Section 18 - Pre-Prosthetic Surgery

Handout Abstracts 001. Peterson, L. J. Principles of ral and !a"illofacial Surgery. #ol. $$. J. %. Lippincott &o., Philadelphia, 1''(. a. )arb, *. Prosthodontic #ie+ of ,raditional and &onte-porary Preprosthetic Surgery. &hapter .(, pp. 10'1-110(. b. ,uc/er, 0.!. A-bulatory Preprosthetic 0econstructi1e Surgery. &hapter .2, pp. 1102112(. c. Stoelinga, P.J.3. Preprosthetic 0econstructi1e Surgery. &h. .2, pp. 114'-1(05. 00(. 18-00(. &hase, 6.&. and Las/in, 6.!. Procedure to $-pro1e the Al1eolar Soft ,issue. %asic Preprosthetic Surgery, #ol. $$, ral Surgery. a. &hase, 6.&. and Las/in, 6.!. Procedure to $-pro1e the Al1eolar Soft ,issue. %asic Preprosthetic Surgery. &hapter ', pp. ('272.5. b. &hase, 6.&. and Las/in, 6.!. Procedure to $-pro1e the Al1eolar Soft ,issue. %asic Preprosthetic Surgery. &hapter 10, p.2.'-241. 002. Peterson, L.J., &onte-porary ral and !a"illofacial Surgery, (nd ed., !osby 8ear-boo/ $nc., St. Louis, 1''2. a. ,uc/er, !.0. %asic Preprosthetic Surgery. &hapter 12, pp. 2'9-22.. b. ,uc/er, !.0. Ad1anced Preprosthetic Surgery. &hapter 1., pp. 229-248. 00.. :onseca, 0.J. and 6a1is, 3.H. 0econstructi1e Preprosthetic ral and !a"illofacial Surgery. 3.%. Saunders &o., Philadelphia, 1'84. a. Scott, 0.:. and lson, 0.A. !inor Preprosthetic Procedures. &h ., pp. 41-48. b. 6a1is, 3.H. Surgical !anage-ent of Soft ,issue Proble-s. &h 9, pp 4'-114. c. :onseca, 0.J. sseous 0econstruction of ;dentulous %one Loss. &hapter 4, pp 115-149. Handout Section 18 - Pre-Prosthetic Surgery ,he -a<ority of patients +ho re=uire prosthodontic treat-ent +ill not re=uire surgical inter1ention prior to co--ence-ent of their prosthodontics. :or -any others, ho+e1er, a thorough and co-prehensi1e e"a-ination, diagnosis and treat-ent plan +ill re1eal that surgical inter1ention can i-pro1e the prognosis for the case. &onsideration of pre-prosthetic surgery is one of nu-erous -ethods by +hich a patient>s clinical presentation -ay be ad1antageously altered. As a general ?rule of thu-b? the best procedure to consider is the least in1asi1e process that +ill produce clinical success. ,his -ay -ean that it could be a disser1ice to the patient to

perfor- surgery +hen a non-surgical -ethod could be used. $t is li/e+ise a disser1ice to fail to consider and perfor- surgery +hen a non-surgical approach +ill produce a less than satisfactory result. ,ypes of pre-prosthetic surgery can be classified in a nu-ber of different +ays. ne -ethod is to categori@e the surgery as resecti1e, recontouring or aug-entation of bony or soft tissue. 3hile -any of these procedures are directed to+ards treat-ent of the patient +ho is co-pletely edentulous, there are -any indications for pre-prosthetic surgery for the patients +ho are either partially edentulous or co-pletely dentate. ,reat-ent planning of pre-prosthetic surgeryA 3hat t+o challenges -ust be faced in the prosthodontic rehabilitation of a patientB C,uc/er &hapter 12, p ('9D The restoration of the best masticatory function possible combined with restoration or improvement of dental and facial esthetics. %efore any surgical or prosthetic treat-ent, a thorough e1aluation outlining proble-s to be sol1ed and a detailed treat-ent plan should be de1eloped. 3hat factors should be considered in de1eloping the treat-ent planB C,uc/er &hapter 12, p. ('4D. History, physical examination, patients chief complaint, expectations, esthetics, functional goals, psychological factors, patients surgical risk status, intraoral and extraoral examination. 3hat are the t+o ob<ecti1es, goals or pre-ises of pre-prosthetic surgery for the edentulous patientB C)arb p10'(D The provision of a comfortable tissue foundation to support the denture, and enlargement of the denture bearing area in attempt to provide stability for a denture. Soft tissue related surgery A. Resective surgeriesA 1. Hypermobile tissueA ;"cessi1e tissue is usually the result of the resorption of the underlying bone. $f ade=uate al1eolar height +ill re-ain after reduction of hyper-obile tissue, then e"cision -ay be indicated. $f the ridge is atrophic and the bone is thin and sharp, e"cision -ay result in a greater deficiency. 3hat should be considered if the al1eolar height is inade=uateB C,uc/er p 21', &haseELas/in p2.'D Ridge augmentation or vestibuloplasty. (. Papillary hyperplasiaA 3hen hyperplastic tissue for-s on the hard palate, it usually ta/es a papillary for-. ,he condition usually begins as a series of tiny papillary pro<ections that gi1es the palate a 1el1ety appearance. Later it assu-es a -ore nodular for-. 3hat are so-e potential causes of papillary hyperplasiaB C,uc/er p 2((, &haseELas/in p 294-5D Mechanical irritation, ill fitting dentures, poor oral hygiene, fungal infections, and the associated inflammation. hase and !askin point out that it has been reported in

