Abused tissue and resilient liners

By
Prof. Dr. Osama Baraka

Abuse of the tissues supporting complete dentures deforms these

tissues and destroy bone. The alveolar bone is replaced by fibrous tissue
which lead to the formation of hyperplastic tissues. Edentulous ridges
that are mobile or resilient with little evidence of underlying supportive
bone, may give the appearance of being “flabby.”
Etiology:
A- Systemic causes e.g. diabetes.
B- Local causes as:
1- Natural teeth against denture cause excessive occlusal loading on
the residual ridge.
2- Ill-fitting denture and denture instability.
3- Occlusal disharmony and unbalanced articulation.
4- Long term denture wearing without regular maintenance and
serviceability.
Problem:
These areas of mobile tissue provide limited support for the complete
denture. In extreme cases, where the patient has a complete upper denture
and only anterior mandibular teeth remaining, a so-called combination or
Kelly’s syndrome.
Sites of occurrence:
1- The maxillary anterior, especially when only the natural mandibular
anterior teeth remain (Fig. 1).
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 2- The maxillary tuberosities may become hypertrophied and appear
to grow downward.
3- Anterior area or all over the lower ridge due to ill-fitting denture.

Fig. (1): Anterior localized ridge resorption has occurred and been replaced by
hyperplastic tissue. Left: Maxillary arch. Right: Mandibular arch.

Treatment:

I. Localized flabby area: If the movable tissues are localized and not
expected to interfere with denture stability, then these tissues can be retained
and a conservative prosthetic technique should be employed.

Conservative treatment:

1- Educate the patient in his responsibility in treatment plane,

the treatment may be expensive, time consuming and may require surgery.
2- The patient should remove the denture until recovery of the
tissues occurs. If this not possible it is advisable to leave the denture eight
hours every twenty-four hours (at night).
3- If there is any systemic disease consultation of the physician
is essential to treat the disease.

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 4- A good nutritional program must be emphasized for each edentulous
patient.
5- Massage of the soft tissues 2-3 times/day to stimulate blood supply
and aid recovery. Instruct the patient to dissolve 1/2 teaspoon of salt in 1/2
glass of warm water and vigorously swirl the solution against the tissue.
6- Pressure indicating paste to correct pressure areas &
overextensions.
7- Correction of occlusal disharmony by the intra-oral check
method or by the use of a clinical remounting.
8- Occlusal pivots to restore the OVD.
9- Tissue conditioning: The need to rehabilitation of abused
tissues without the continuous removal of patient's dentures has led to the
development and widespread acceptance of tissue-conditioning materials.

They are composed of a powder and a liquid (Plasticizer). Tissue

conditioning materials are formulated to be soft, resilient, and to flow
under pressure; and adapt to the basal mucosa and the basal denture
surface to form an intervening cushion. It permits the tissues to recover
and provide an excellent medium to aid in conditioning traumatized
hyperplastic bearing mucosa as they improve denture stability and
equalize pressure.

The flushing action of saliva causes the plasticizer in tissue

conditioner to leach out and it gradually changes into a rigid liner.
Accordingly, the material should be removed and replaced every 4 to 5
days.

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 II- Hyperplastic replacement of the entire residual ridge does not
usually provide a firm denture-bearing area and can be treated surgically
with one or more of the following techniques:

1. Surgical excision.
2. Alveoloplasty.
3. Alveolar ridge augmentation.

III- Prosthetic treatment:

1- Relining:

Objectives of relining:

a- To correct pressure area in tissue side of the denture and to

stabilize it.
b- Maintenance of the correct inter-occlusal space,

c- Harmonizing the occlusion with the mandibular movement.

A- Chairside relining using soft liners:

1- The use of soft tissue conditioning material will help in

distributing the load over the ridge may solve the problem. But the tissue
conditioning material continuously flow so certain procedures cannot be
done accurately e.g.:
a- Accurate cast cannot be obtained for remount.
b- Accurate inter-occlusal record cannot be made.
c- Accurate occlusal correction cannot be done.
Technique of tissue conditioning:

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 Will be discussed later under tissue conditioning.
2- Relining by cold cured soft liner is indicated when the denture will
be used for a prolonged time (Discussed later).

