Dental Science - Review Article

Pre-prosthetic surgery: Mandible

Veeramalai Naidu Devaki, Kandasamy Balu, Sadashiva Balakrishnapillai Ramesh1, Ramraj Jayabalan Arvind2, Venkatesan2

Departments of Prosthodontics, 1 Periodontics, and 2Oral Surgery, Vivekanandha Dental College, Thiruchengode, India
Address for correspondence: Dr. Veeramalai Naidu Devaki E-mail: drdevaki_2005@ gmail.com

ABSTRACT
Pre-prosthetic surgery is that part of oral and maxillofacial surgery which restores oral function and facial form. This is concerned with surgical modification of the alveolar process and its surrounding structures to enable the fabrication of a well-fitting, comfortable, and esthetic dental prosthesis. The ultimate goal of pre-prosthetic surgery is to prepare a mouth to receive a dental prosthesis by redesigning and smoothening bony edges.

Received : 01-12-11 Review completed : 02-01-12 Accepted : 26-01-12

KEY WORDS: Alveolectomy, alveoloplasty, denture retention, pre-prosthetic surgery, undercuts

bone loss differs in maxilla from mandible. In maxilla, the usual resorption is on the buccal and inferior portion of the alveolar ridge. The pattern of edentulous bone loss results in upward and inward loss of structures. In the anterior maxilla, there is less horizontal bone loss and posterior drift of anterior rest is seen more than in edentulous mandible. In the posterior maxilla, there is invented drift of posterior rest. The width of maxilla is reduced.

re-prosthetic surgery is done to provide a better anatomic environment and to create proper supporting structures for denture construction.[1] Ultimate goal should be rehabilitation of the patient with restoration of the best possible masticatory function, combined with restoration or improvement of dental and facial esthetics. To achieve this goal, maximum preservation of hard and soft tissues of the denture base is of utmost importance. Wearing dentures for prolonged period manifests adverse changes in the denture-bearing areas due to change in the size of the jaw bones resulting in ill-fitting and painful dentures.[2,3] Since the end of World War II, through the development of better materials, improved accuracy of processing techniques, and better understanding of oral physiology, dental prosthesis has made great strides in increasing the successful use of prosthetic appliances in edentulous patients. The pattern of
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Pattern of Resorption Mandible

The mandible resorbs downward and outward, causing rapid flattening of ridge with greatest loss occurring within 12 18months after extraction. Gross anatomic studies[4,5] of dried jaw bones have shown a wide variety of shapes and sizes of residual ridges. In order to provide a simplified method for categorizing, the most common residual ridge form has been described[5]: Order I, pre-extraction; OrderII, post-extraction; Order III, high, well-rounded; Order IV, knife edge; Order V, low, well-rounded; and Order VI, depressed. This self-descriptive system is useful clinically as well as for research purposes and helps one to differentiate the various stages of residual ridge resorption in the individual patient.

Website: www.jpbsonline.org DOI: 10.4103/0975-7406.100312

How to cite this article: Devaki VN, Balu K, Ramesh SB, Arvind RJ, Venkatesan. Pre-prosthetic surgery: Mandible. J Pharm Bioall Sci 2012;4:414-6.

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Devaki, et al.: Pre-prosthetic surgery

Pre-prosthetic surgery is an integral part of oral and maxillofacial surgery and prosthodontics. It comprises both basic procedures and sophisticated techniques of reconstructions and rehabilitation of oral and maxillofacial region. The treatment planning, therefore, should involve coordination between the prosthodontist and oral maxillofacial surgeon. As the goal of the prosthetic appliance construction is to improve functions and esthetics, the requirements to achieve these goals should be discussed by the team members. Good shell had recommended the following criteria for a healthy and edentulous ridge:[6] 1. The bony ridge should have adequate width and height and should be U-shaped for a denture to be retentive and efficient. 2. The oral mucosa should have adequate uniform thickness. 3. The ridge should not have any undercut (or) sharp ridges. 4. No bony (or) soft tissue protuberance should be present. 5. Should have adequate buccal and lingual sulci depth.

bony process. This causes the margins of the mental foramen to extend and have very sharp edges. Pressure from the denture against the mental nerve will cause pain. If, however, constant irritation develops as a result of soft tissue being pinched between the denture and the bone, the spicules and the knifeedged ridge most be reduced.