patients with maxillary partial dentures and even in patients with natural teeth and poor oral hygiene. 3hat are so-e of the options in the treat-ent of papillary hyperplasiaB C,uc/er p2((,&haseELas/in p 294-5D "on surgical treatment such as proper denture ad#ustment and tissue conditioning, surgical excision, electrosurgery, or abrasion of the superficial layer of palatal mucosa. 2. Inflammatory fibrous hyperplasia Cepulis fissuratu-D A continuous fold of hyperplastic tissue -ay for- to fill the space bet+een an ill fitting denture and the al1eolus. $t -ay appear as a lobulated locali@ed -ass +hich can be hidden under the denture, or -ay be bifid, e"tending both behind and in front of the flange. $n longstanding cases, -ultiple folds -ay for-. 3hat is the -ost co--on causeB CLas/in p 292D denture irritation from an ill fitting denture. 3hat are other possible causesB $llergic or chemical reactions to the denture material, or carcinoma. $ll excised tissue should be submitted for histological examination. ,reat-entB C,uc/er p 2(0D orrection of denture irritation, placement of a soft liner, electrosurgery%if small& or conventional surgery %if larger& .. Frenectomy ,he labial frenu- is usually not a proble- in the dentate patient unless associated +ith a diaste-a. $n the edentulous patient, it -ay be irritated by the flange of the denture. !o1e-ent of the soft tissue ad<acent to the frenu- -ay create disco-fort and ulceration and -ay interfere +ith the peripheral seal and dislodge the denture. An abnor-al lingual frenu- -ay bind the tip of the tongue to the posterior surface of the -andibular al1eolar ridge, and can affect speech and interfere +ith denture stability. ,reat-entB CLas/in p 298, ,uc/er p 2((D 'imple excision, ()plasty, or locali*ed vestibuloplasty with secondary epitheliali*ation, locali*ed supraperiosteal dissection removing the fibrous attachment. 9. Ma illary tuberosity reduction of soft tissue. ,he a-ount of soft tissue a1ailable for reduction can often be deter-ined radiographically, or +ith a sharp probe after local anesthesia. $t -ay be necessary to re-o1e both soft tissue and bone to achie1e the desired result. CSee belo+ under %ony resecti1e surgeriesD A. Ridge e tension surgeriesA !estibuloplastyA 3hat is the goal of the 1estibuloplastyB CLas/in p221D +t attempts to expose and make available for denture construction that bone which is still present. %riefly describe the procedure C)arb p 10'4D The surgeon detaches the origin of muscles on either facial or lingual side of the edentulous ridge. Healing occurs by secondary

epitheliali*ation or by skin or mucosal graft. ,estibuloplasties with skin grafts do not seem to accelerate bony resorption. +f healing occurs by secondary epitheliali*ation, bone resorption changes of -)./0 may occur over a . year period. 3hat are so-e potential co-plicationsB C6a1is p '(, Stoelinga p 1184DD !oss of sensation if the mental nerve is dissected, sagging of the chin if the mentalis muscle is completely dissected, and hypotonia of the circumoral muscles. 3hat are the indications for perfor-ing a transpositional flap vestibuloplasty CLip s+itchD C,uc/er p 11(0DA This procedure is indicated primarily for patients with sufficient mandibular bony height and an ade1uate vestibular sulcus on the lingual aspect of the mandible. +t can be accomplished successfully without a splint or can be combined with immediate reinsertion of a modified relined denture or splint in order to maintain tissue adaptation in the depth of the vestibule. 3hat are the indications for lo"ering the floor of the mouthB C,uc/er p 11((D $s the alveolar bone is resorbed, the attachments of the mylohyoid and genioglossus muscles may interfere with the lingual aspect of the denture. #ony related surgery $% Resective surgeries& 1. Al1eoloplastyA $rregularities of the al1eolar bone can be recontoured either at the ti-e of tooth e"traction, or after a period of initial healing before fabrication of the final prosthesis. 3hen -ight an intraseptal al1eoloplasty be indicatedB C,uc/er p(''D 2here the ridge is of relatively regular contour and ade1uate height, but presents an undercut to the depth of the labial vestibule because of the configuration of the alveolar ridge. (. ,ori re-o1alA A torus is a slo+ly gro+ing osseous for-ation of un/no+n etiology. ,hey can be 1ariable in si@e, shape, location, and pattern. Fsual locations are along the -idline of the palate, and along the lingual aspect of the -andible. 3hat is the pre1alence of -a"illary tori C,uc/er p 210D They are found in ./0 of the female population, approximately twice the prevalence in males. 3hat are the indications for re-o1al of tori CScott p 45DB 1. ;"tre-ely large torus (. ,orus that e"tends beyond denture periphery 2. ,orus +ith trau-ati@ed -ucosal co1erage .. ,orus +ith deep undercuts

9. ,orus that interferes +ith speech or deglutition 4. Psychological reasons 2. Ma illary tuberosity reduction& As pre1iously -entioned under soft tissue surgeries, either hori@ontal or 1ertical e"cess of the -a"illary tuberosity -ay interfere +ith proper denture fabrication. ,his -ay be as a result of e"cess soft tissue, bone, or both. 3hat is the -ost co--onEtypical proble- created by enlarged -a"illary tuberositiesB 3nlarged tuberosities encroach upon the available interarch distance for denture fabrication Recontouring and removal of bone and4or soft tissue may be necessary to remove irregularities or allow for ade1uate interarch distance. 3hat is the -ost fre=uent co-plication of tuberosity reduction surgeryB CLas/in p20.D 5erforation of the maxillary sinus. .. Ridge undercuts' irregularities' e ostosesA ;"cessi1e bony protuberances and the resulting undercuts can interfere +ith fabrication of the prosthesis. ,he denture bearing area should be palpated as +ell as 1isually inspected for such potential proble- areas. %riefly describe the procedure for surgical correction. C,uc/er p 209D $fter reflection of a flap, the areas of irregularity are recontoured with a bone file, rongeur, or rotary instrument. $fter completion of the bony recontouring, the soft tissue is readapted, and visually inspected and palpated to assure that no irregularities or bony undercuts exist. Ho+ long should an area be allo+ed to heal prior to -a/ing i-pressions for denture fabricationB C,uc/er p 209D $pproximately - weeks. 3hat alternati1e should be considered if resecti1e surgery +ould result in a narro+ed crest of al1eolar ridge and a less desirable area of support for the dentureB C,uc/er p209D onsider augmentation of the site with either autogenous, allogenic, or alloplastic material. 9. (enial tubercle reductionA As the -andible undergoes resorption, the area of attach-ent of the genioglossus -uscle -ay beco-e increasingly pro-inent. $n so-e cases the tubercle -ay actually function as a shelf against +hich a denture can be -ade, and in other cases -ay interfere +ith proper denture fabrication. 3hat alternati1e to genial tubercle reduction should be consideredB C,uc/er p 20'D Ridge augmentation.

4.

Mylohyoid ridge reductionA ften the shelfli/e pro<ection at the insertion of the -ylohyoid -uscle -ust be re-o1ed to lessen the a-ount of undercut present or to relie1e irritation of the -ucosa o1er a /nifeli/e bony structure. 3hen should the denture be deli1ered follo+ing surgeryB C,uc/er p 20'D +mmediately, to help facilitated a more inferior relocation of the muscular attachment.