B- Chairside relining using hard liners:

1- The fitting surface of the denture must be relieved to create a space

for the reline material.
2- Separating medium must be applied to the areas where bonding is not
desired (polished surface and teeth).
3- The mucous membrane having previously been smeared with
Vaseline.
4- Direct relined materials generally supplied as a powder and liquid.
The material is mixed and poured into the denture, and the denture is seated
into the mouth after inserting the opposing denture.
5- The patient is asked to close into centric occlusion and the borders
are molded.
6- The denture is then removed from the mouth after the initial set of the
material and placed in warm water for twenty minutes to allow the material to
cure; the denture is then trimmed and polished.

Disadvantages of the chair side reline materials:

a- Some materials may produce a chemical burn on the mucosa.

b- With some materials the resulting relines porous and subsequently

develop bad odor.

c- Color stability is low.

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 d- If the denture was not positioned correctly, the material could not
be easily removed in order to start again.

C- Indirect relining technique:

Impression:
A closed mouth impression technique may cause displacement of the
tissues beyond acceptance. Also, premature contact can shift the denture
before the setting-up of the impression material which give faulty
occlusion. So that:
a- A minimum pressure impression technique must be used.
b- Complete recovery of the abused tissue should occurs before the
impression.
c- It is preferable to reline the upper denture first, then correcting the
occlusal disharmony by the intraoral method then proceeding in the
lower denture. This reduce the errors which can be corrected after
clinical remounting.
Technique:
a- Reduce the borders of the denture 1-2 mm.
b- Make an impression to the denture using impression
compound.
c- Remove the compound from the fitting surface except in stress
bearing areas and provide escape holes in the denture.
d- Mixing of silicon impression material according to the
manufacturer instruction.
e- Loading the denture by the impression material.
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 f- Seat the denture gently in place.
g- Instruct the patient to close the jaw until tooth contact occurs
in centric relation. Then instruct the patient to open the jaws to relaxed
position, to protrude and retrude the lips as in grinning, to swallow and to
relax, while the operator support the denture with the index and middle
finger in bicuspid area.
h- Allow the material to set. Remove the impression, bead, box,
and pour the stone cast.
i- The impression material then replaced by processed acrylic
resin.

II- Remounting:
It is necessary to correct the OVD and providing the necessary
interocclusal space and to correct the occlusal disharmony. If the upper
denture is relined first, the occlusion is corrected before making the lower
impression. If both dentures will be relined together, the occlusion is
corrected after making the maxillary impression and before making the
lower impression. This procedure is carried-out as follows:
a- Insert the relined upper denture or upper impression in place.
b- Apply occlusal indicating wax to the lower denture, insert in
the patient's mouth, and ask the patient to close in centric relation.
c- Remove the premature or heavy contact areas until an even
contact of the posterior teeth occurs.
After processing both dentures remounting is done as follows:

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 a- Eliminate any undercuts in the denture base and make an
accurate remount cast for both arches.
b- Make face bow transfer of the maxillary cast.
c- Relate the mandibular cast to the maxillary by interocclusal
record in centric relation.

d- Using selective grinding procedure return the teeth to an

acceptable occlusion relation at the correct vertical dimension of
occlusion.

III- New denture construction:

Impression:
A- Mucostatic impression technic: using easily flowing material as
plaster of paris to disturb the tissues to the minimal.
B- Selective pressure impression technic: this implies pressure in
other areas than the flabby tissues.
a- Splint method: A tray which highly relived over the flabby area is
used. Thin mix of plaster is applied over the flabby area and left until it
hardens then overall plaster impression is taken.
b- Scraping method, plaster wash impression: Compound
impression is made which then relived over the flabby and a plaster wash
impression is taken.
c- Composition method or two segments impression is used when
the flabby tissues in the anterior area of the ridge. Acrylic or metal tray is
used which cover the healthy tissues only. Impression made by

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compound or paste under the biting force. Then plaster mix applied to
the flabby area in sufficient thickness to be removed with the impression.
The advantage of this technic is that there is no compression of
flabby tissues at rest and during function.
C- Functional impression in flabby ridges:
Upper impression:
- It is done to compress the flabby tissues without its distortion.
- Primary impression with soft material as alginate.
- Acrylic special tray.
- Compound impression, then trimming the excess compound.
- Marking the flabby tissues in the mouth by indelible pencil then
placing the impression in the mouth to mark site of flabby tissues.
- Soften the compound all over the impression except area of flabby
tissues and compress it in the patients mouth and do border moulding,
this keep the flabby area undistributed be hard compound while
compressing the tissues.
- Wash impression by Zo-E paste of thin section.
Lower impression:
- Primary alginate impression.
- Acrylic special tray with perforation at the flabby area on the crest
of the ridge.
- Compound impression. Scrapping the compound at crest of the ridge
till exposing the perforations, then placing the impression in patients
mouth and border moulding is taken.
- Wash impression by paste is made.