Removal of Sharp Ridge (or) Knife Edge Ridge

Bony prominences, undercuts, and spiny ridges[5,6] are usually removed to avoid undercuts and to make possible a border seal beyond them against the floor of the mouth. A sharp knife edge like edentulous ridge causes great denture irritation. It is usually found in the anterior part of mandible. Place an incision on the crest of the ridge and elevate the mucoperiosteum as minimally as possible in order to maintain the vestiblular depth. Irregular and sharp bony edges are trimmed to a depth of 12 mm with the help of rongeurs, bone files, or burs, and the wound is closed with silk sutures.

Objective of Pre-prosthodontic Procedure

Correcting conditions that preclude optimal prosthetic function
1. Hyperplastic replacement of resorbed ridges 2. Unfavorably located frenular attachments 3. Bony prominences, undercuts

Reduction of Genial Tubercle

The genial tubercles are extremely prominent as a result of advanced ridge reduction in the anterior part of the body of mandible. If the activity of the genioglossus muscle has a tendency to displace the lower denture, the genial tubercle is removed and the genioglossus muscle detached. Genial tubercles are the bony projections located on the lingual aspect of the mandible, two on either side of the midline, which gives attachment to the genial muscles. The two genial tubercles located superiorly are more prominent than the inferior ones due to the gross resorption of the mandibular ridge. This may elevate the ridge lingually, giving a shelf-like appearance and making the anterior lingual seal impossible. Genial tubercles are exposed by blunt dissection. Using bur, chisel, or rongeurs, the tubercle is removed, and the rough bony margins are smoothened using file.

Enlargement of denture bearing areas

1. Vestibuloplasty 2. Ridge augmentation

Placement of tooth root analogues by means of implants

Treatment Plan The prognathic patient frequently places considerable stress and unfavorable leverages on maxillary basal seat. This may cause extensive reduction of maxillary residual ridge. A mandibular osteotomy of these cases can create a more favorable arch alignment and improve cosmetics as well.

Alveoloplasty
The bony prominences are removed by means of alveolectomy and alveloplasty. Alveoloplasty is the term used to describe the trimming and removal of the labiobuccal alveolar bone along with some interdental and interradicular bone and is carried out at the time of extraction of teeth and after extraction of teeth. When surgery is planned on the edentulous ridge, incision should be made on the crest of alveolar ridge; usually the envelope flap would suffice, but releasing incision can be made on the labial side to provide broad base to the flap. Bony contouring is accomplished with bone files, rongeurs, or burs. Digital palpation can be used to determine the uniformity of the ridge. If bone resorption in the mandible has been extreme, the mental foramen may open directly at the crest of the residual

Ridge extension procedure

Vestibuloplasty[7-9] is a surgical procedure wherein oral vestibule is deepened by changing the soft tissue attachments. Vestibuloplasty can be done either on the labial or on the lingual side.

Kazanjians technique
An incision is made in the mucosa of the lip and a large flap of labial and vestibular mucosa is retracted. The mentalis muscle is detached from the periosteum to the required depth and the vestibule is deepened by supraperiosteal dissection. A flap of the mucosa is turned downward from the attachment of the alveolar ridge and is placed directly against the periosteum to which it is sutured. A rubber catheter stent can be placed in
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Devaki, et al.: Pre-prosthetic surgery

the deepened sulcus and secured with percutaneous sutures. This catheter helps to hold the flap in its new position and maintains the depth of the vestibule. It is removed after 7 days. The labial donor site is coated with tincture of benzoin compound, and the surface heals by granulation and secondary epithelialization. Contracture of the wound margins take place.

supply is maintained. In this procedure, mandible is divided buccolingually by a vertical osteotomy from external oblique ridge of one side of the mandible to the other side. The osteotomized lingual segment is pushed superiorly and fixed with the buccal segment using stainless steel wire in the lower border of the lingual segment.