A. $ugmentation surgeriesA 1. $ugmentation "ith synthetic graft materials. Hydro"yapatite is a nonresorbable cera-ic bone substitute, +hich co-es in a granular for- in a syringe, and -ay be placed alone, or co-bined +ith autogenous bone to aug-ent the atrophic ridge. %riefly describe the procedure CLas/in p2(8D +ncisions are made down to the periosteum, and a subperiosteal tunnel developed on the crest of the alveolar ridge. The hydroxyapatite is in#ected, filling the tunnel. The incisions are then sutured closed. The hydroxyapatite is then molded with finger pressure to form an ideal ridge, and a stent placed. 2hat are some potential complications of the procedure6 %Tucker p 7-8& Migration of the material, nerve dysesthesias, difficulty achieving height augmentation, inade1uate increase in strength of mandible. (. )nlay bone graftingA !a"illary autologous onlay bone graft C0ibD. 3hat are the treat-ent indications for a -a"illary onlay bone graftA C:onseca 118D 'evere maxillary alveolar atrophy, flat palatal vault form, mild to moderate anteroposterior ridge relation discrepancy. 3hat are the ad1antagesB C:onseca p 118D $ugments alveolus, improves vault form, improves anteroposterior relations, remodeling leaves good ridge form. 3hat are the disad1antagesB C,uc/er p. 2.5D 'econdary donor site re1uired, unpredictable resorption, secondary soft tissue surgeries necessary, delay in wearing dentures 8)9 months. !andibular superior border aug-entationC0ib or iliac crestDA C,uc/er p 228, :onseca p 1.9D 3hat are the additional disad1antages of a -andibular superior border graftB 'ignificant postoperative resorption, from one)half to two)thirds with rib, up to :/0 with iliac crest bone. !andibular inferior border aug-entation C0ibDA $n this procedure, a rib graft is used for aug-entation of the inferior border of the -andible. 3hat are the ad1antagesB C,uc/er p. 228D 5revention and management of fractures of the atrophic mandible. 6isad1antagesB +t does not address abnormalities of the denture bearing area.

2. $nterpositional bone graftA ,his procedure can be used to aug-ent the atrophic -a"illa or -andible. $t +as de1eloped in an atte-pt to o1erco-e the -ain disad1antage of -andibular onlay grafting, i.e., rapid resorption. %riefly describe the procedure C:onseca p 1((-1(9, 1.9-1.5, ,uc/er p 2.0, 2.5-8D The maxilla or mandible is ;split;, elevated, positioned and supported by interposed grafts of autogenous bone or cartilage, free*e dried bone, alloplastic material, or combinations of these grafts. .. )steotomiesA !andibular ?1isor? osteoto-yA Fsed usually in co-bination +ith a graft, the osteoto-y is a 1ertical one +ith an ele1ation of the lingual seg-ent in a 1isor or sliding -anner, +ith graft -aterial placed along the lateral aspect to pro1ide the proper contour of the ridge. Seg-ental osteoto-y in the partially edentulous patientA 3hat are so-e indications for a seg-ental osteoto-y in a partially edentulous patientB C,uc/er p 24(-2D 'upraeruption of teeth and bony segments into an edentulous area, repositioning of abutments, loss of teeth in one arch producing esthetic and functional concerns. !a"illary osteoto-y +ith ad1ance-entA ,he natural tendency is for the -a"illa to resorb to a s-aller, -ore posterior position +hile the -andible beco-es -ore pro-inent. $f after thorough e1aluation, the patient is deter-ined to ha1e a deficiency in the anteroposterior di-ension, the -a"illa can be positioned for+ard a predeter-ined distance and stabili@ed +ith transosseous +ires and an interpositional grafts. Miscellaneous& 1. *erve relocationA $n the case of se1ere atrophy of -andibular al1eolar bone, the -ental neuro1ascular bundle -ay occupy a position at the superior aspect of the -andible. 3hat co-plication does this present for the denture patientB C,uc/er 298D Trauma from the denture on the superior portion of the alveolar ridge in this area can produce pain. 2hen the discomfort is persistent, relocation of the mental neurovascular bundle may be re1uired. (. Sinus graftingA Place-ent of endosteal i-plants in the posterior edentulous -a"illa often re=uires grafting of the floor of the -a"illary sinus. Also co--only referred to as a sinus lift procedure, 3hat -aterials -ay be usedB C,uc/er p 291D $lloplastic material, allogenic bone, autogenous bone, or a combination of these materials. 2. +issue sclerosingA As an alternati1e to other procedures for treating the hyper-obile al1eolar ridge, in<ection of a sclerosing agent Csodiu- -orrhuateD can produce fibrosis in soft hyperplastic tissue. CSee 6es<ardins, 0.P., J P0 S,H;, 6;G, 1'5.H 2(A41'-428D

$bstracts 18-,,1a% Peterson' -% .% Principles of )ral and Ma illofacial Surgery% !ol% II% .% #% -ippincott /o%' Philadelphia' 1001% 2arb' (% Prosthodontic !ie" of +raditional and /ontemporary Preprosthetic Surgery% /hapter 31' pp% 1,01-11,1% PurposeA ,he ob<ecti1e of the chapter +as to re1ie+ the then current rele1ance of traditional and ne+er preprosthetic surgical techni=ues and their i-pact on prosthetic treat-ent. $t +as stated that the role of preprosthetic surgery should be considered as ad<uncti1e. 6iscussionA $t +as stated that the traditional pre-ise of preprosthetic surgery is based on t+o ob<ecti1esA the pro1ision of a co-fortable tissue foundation to support the dentureA and 1ariations on a the-e of enlarge-ent of denture bearing areas C6%AsD in an atte-pt to pro1ide denture stability. $t +as e-phasi@ed that surgical results -ay be unpredictable, that the ad1erse process leading to residual ridge reduction is not eli-inated and that the results often turn out to be interi- in nature. Se1eral age-related changes of the denture supporting tissues +ere addressedH one of +hich +as the increased dependence of the -andible on the subperiosteal ple"us of 1asculature due to collagenosis of the inferior al1eolar artery. ,his change has i-plications for surgical procedures that in1ol1e reflection of the periosteu- leading to so-e necrosis and resorption of bone. ,able .(-1 outlines ?&onditions re=uiring preprosthetic inter1ention?. $t co1ers se1eral toothrelated issues such as cysts, se=uestra, unerupted teeth and retained roots. $t also addresses se1eral bone-related entities such as tori, e"ostoses, tuberosities, ridge undercuts, painful and pronounced -ylohyoid ridges, and the sharp spiny ridge. Soft tissue related topics include hyperplastic, fibrous cord-li/e and hyper-obile ridge conditions. ,he table outlines the associated features and proposed treat-ent of the abo1e conditions. ,he section on bone related topics reflects a conser1ati1e approach to perfor-ing surgery and suggests the use of per-anent soft liners andEor the -odification of prosthetic design +hen possible. ,he re-ainder of the chapter addresses t+o topicsA enlarge-ent of the 6%As using 1estibuloplasty and ridge aug-entation procedures, and the osseointegrated i-plant techni=ues that are replacing the need for -uch of traditional preprosthetic surgery. ,he final section concerned the peri-i-plant -ucosa. ,he opinion of the author +as that the presence of attached tissue is beneficial but not re=uired. &onse=uently the deepening of labial or buccal 1estibules around the i-plants and the grafting of attached tissues is not al+ays prescribes and can cause the sulci to gape and entrap food particles leading to infla--ation and disco-fort. 18-,,1b% Peterson' -% .% Principles of )ral and Ma illofacial Surgery% !ol% II% .% #% -ippincott /o%' Philadelphia' 1001% 2arb' (% $mbulatory Preprosthetic Reconstructive Surgery% /hapter 34' pp% 11,4-1141% :actors Affecting %ony and Soft ,issue &hanges

