture

1.2.4. Vestibuloplasty Series of surgical procedures to restore alveolar ridge height/width By lowering muscle attachment +unattached mucosa

1.2.5. Pressure on the mental foramen May open near or direct at the crest of the ridge due to extreme bone resrption Impingement / pressure may cause numbness in the lower lip Treatment Relieve of the denture base Trim the bone

1.2.6. Denture stomatitis pathological reaction of the palatal portion of the denture bearing mucosa Classifications Type I: (trauma induced) Type II: (Erythematous) Type III: (Granular type) Factors Systemic Local

1.2.7. Papillary palatal hyperplasia

1.2.8. Epulies fissuratum Denture Irritation Hyperplasia overgrowth of fibrous connective tissue. inflammatory fibrous hyperplasi Causes Chronic injury by unstable denture Composed over-extended denture flange Signs/Symptoms Single/numerous flaps of hyperplastic connective tissue. deep ulcerations, fissuring and inflammation Management 1.Adjustment of denture 2.Replacement of denture 3.Surgical excision

1.2.9. Traumatic Ulcers Signs/Symptoms Develop within 1-2 days after placement of new denture. Small and painful lesion and surrounded by inflammatory halo Causes 1. Overextended denture flange 2. Unbalanced occlusion 3. Nodules on the impression surface Management adjustment of denture not corrected may develop into denture irritation hyperplasia.

1.2.10. Angular stomatitis correlated with candida associated denture stomatitis Factor Over-closure of jaw Nutritional Deficiencies Iron Deficiency Anemia

1.2.11. Burning Mouth Syndrome (Denture Sore Mouth) characterized by burning sensation without any visible changes in mucosa. Common in post –menopausal women above 50 yrs old. Clinical features pain starts in the morning and aggravates during the day. Accompanied with dry mouth Headache, insomnia, Causes Local Systemic Psychogenic

1.3. Ideal Edentulous Ridge

1.3.1. Provide adequate bony support

1.3.2. No undercut

1.3.3. No scar bands prevent seating of denture

1.3.4. No soft tissue fold&hypertrophies

1.4. Objectives

1.4.1. Correcting conditions that preclude optimal prosthetic function

1.4.2. Enlargement of denture-bearing area(s)

1.4.3. Provision for placing tooth root analogues

2. Non-surgical methods

2.1. Occlusal Corrections

2.1.1. Dentures can apply excessive forces to the supporting tissues because of poor fit or occlusal errors.

2.1.2. loads maybe localized or generalized and can cause accelerated bone resorption, inflammation, and hyperplasia

2.1.3. Ridge Resorption produces changes in position Acrylic resin can be added to correct

2.1.4. Tissue abuse caused by Improper occlusion correcting the occlusion and refitting the dentures by (tissue conditioner)

2.2. Rest for denture supporting tissues

2.3. Good nutrition

2.3.1. Elderly undernourished

2.3.2. Mucosal intolerance responds to nutritional supplements

2.3.3. Vitamins , minerals and other dietary supplements can be prescribed.

2.3.4. Nutritional Guidelines Eat a variety of food Build diet around complex carbohydrates Eat atleast 5 servings of fruits and vegetables daily Select fish, poultry, lean meat, eggs Consume 8 glasses of water, juice or milk daily

2.4. Conditioning materials

2.5. Conditioning of the patient’s Musculature

2.5.1. Jaw exercises can permit relaxation and strengthen of the muscles

2.5.2. Mandibular Exercise: 4x/day Open wide and Relax Move the Jaw to the Right and Relax Move the Jaw to the Left and Relax Move the jaw forward and Relax

2.5.3. Tongue Exercises Thrusting the tongue out and in, in rapid succession. alternating action of geniglossus muscles Swinging the tongue sideways with great rapidity. alternating action styloglossus Thrusting the tongue to its most extended position and pulling it back quickly. anterior and posterior fibers of geniglossus muscles with assistance of styloglossus and hyoglossus Raising the tongue to its highest position well forward through the articulation of “eeyuh” stloglossus, stylohyoid,stylopharynggeus,the tensors and palatoglossi

2.5.4. Tissue Conditioner soft elastomers

2.6. Managing Traumatized tissues

2.6.1. Rest for Denture-supporting Tissue Leaving the dentures out of the mouth Allows the tissue recovery

2.6.2. Soft tissue stimulation Massage for 3x a day Stimulate the blood supply

2.6.3. Application of Temporary liners inside the old dentures Provide an interim cushioning stage