Ridge Augmentation
Superior border augmentation
It was described by Davis[10-12] in the year 1970. This procedure is indicated when mental foramen is situated in the superior border. In this procedure, autogenous bone graft is used. The rib graft can be fixed to the superior border of the mandible. Two segments of the rib, about 15 cm long, are obtained from the 5th and 9th ribs. The rib is contoured by vertical scoring in the inner surface. The second rib is cut into small pieces to laterpack against the solid rib. Fixation is done by means of transosseous wiring or circumferential wiring.

References
1. Taylor RL. A Chronological review of the changing concepts related to modifications, treatment, preservation, and augmentation of the complete denture basal seat. August Prosthodont Soc Bull 1986;16:17-39. Hopkins R. A colour atlas of preprosthetic oral surgery. London: Wolfe Medical Publications; 1987. p. 136-43. Lytle RB. Complete denture construction based on a study of deformation of the underlying soft tissues. J Prosthet Dent 1959;9:539-51. Mercier P , Lafontant R. Residual alveolar ridge atrophy: classification and influence of facial morphology. J Prosthet Dent 1979;41:90-100. Wowern N. Bone mineral contents of mandibles: Normal reference valuesrate of age-related bone loss. Calcif Tissue Int 1988;43:193-8. Harrison A. Temporary lining materials. A review of their uses. Br Dent J 1981;151:419-22. HIllerup S. Preprosthetic Mandibular vestibuloplasty with split-skin graft: A two-year follow-up study. Int J Oral Maxillofacial Surg 1987;16:270-8. Hillerup S. Hjrting-Hansen E, Eriksen E, Solow B. Influence Mandibular vestibuloplasty. A 5-year clinical and radiological followup study. Int J Oral Maxillofac Surg 1990;19:212-5. Hj rt ing-Ha nsen E , A da w y A M , Hilerup S. M a nd ibula r vestibulolingualsulcoplasty with free skin graft: A five-year clinical follow-up study. J Oral Maxillofac Surg 1983;41:173-6. Mller JF, Jolst O. A hostologic follow-up study of free autogenous skin grafts to the alveolar ridge in humans. Int J Oral Surg 1972;1:283. Bays RA. The pathophysiology and anatomy of edentulous bone loss. In: Fonseca R, Davis W, editors: Reconstruction pre-prosthetic oral and maxillofacial surgery. Philadelph ia: WB Saunders;1985. Weintraub JA, Burt BA. Oral health status in the united states: Tooth loss and edentulism. J Dent Educ 1985;49:368-78. Quayle AA. The atrophic mandible: aspects of technique in lower labial sulcoplasty. Br J Oral Surg 1979;16:169-78. Tallgren A. The continuing reduction of residual alveolar ridges in complete denture wearers: mixed longitudinal study covering 25years. J Prosthet Dent 1972;27:120-32.
Source of Support: Nil, Conflict of Interest: None declared.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Disadvantage
1. Morbidity of the donor site. 2. Secondary surgical site. 3. Necessity of the patient to withdraw denture till the surgical wound heals for period of 68 months.

Inferior border augmentation Visor osteotomy

This technique was first described by Sanders and Cox in the year 1986 for reconstruction of a resected mandible. This procedure is indicated to prevent and manage fractures of an atrophic mandible.[13-14] Visor osteotomy was described by Harle to overcome the resorption of free onlay bone graft. This technique is followed where the muscle insertion to the mandible and nutrient

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