*eneral factors- syste-ic bone disease, nutritional abnor-alities, Local factors-si@e, shape of al1eolus before and after e"traction, effects of ill fitting prosthesis

*oals of Preprosthetic surgeryA &reate broad ridge for-, ade=uate fi"ed tissue o1er denture bearing area, ade=uate 1estibular depth for prosthesis e"tension, proper interarch relations, ade=uate integrity Cto pre1ent -andible fractureD, Protection of the neuro1ascular bundle, ade=uate palatal 1ault for-, proper posterior tuberosity notching, to facilitate i-plant place-ent +here desired Patient ;1aluationA 6etailed intraoral e"a-, re1ie+ -edical history, physical e1aluation +hen appropriate, discussion of patients goals and e"pectations for long ter- function and esthetics

%ony ;1aluationA ;1aluate height, +idth and general shape of al1eolar ridge and underlying basal bone, locate undercuts, neuro1ascular bundle and conca1ities Soft tissue e1aluationA Lesions to biopsy, attached -ucosa, flabby tissue, frenuattach-ents ,reat-ent PlanningA &onsider aug-entation of 6%AH consider age of patient, ris/s of sedation, patient +illingness to undergo preprosthetic procedures, health status of patient.

!andibular %ony Procedures

,otal Al1eolar ridge aug-entation +ith HA-the -ost +idely used surgical procedure for correcting -andibular al1eolar deficiency !odified ,echni=ues for HA grafting-sub-ucosal dissection through the standard 1ertical incisions to release periosteu- o1erlying the site to be aug-ented Aug-entation for $solated &ontour Proble-s-anterior -andibular conca1ities and /nifeli/e ridges can be easily corrected +ith locali@ed HA or allogenic bone grafting

&hoice of !aterials

HA bloc/s-car1able, easily placed does not disperse, 6ehiscence, ulcers o1er the graft -aterial, chronic pain HA particles-contained in collagen tubes or stoc/ings

Ger1e 0elocation-either at the ti-e of i-plant place-ent or during aug-entation !a"illary Aug-entation

Standard techni=ue-#ertical incisions, connecting subperiosteal tunneling, in<ections of HA !odified ,echni=ue-sub-ucosal dissection si-ilar to that in a sub-ucosal 1estibuloplasty co-bined +ith a subperiosteal tunnel on the facial aspect of the -a"illa ,uberoplasty-to increase the depth of the ha-ular notch by posteriorly repositioning the pterygoid plates and ha-ulus &o-plications of Al1eolar 0idge Aug-entation-loss of contain-ent or particle -igration, he-ato-a for-ation, infection, -obile i-plant -aterial, neurosensory disturbances

Soft tissue surgery for -andibular ridge e"tension

,ranspositional flap 1estibuloplasty C lip s+itchDLo+ering of -outh floor$solated 1estibuloplasties-s-all s/in grafts

!a"illary Soft tissue ;"tension Procedures

Sub-ucous #estibuloplasty !a"illary s/in grafting 1estibuloplasty

&o-bining Soft tissue -odification +ith aug-entation techni=ues

!andible-ad1antagesA single surgical procedure Ctherefore one sedationD, i-pro1ed access for place-ent of the graft -aterial, decreased postsurgical displace-ent of the -aterial, -aintenance or increase in the e"isting sulcular depth, no splint needed, less -ental ner1e da-age. !a"illa-ad1antages are the sa-e.

18-,,1c% Peterson' -% .% Principles of )ral and Ma illofacial Surgery% !ol% II% .% #% -ippincott /o%' Philadelphia' 1001%Stoelinga' P%.%5% Preprosthetic Reconstructive Surgery% /h% 34' pp% 1160-11,7%

18-,,1a% /hase' 8%/% and -as9in' 8%M% Procedure to Improve the $lveolar Soft +issue% #asic Preprosthetic Surgery' !ol% II' )ral Surgery' /hapter 0' /%!% Mosby /o%' St% -ouis' 108:' pp% 104;437% PurposeA ,he purpose of this chapter is to discuss the procedures in1ol1ed in i-pro1ing the bony al1eolar ridge. !ethods I !aterialsA !ethods are general prosthetic and surgical guidelines in order to i-pro1e the al1eolar architecture. 6iscussionA Surgical planning prior to denture construction is essential. Proper assess-ent, history ta/ing and radiographs are the /ey for future success. #arious techni=ues +ill be co1ered in order to -a"i-i@e the prosthetic success. 1. ;"cess Al1eolar %one. Al1eoloplasty 7 Shaping of the al1eolar process Al1eolecto-y 7 re-o1al of the al1eolar process (. Single ,ooth ;"traction $f a single tooth is e"tracted, a conser1ati1e al1eoloplasty should be co-pleted in order to i-pro1e future denture fabrication. ,he site should be s-ooth and rounded for either 0P6 or :P6 treat-ent in the future.

2. ;"traction of ;ntire Arch &onser1ati1e re-o1al of the teeth and the bone has sho+n better long-ter- success. %oth Schlosser and Lis/o+s/i sho+ed this in their studies fro- the 1'.0>s. ,hey sho+ed that e"cessi1e soft tissue and bone re-o1al should be a1oided. $n this case a s-ooth al1eolar surface de1oid of undercuts and pro-inences should be achie1ed. ,he -ore bone that re-ains post e"traction is i-portant for the long-ter- resorption patterns of the patient. .. Preirradiation Patient All unsal1ageable teeth should be e"tracted prior to radiation therapy. $n -ay of these cases an al1eoloecto-y procedure is co-pleted in order to pre1ent any osteoradionecrosis during radiotherapy. Long ter- planning is para-ount in these cases. 9. $ntercortical Al1eoloplasty ,he re-o1al of interseptal bone allo+s for the re-o1al of undercuts but preser1es all stress-bearing cotices. ,his is an ideal procedure for i--ediate dentures. $t is -ore successful in the anterior region bur can be utili@ed successfully in the posterior region. 4. Al1eolar 0epositioning 3hen al1eolar bone is o1er basal bone, there is better retention and stability of the denture. $n these cases al1eolar repositioning is achie1ed either 1ia an steoto-y or Le:ort techni=ue. 5. ,uberosity 0eduction 0e-o1al of both soft tissue and al1eolar bone +ill allo+ for an increase in posterior 1ertical clearance. 8. !ylohyoid 0idge 0eduction 0eduction of the -ylohyoid ridge is necessary +hen a /nife-edge e"ists, a pro-inent undercut e"ists or chronic irratation is occurring. *reat care -ust be ta/en in this area because of thin -ucosa and the -ylohyoid -uscle attach-ent. $f the -ylohyoid -uscle is to be repositioned proper tonicity -ust be -aintained in order to -a"i-i@e denture retention. '. 0e-o1al of ;"ostoses 0e-o1al of all tori is indicated +hen the tori +ill interfere +ith the construction of the prosthesis. Proper surgical techni=ue is i-portant to -ini-i@e trau-a to the soft tissue and re-aining bone. 10. ;"cessi1e Al1eolar 0esorption