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 Jaw relation record:
Static jaw relation record is used.
Setting-up of teeth:
Bilateral balanced articulation should be made.

Resilient linings

The relining material must be simple to use, compatible with the

tissues, free flowing, easy to remove from the dentures, quick set and hard
enough to allow patient remount procedure.
I- Tissue conditioners:
- Acrylic polymer (powder).
- Plasticizer + solvent as ethanol (liquid).
- On mixing, the solvent dissolves the polymer powder and the
plasticizer give resiliency.
It is viscoelastic:
- Viscus under constant load so distribute stresses.
- Elastic under heavy masticatory load.
Uses:
1- Give stability to the denture and equalize pressure on the
irritated, traumatized or hyperplastic tissues will recover, before new
denture construction.
2- To line temporary obturators, this protect the tissues and
enhance healing.
3- Stabilize surgical splint or stent in vestibuloplasties this gives
closer adaptation to the healing tissue and so protect them from trauma.

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 4- Impression making when it is difficult to extend the denture
base by means of the movable oral structure. This impression is used to
make special tray for final impression. Minor correction can be made to
make the material acceptable as the final impression.
5- In patients who cannot wear well-constructed denture
comfortable due to chronic soreness. If the patient can wear the denture by
tissue conditioner a permanent soft liner is used.
Technique in the use of tissue conditioner:
Denture preparation:
a. The dentures should have adequate coverage of the bearing
area.
b. There should be good centric occluding relation.
c. No gross cusped interference.
d. Remove all undercuts and scrub the ridge area to a depth of 1
mm.
e. Any overextension is grinded and underextension is added by
a self-curing acryl.
Material preparation:
a. The plasticizer (liquid) is placed in a glass jar then the powder
is added slowly, according to the manufactures instruction.
b. When the mix is creamy, it is poured into the denture, when it
ceases to flows readily it is placed in the patient's mouth.
c. The patient is guided to close in centric relation and do
functional movement with the lip and tongue.

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 d. The excess material in the flanges (polished surface) is
removed.
e. Any pressure areas are removed and the material added then
placed in the mouth again.
f. All sharp edges are covered by flow control (plasticizer) to
allow the material to flow easily.
g. The patient is instructed to not eat hard in the first 8 hours to
not squeeze the lining material.
h. This procedure is repeated every 3-4 days till complete tissue
recovery.
i. The patient is warned to not use it long because it hardens and
roughen within 4-8 weeks.

II- Resilient (Soft) Liners:

They are elastomeric polymers used in the prevention of chronic

soreness from dentures and preservation of supporting structures.
Length of use ranges from six months to five years depending on need
and material. Their usage is to prevent denture soreness while tissue
conditioners are used to treat denture soreness.

Requirements
1- Biologically inert.
2- Resilient and capable of maintaining this characteristic; the average
period of satisfactory service for a denture is 7 years.

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 3- Dimensionally stable and insoluble in oral fluids to maintain
proper tissue contact.

4- Cooler stable.
5- Resist abrasion and thereby allow the practice of proper
hygiene of the surface.
6- Maintain their bond to the denture base without damaging it.
7- Relatively easily to work.
Uses:
Permanent soft liners provide comfort by reducing the impact of
forces during function and are used to prevent chronic soreness from the
dentures and preserve the supporting structures. They have been used in
the following situations:
1- Repeated ulcers at the periphery and under the fitting surface of
denture.
2- If the patient cannot tolerate the hard base of acrylic resin.
3- Ridge atrophy and resorption e.g. (areas require protection):
a. Mental foramen.
b. Rugae.
c. Exposure of mandibular canal.
d. Knife edge lower ridge.
e. Areas where bony and skin grafts are used.
4- Surgery contraindicated:
As in bilateral opposing undercuts in maxillary tuberosity area or
lingual pouch area. And the patient not agree to do surgery or his general
health not permit surgery.