;"cessi1e ridge resorption is a perple"ing and its causes are not co-pletely /no+n. $n -any cases a graft ta/en either fro- a rib, illac or fe-ur aug-ents the se1erely resorbed ridge. Additional surgeries are also necessary to ensure proper 1estibule depth for denture construction. 6a1is did sho+ that a 45J resorption rate occurred at 2 years. Sliding osteoto-ies also allo+ for al1eolar bone increase. ;ither a 1ertical techni=ue or hori@ontal techni=ue can be utili@ed in order to gain the necessary height. ne disad1antage to using this techni=ue is the increased possibility of future iatrogenic fracture. Synthetic graft -aterials ha1e been proposed and +ere used in the past, the long-ter- studies ha1e sho+n the -aterial either resorbed or +as displaced. 11. #estibuloplasty ,his techni=ue has beco-e popular and -a/es no atte-pt to cure the ridge but it atte-pts to e"pose -ore of the ridge. ,he assu-ption is -ade, +hen using this techni=ue, that bony resorption +ill ha1e an end and better support of the denture +ill distribute the forces of -astication -ore e1enly and slo+ the resorpti1e process. Flti-ately, i-plants ha1e been used to co-pensate for deficient al1eolar bone and ha1e no+ beco-e the best choice. 0efer to &hapter 11 or the abstract of the abo1e te"t for the i-plant -ethods and techni=ues to co-pensate for deficient bone height. 18-,,1b% /hase' 8%/% and -as9in' 8%M% Procedure to Improve the $lveolar Soft +issue% #asic Preprosthetic Surgery' !ol% II' )ral Surgery' /hapter 1,' p%430-461% /%!% Mosby /o%' St% -ouis' 108:% ,he follo+ing preprosthetic tissue conditions -ay e"ist A 1. Hypermobile tissue& ,his proble- can occur after e"traction fro- al1eolar bone resorption under an ill-fitting denture, fro- e"cessi1e force placed on the al1eolar process +hen natural teeth in one arch occlude against a denture or fro- e"cessi1e sub-ucosa that de1eloped during an e"tended period of periodontitis and acco-panying bone resorption. Treatment< ;"cision of the e"cessi1e tissue and in<ection of (-.-l of a sclerosing solution C 9J sodiu- -orrhuateD to produce fibrosis in the soft hyperplastic tissue. Go atte-pt to li-it s+elling is -ade as s+elling is an indication of infla--ation and fibrosis is related to the degree of infla--ation. ,he patient should not +ear hisEher dentures for .-4 +ee/s follo+ing the in<ection of a sclerosing agent. $f a second in<ection is re=uired it -ay be done. (. <pulis fissuratum& ,his is the -ost co--on soft tissue abnor-ality and is caused by denture irritation resulting fro- ill fitting dentures, faulty denture construction or allergic reaction to the denture -aterial. Treatment< $f a single fold is present si-ple e"cision +ill suffice. $f -ultiple folds e"ist each fold should be indi1idually e"cised.

2. Fibrous hyperplasia of the ma illary tuberosity A ,his entity is often due to the presence of a relati1ely dense a1ascular connecti1e tissue. Fse of radiograph +ill aid in distinguishing this entity fro- bony enlarge-ent. Treatment< Surgical incision +ith re-o1al of e"cessi1e fibrous connecti1e tissue and reduce thic/ness of the flaps. .. Fibrous hyperplasia of the mandibular retromolar pad& ,his is a result of the retro-olar pad being in contact +ith the -a"illary tuberosity or -olar teeth during <a+ closure. Treatment< sa-e as for fibrous hyperplasia of the -a"illary tuberosity. 9. Hyperplastic palatal mucosa& :ibrous enlarge-ent of the -ucosa in the -a"illa in the region of the first, second and third -olars. Treatment< Sub-ucosal dissection is one +ay to treat this but it is a difficult procedure and -ay lead to sloughing due to interference of the palatal blood supply. 4. Papillary palatal hyperplasia& &aused by poor oral hygiene and ill fitting dentures +orn day and night. andida albicans has been i-plicated as an etiologic agent. Treatment< ;lectrosurgery +ith a large +ire loop. 0eline the denture +ith a tissue conditioner or soft cold curing acrylic and then reline denture at +ee/ly inter1als until healing occurs. 5. Hypertrophic labial frenum& $deally a hypertrophic frenu- should be corrected at ti-e of e"traction. Treatment< A frenecto-yC either a )-plasty or #-8 plastyD is the treat-ent of choice. 8. High buccal frenum attachments& n occasion frenal attach-ents are found in the pre-olar region. ,hey should only be treated if they interfere +ith ade=uate e"tension of the denture flange. Treatment< ,ransplantation by a u shaped incision or a dia-ond shaped incision. '. $bnormal lingual frenum& An/yloglossia. Treatment< :renecto-yH ede-a is controlled +ith parenteral steroids. He-ato-a for-ation is pre1ented by not suturing the +ound too pre1ent. 10. Scar contractures& ,he result of -ultiple frena or contracted scars fro- pre1ious surgeries. So-eti-es +ide scar bands can result in deficient denture-bearing -ucosa o1er the ridge or at the depth of the sulcus.

Treatment< $ncise the frenu- and e"cise the scar tissue follo+ed by supraperiosteal dissection of the -ucosa and connecti1e tissue fro- the al1eolar process in the sa-e -anner as used for 1estibuloplasty. Palatal -ucosa or a partial thic/ness s/in graft can be used to co1er the periosteu-. Allo+ 4 +ee/s before final denture fabrication. 18-,,4a% Peterson' -%.% /ontemporary )ral and Ma illofacial Surgery% 1nd ed%' Mosby =ear-boo9 Inc%' St% -ouis' 1004% +uc9er' M%R% #asic Preprosthetic Surgery% /hapter 14' pp% 40:-443% PurposeA the ob<ecti1e of preprosthetic surgery is to create proper supporting structures for subse=uent place-ent of prosthetic appliances. 6iscussionA ,he best denture support has the follo+ing characteristicsA 1. Go e1idence of intraoral or e"traoral pathologic conditions. (. Proper <a+ relationship in the anteroposterior, trans1erse, and 1ertical di-ensions. 2. Al1eolar processes as large as possible and proper configuration. ,he ideal shape of the al1eolar process is a broad F-shape ridge +ith the 1ertical co-ponents as parallel as possible. .. Go bony or soft tissue protuberances or undercuts. 9. Ade=uate 1estibular depth. 4. Ade=uate attached /eratini@ed -ucosa in the pri-ary denture-bearing areas. 5. Ade=uate for- and tissue co1erage for possible i-plant place-ent. $rregularities of the al1eolar ridges either at the ti-e of tooth e"traction or after a period of initial healing re=uire contouring before final prosthesis is fabricated. 6igital co-pression in -any cases after e"t. can pro1ide ade=uate contours of the underlying bone. ,he si-plest forof al1eoloplasty is the co-pression of the lateral +alls of the e"t. soc/et. An alternati1e is an intraseptal al1eoloplasty or 6ean>s techni=ue. Hard tissue recontouringA !a"illary tuberosity reduction is best perfor-ed +ith a full thic/ness flap to allo+ ade=uate access. A surgical te-plate -ay be used as a reduction guide and blanching indicates inade=uate reduction. $f sinus perforation has occurred, antibiotics CP&GD 510 days +ith a decongestant is reco--ended. %uccal e"ostosis and e"cessi1e undercuts are -ore co--on in the -a"illa and a 1ertical releasing incisions are indicated. Lateral and -idline palatal e"ostosis should be re-o1ed if large and interfere +ith speech or beco-e ulcerated frofre=uent palatal trau-a. ,he origin of -a"illary tori are unclear. ,hey are found in (0J of fe-ales and t+ice the pre1alence in -ales. 0e-o1al of tori once e"posed is perfor-ed +ith fissure bur and handpiece. n the -andibular a trough is created bet+een the ridge and the tori, and the use of a s-all osteoto-e is utili@ed in the final re-o1al. A -ore co--on area interfering +ith the -andibular denture is the -ylohyoid ridge area. 3hen the ridge is sharp it -ay produce pain fro- the denture. A full thic/ness flap is indicated and use of a rotary instru-ent or bone file can be used to re-o1e the sharp pro-inence of the -ylohyoid ridge. As the -andible begins to resorp, the area of the attach-ent of the genioglossus -uscle beco-es pro-inent and the tubercle -ay act as a shelf for the denture, but usually re=uires reduction. Soft tissue abnor-alities include soft tissue -a"illary tuberosity reduction, retro-olar pad

reduction or recontour CrareD, unsupported hyper-obile tissue, infla--atory fibrous hyperplasia and papillary hyperplasia. Labial frenecto-y -ay be indicated due to disco-fort, ulceration and lac/ of peripheral seal that +ill dislodge the denture. )-plasty for a narro+ band, locali@ed 1estibuloplasty for a +ide band and locali@ed 1estibuloplasty +ith secondary epitheliali@ation. $--ediate dentures in1ol1es the -ost conser1ati1e tech as possible. A clear acrylic guide +ill indicate any gross irregularities. 1erdenture abut-ents should be e1aluated as to the poc/et depth and should not e"ceed 2--. $f e"cessi1e, a gingi1ecto-y -ay be perfor-ed, or an apically positioned flap. A split thic/ness flap -ay be used +hen less than 2-- of attached gingi1a +ould be left if a gingi1ecto-y +ere perfor-ed or +hen there is less than 2-- of attached gingi1a before surgery. 18-,,4b% Peterson' -%.% /ontemporary )ral and Ma illofacial Surgery% 1nd ed%' Mosby =ear-boo9 Inc%' St% -ouis' 1004% +uc9er M%R%' $dvanced Preprosthetic Surgery% /hapter 13 pp44:-468% PurposeA ,e"tboo/ chapter to discuss procedures for ad1anced preprosthetic surgery. 6iscussionA &o1ered are the follo+ing proceduresA $. $$. $$$. $#. :actors affecting bone resorption- *eneral and syste-ic factors *oals of ad1anced preprosthetic surgery- +hen basic preprosthetic surgery -ay not be ade=uate, ad1anced procedures -ay be re=uired to satisfy the functional, esthetic, and co-fort re=uire-ents of the patient. Patient e1aluationA should include- bony e1aluation, soft tissue e1aluation and treat-ent planning !andibular aug-entation A. %. &. 6. $. Superior border aug-entation $nferior border aug-entation Pedicle or interpositional grafts Hydro"yapatite aug-entation of the -andible

!a"illary Aug-entation A. %. &. 6. ;. nlay bone grafting $nterpositional bone grafts !a"illary hydro"yapatite aug-entation Sinus lift ,uberoplasty

$.

Soft tissue surgery for ridge e"tension of the -andible A. ,ranspositional flap 1estibuloplasty Clip s+itchD %. #estibule and floor of the -outh e"tension procedures &. 0elocation of the -ental ner1e

$.

Soft tissue surgery for -a"illary 1estibule e"tension

A. Sub-ucosal 1estibuloplasty %. !a"illary s/in grafting 1estibuloplasty $. &orrection of abnor-al ridge relationships A. Seg-ental al1eolar surgery in the partially edentulous patient %. &orrection of s/eletal abnor-alities in the totally edentulous patient &onclusionA 3hen se1ere bony atrophy e"ists, treat-ent -ust be directed at correction of the bony deficiency and alteration of the associated soft tissue. 3hen ade=uate bony tissue re-ains, i-pro1e-ent of the denture-bearing area -ay be acco-plished either by directly treating the bony deficiency or by co-pensating for it +ith soft tissue surgery. ,he patientKs health status -ust be carefully e1aluated, along +ith the ability and +illingness to undergo these procedures including possible long periods +ithout dentures during healing phases. 18-,,3a% Fonseca' R%.% and 8avis' 5%H% Reconstructive Preprosthetic )ral and Ma illofacial Surgery% 5%#% Saunders /o%' Philadelphia' 1086% Scott' R%F% and )lson' R%$% Minor Preprosthetic Procedures% /h 3' pp% 61-68% $. Al1eoloplasty along +ith tooth re-o1al.

&restal bone should be spared. Alloplastic -aterials into e"traction sites are being e1aluated, but no long ter- studies are a1ailable. C1'84D ,oday C(000D no -aterial stops bone loss due to soc/et healing.

$$. Secondary al1eolar recontouring.