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 5- In patients who have the habits of bruxing their teeth
(bruxomania).
6- The relief areas as the median palatine raphe, anterior nasal
spine and rugae area. This obviate use of relief chamber in maxillary
denture and subsequent development of hyperplastic tissues.
7- Used to line the obturators to engage undercuts and help in
retention.
8- Xerostomia in diabetes and irradiation to protect the oral
tissues and prevent osteoradionecrosis.
9- In edentulous arches opposing natural teeth.

Materials:
1- Acrylic:
a- Cold cure (Chair side procedure).
b- Heat cure (Laboratory procedure).
Mode of supply: Acrylic powder and liquid.
Properties:
- Good bond to denture base.
- Plasticizer give resilience but less than silicone.
- Plasticizers leach out so becomes hard.
2- Silicon:
a. Cold cure (Chair side procedure; Fig. 2)
b. Heat cure (Laboratory procedure).
Mode of supply: Main silicone Paste and Primer.
Properties:
- More resilient.

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 - Low abrasion resistance.
- Low bond strength to acrylic in spite of the use of adhesive.
- Porous absorb water which make it peel off.
- Affected by some cleaning agent e.g. oxygenating sol. as perborates
and percarbonates.
- Encourage growth of candida so fungicide should be added.

Chairside relining (Cold-cured liners):

Denture preparation and material application is the same as discussed

for applying tissue conditioner. The material proportioning, mixing and
primer application as directed by the manufacturer’s instructions.

Fig. (2): Silicone soft lining of denture: A. Roughening the fitting surface, B.
Applying adhesive, C. Mixing soft liner, D. Applying soft liner to the fitting surface
of the denture.

Laboratory Procedure for heat cured soft liners:

This lining can be applied,
A- To the existing denture base or
B- While making a new denture.

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 A- Applying soft liner to the Existing Denture Base
- Make a cast on the existing denture base.
- Remove the cast
- Adapt a wax spacer over the cast
- Put the denture back on the cast and seal at the periphery
- Flask the denture and place in hot water to soften wax spacer.
- Open the flask
- Remove all traces of wax spacer by boiling water.
- Dry the cast
- Apply separating medium to the cast surface
- Apply to the fitting surface of denture primer of silicone soft liner
or monomer to acrylic soft liner.
- Wait for 10 minutes for the primer to dry
- Apply enough soft liner over the fitting surface of denture.
- Close the flask-make sure there is excess but excess is not
removed.
- Cure for nine hours at 75°C.
- Open the flask and recover the denture.
- Trim the lining with scissors or fine abrasive stone or hot wax
knife.
B- Applying soft liner to the New Denture
A tin foil spacer is applied to the cast before packing of acrylic denture
base to provide a space for the soft liner. After trial packing of acrylic base
material, the foil is removed and the soft lines is packed as follow:

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 1- Acrylic soft liner:
The conventional compression molding technic is used for acrylic
resin soft liner. No trial pack is made after soft liner packing due to the
flow of the material and flash appeared on the edges of the denture flanges.
2- Silicone soft liner:
Injection of the silicone into the flask once the denture had been trial
packed, as follows:
a. Two holes are made in the top of lower half of the flask and
brass plug is made to them and holes are drilled to connect this holes to
the retromolar pad area in the mould.
b. During packing of acrylic resin, a spacer of 1.5-2 mm of wax
is adapted in the cast and after the bench cure of acrylic resin (20-30 min)
the wax spacer is removed.
c. A silicone primer is applied by brush to the surface of acrylic
to give good bond, and allowed to remain for 3-4 min then the flask closed.
d. The silicone is aspirated from its tube into a plastic syringe and
injected into the mould through a hole till silicone comes from other hole,
then the holes closed with the plug.
e. Then curing of the acrylic and silicone in the usual manner. If
surface of silicone becomes milky this means incomplete curing, it is
completed by placing the denture in hot water for 1 hour.
f. The liner is finished by cutting the excess by a scalpel and the
margins by carbide burs or wire brush wheal.

Limitations
1- Not easy to clean and maintain.

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 2- Difficult to trim and adjust.
3- Lack bonding to the denture base.
4- Ineffective in thin sections, thickness should be at least 1.5–2 mm,
hence cannot be used in maxillary dentures.
In conclusion, soft liners have good application as ‘tissue conditioners’
on a temporary basis. To use them as a definitive denture base for
prolonged period of time has not been successful as patients continue to
experience discomfort and the properties of the current materials are far
from ideal for use in these situations.

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