,he ridge does not need to be perfectly s-ooth.

$$$. 0edundant crestal tissue re-o1al.

An elliptical incision is -ade to allo+ access to the -ass of -obile tissue. ,he incision is # shaped +ith the opening of the # at the -ucosal surface.

$#. !a"illary tuberosity reduction.

3hen the tuberosity i-pinges on the inter-a"illary space. ne centi-eter is needed bet+een arches. $-pinge-ent on the space -ay be produced by soft tissue and osseous hypertrophy in the -andibular retro-olar area. Pendulous tissue inhibits denture stability. ;"cess tissue is re-o1ed by a +edge resection. %oth lateral and 1ertical di-ensions are re-o1ed by this procedure. %one re-o1al can be done at this ti-e. Go proble- should occur +hen the -a"illary sinus is entered if the soft tissue is closed and no antral infection is present.

At least (-2 -- of 1ertical sulcus height should re-ain distal to the tuberosity to produce denture stability.

#. Ha-ular notch deepening C,uberoplastyD

,he notch -ay be 1ery shallo+ in patients +ith decreased 1ertical height of the tuberosity. Poor retention due to loss of seal and resistance to displace-ent can result. An incision 9 -- posterior to the notch e"tending the depth of the 1estibule and -edially ( c- lateral to the -idline is -ade. A cur1ed ostoeto-e in the notch is -aleted until the pterygoid plates fracture free and are displaced posteriorly. Healing by secondary epitheliali@ation.

#$. Abnor-al labial or buccal frenu- correction.

6ia-ond incision - t+o he-ostats, one superior, one inferior, blade follo+s the he-ostats, suture fro- the superior. ) plasty - cut superior to inferior in the -iddle of the frenu-, t+o triangles are transposed. Locali@ed 1estibuloplasty - se-ilunar incision at the <unction of the free and attached -ucosa. Heal by secondary epitheliali@ation.

#$$. Abnor-al lingual frenu- Ctongue tie, an/ylglossiaD correction.

Pre1ents stability and retention of a denture. &ut frenu- close to the tongue to pre1ent cutting the sub-andibular gland orifice. &ut posteriorly until tongue tip reaches the palate +ith the -outh open.

#$$$. ;pulis fissuratu- re-o1al.

%enefit fro- so-e treat-ent before surgery - tissue conditioner, lea1e denture out. Spontaneous resorption -ay re=uire -any +ee/s then the re-aining is re-o1ed. &ryosurgery is -ore conduci1e to ner1e regeneration than e"cision. Secondary epitheliali@ation.

$L. !andibular ClingualD torus re-o1al.

;dentulous - incision on crest. 6entate - en1elope-type incision including the gingi1al -argin a1oid 1ertical incisions as they -ay interfere +ith blood supply to the thin -ucosa. &ut a groo1e 1-( -- deep and -aleting +ill free the torus.

L. Palatal torus re-o1al.

$ncision o1er the -iddle +ith releasing incisions at the anterior and posterior that fro- a ?8? at each end.

&hisel techni=ue or burr.

L$. Palatal papillary hyperplasia re-o1al.

Fn/no+n etiology. $nitial conser1ati1e therapy - reline, eli-inate candidal infection. &urette lea1ing periosteu-, electrocauteri@ation, -ucoabrasion +ith an acrylic burr, cryosurgery. Secondary epitheliali@ation.

18-,,3b% Fonseca' R%.% and 8avis' 5%H% Reconstructive Preprosthetic )ral and Ma illofacial Surgery% 5%#% Saunders /o%' Philadelphia' 1086% 8avis' 5%H% Surgical Management of Soft +issue Problems% /h :' pp 60-116% ,he chapter discusses procedures to opti-i@e the soft tissues of edentulous area. !andibular archA #estibuloplasty +ith s/in grafting and lo+ering of the floor of the -outh. ,he techni=ue describes placing a s/in graft o1er the edentulous ridge and securing it +ith either sutures or a surgical stent. ,he stent is preferred as it is easier to adapt the tissue to the contours. $n suturing to lo+er the floor of the -outh the sutures -ay circu-na1igate the -andible and use the bone as a sling to hold do+n the 1estibule. Lo+ering the floor of the -outh. ,he 1estibule after reflection -ay be sutured do+n and ligated to a button e"traorally. !andibular anterior 1estibuloplasty +ith free -ucosal graft. A thin -ucosal graft is ele1ated and the periosteu- is incised at the base of the pedicle beyond the pro<ected depth of the 1estibule. ,he reflected periosteu- is again incised <ust abo1e the depth of the dissection of the perostieu-. ,his pro1ides a purchase layer to +hich -ucosa can be sutured. ,he -ucosa is then sutured to the inferior periosteal -argin. ,he superior periosteal -argin, no+ on the lip surface, is sutured as closely as possible of the -ucosa to the lip. !ylohyoid area 1estibuloplasty. $ncise on the top of the ridge and reflect the flap to the lingual beneath the periosteu-, thus e"posing the fibers of the -ylohyoid. 6etach the -uscle fro- the ridge and reduce the ridge +ith a bur. ;"tend the length of the denture +ith co-pound to adapt the tissue to the periosteu-. After 5 days the stent -ay be re-o1ed. !a"illary archA !a"illary 1estibuloplasty +ith s/in grafting. :abricate a stent to be retained by either a scre+, circu-nasal floor +iring, al1eolar pins, or a perial1eolar +ire. %alloon the 1estibular -ucosa +ith local anesthetic and begin incision at the ha-ular notch. At the <unction of the free and attached -ucosa. 6isect the soft tissue lea1ing the periosteu- intact and suture the -ucosa to the periosteu- as far superiorly as possible.Support +ith the stent. Sub-ucous 1estibuloplasty. $ncise at the -idline and disect a layer abo1e the periosteu- and belo+ the -ucosa. Separate the soft tissue lateral to the periosteu- and -o1e it superior in the 1estibule and secure it to the periosteu-.

Secondary epitheliali@ation. ,he is effecti1e in dealing +ith the epulis fissuratu-. $f ridge aug-entation is done it is to be done prior to this procedure. An incision is -ade at the crest of the ridge and the <unction of the free and attached -ucosa. ,he incision is begun posteriorly +here the 1estibuloplasty is indicated and proceeds anteriorly. ,he -ucosal-sub-ucosal flap is ele1ated, lea1ing only the periosteu- re-aining on the bone. ,he edge of the -ucosa is sutured as far superiorly as possible and the denture should not contact the +ound until so-e epitheliali@ation has ta/en place. $f a stent +as used it should re-ain for 1 +ee/. Palatal -ucosal grafts. Palatal -ucosa grafts can be used as an alternati1e to s/in grafts. ,he graft is har1ested fro- the palate and the fat and sali1ary glands re-o1ed and placed +ith a stent as pre1iously described. He disad1antages are li-ited tissue and prolonged donor site -orbidity. S/in lined poc/ets. A syste- of denture retention +as described by 3allenius and +all in 1'44. ,o i-pro1e retention of the -andibular denture, s/in lined pouches pro<ect beneath the anterior portion of the -andible and accept prongs that pro<ect fro- the denture. Si-ilarly, s/in lined tubes are created in the -a"illa. ,hese procedures are rarely used. !a"illary buccal inlay 1estibuloplasty. $s the -ost contro1ersial of -a"illary 1estibuloplasty procedures. After flap reflection an i-pression is -ade in co-pound +ith a surgical stent. ,his is duplicated +ith alginate by the prosthodontist. A ne+ surgical stent is -ade +ith autopoly-eri@ing resin and placed at surgery and left for 1 +ee/. 6enture construction can begin 4 to 8 +ee/s after surgery. ,he patient is to +ear a stent or denture constantly for 1( to 18 -onths. 18-,,3c% Fonseca' R%.% and 8avis' 5%H% Reconstructive Preprosthetic )ral and Ma illofacial Surgery% 5%#% Saunders /o%' Philadelphia 1086% Fonseca' R%.% )sseous Reconstruction of <dentulous #one -oss% /hapter 6' pp 117-16:% PurposeA ,o discuss osseous -anage-ent of physiologic edentulous bone loss C;%LD, using onlay bone grafting and interpositional bone grafting techni=ues in the -a"illa and the -andible. 6iscussionA 3hen the ;%L is se1ere enough to -a/e con1entional prosthetics i-possible, surgical inter1ention +ith 1arious -ethods of osseous bone grafting -ay be indicated. A thorough preoperati1e e1aluation includesA detailed -edical history, a history for possible contributing reasons for ;%L, radiographs Cpanore", lateral ceph, and occlusal radiograph for the -andibleD, articulated study casts, and clinical e"a- of the hard and soft tissues. ,he patient should also be infor-ed that the -a<ority of treat-ent plans in1ol1e t+o -a<or surgical procedures +ith t+o general anesthetics. Maxillary& $ndications for the onlay bone grafting techni=ue includeA se1ere -a"illary al1eolar atrophy, flat palatal 1ault for-, and -ild to -oderate anteroposterior ridge discrepancy that does not include the tuberosities. ,he autologous onlay rib grafts are -ore successful than allogenic bone grafts. ,he surgical procedure generally in1ol1es despining of a rib Cby a thoracic surgeonD, notching it to (50 degrees for contouring to a cast of the -a"illa C-ade of acrylic and gas sterili@edD. A second rib is also split +ith the -arro+ re-o1ed +ith a curette, and the cortical bone layers are particulated stored in nor-al saline or 693. $deally the preparation of the recipient site and donor bone +ill be done si-ultaneously. nce the rib strut is tried and fitted intraorally, then stainless steel +ires are used to secure the bone graft follo+ed by particulate bone and -arro+. $ndications for interpositional bone grafting include an edentulous, bony deficient -a"illa

+ith ade1uate palatal 1ault, and also &lass $$$ relationships usually secondary to ;%L of the -a"illa and -andible. ,here is less rapid resorption than an onlay bone graft. ,he surgical procedure generally in1ol1es do+nfracturing of the -a"illa CLe:ort $D osteoto-y, then either using allogenic or autologous bone graft Cor a co-posite of bothD, shaped to for- a ?du-bbell? for stability of the seg-ent, +ithout danger of slipping. ,his graft is held into place +ith transosseous +ires. ,hree -a"illary osteoto-y cases +ere also presented. Mandibular: A co--on pattern of -andibular ;%L in1ol1es a generali@ed loss of al1eolar bone, fairly unifor- around the arch. ,he genial tubercles and -ylohyoid ridges -ay re-ain ele1ated, +ith the rest of the ridge flat. ,here -ay be a ?negati1e ridge? if the -uscle attach-ents are -ore ele1ated than the denture bearing region. $ndications for the total onlay grafts include a -andible +ith generali@ed atrophy that -easures 9 to 4 -- at the -ental fora-en region. ,he rib is despined si-ilar to the -a"illary onlay rib grafting techni=ue -entioned abo1e, and shaped to fit an acrylic cast of the -andible. 3hen placed in the -outh, the rib should be placed slightly lingual to reproduce the position of the resorbed al1eolar bone, and +ired either transosseous or circu--andibular. An alternate -ethod is also described by splitting t+o ribs and placing four sections of the ribs +ith each inner surface ne"t to an outer surface. ,his total onlay graft techni=ue sho+s rapid 1ertical resorption, studies sho+ that after t+o years, one half to t+o thirds of the aug-entation -ay be in1ol1ed. ,his is true for both rib and iliac bone grafts. &linically, the healed ridge has a broader base and better contour for denture stability. ,he procedure re=uires a 1estibuloplasty after healing of the bone graft. An interposed bone graft aug-entation, -aybe done to o1erco-e the -ain disad1antage of the subperiosteal onlay bone grafting, ie. rapid resorption. ,here are basic three techni=ues in1ol1ed +ith the interposed graft aug-entationA 1. ,he sliding?1isor? osteoto-y +here a sagittal osteoto-y is perfor-ed and -o1ed 1ertically. ,he -ain dra+bac/ is potential da-age to the ner1e (. ,he ?sand+ich techni=ue? +here a hori@ontal osteoto-y is perfor-ed bet+een the t+o -ental fora-ina, and thus only the anterior frag-ent is lifted. ,his techni=ue is li-ited by the anato-y of se1ere atrophic -andibles. 2. A co-bination of the ?1isor and sand+ich techni=ues?, this is called a -odified ?1isor? osteoto-y. Here the osteoto-y posterior to the -ental fora-ina is in a 1ertical plane, changing to .9 degrees in the anterior region. ,here needs to be at least 8 -- of bone height as -easured in the -ental ner1e region. ,he -ain dra+bac/s of these procedures is the relati1ely high incidence of sensory disturbances of the chin and lo+er lip. Another 1ariation of -andibular osteoto-y is called ?three piece aug-entation?, in +hich the osteoto-y is done in three frag-ents, this greatly reduces the chances of da-aging the neuro1ascular bundle.

,he article also -entions another procedure +ith the sa-e indications as the -odified ?1isor? techni=ue, this is called an anterior osteoto-y +ith posterior onlay graft. ,hree -andibular osteoto-y cases +ere also presented. 8onor Site SurgeryA Surgical techni=ue +as described for har1esting bone fro- both anterior and -edial iliac crest, as +ell as resection of the rib in the region of ribs 9-5.