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Definition

 Surgical procedures designed to facilitate


the fabrication of a prosthesis or to
improve the prognosis of prosthodontic
care .

Glossary of prosthodontics 1988


Aims of preprosthetic surgery

 To conserve oral structures.


 To provide optimum ridge(height ,width & contour )
 To provide adequate soft tissue support .
 Eliminating pre existing bony &soft tissue deformities .
 Correction of maxillary and mandibular ridge relationship .
 Relocation of frenal / muscle attachments.
Denture base areas of concern

 Maxilla –
Maxillary alveolar ridge,
labial & buccal vestibular area
& palatal vault .
Frenal / muscle attachments,
tuberosity area

 Mandible –
Mandibular alveolar ridge ,
vestibule , retromolar area ,
mylohyoid ridge and
frenal /muscle attachments .
PATHOPHYSIOLOGY OF
EDENTULOUS BONE LOSS-
•Alveolar atrophy-
It is the regression of teeth supporting
crescent shaped osseous part of upper and lower jaw,
after the loss of teeth.

CAUSES OF BONE LOSS-


•Physiologic
•Environmental
•Pathologic or
•Combination of above causes
 Metabolic factors – Osteoporosis
Osteomalacia
 Aging

 Trauma - Bone loss secondary to trauma (during extraction )


 Combination problems
 Periodontal disease – usually vertical bone loss
 Disuse atrophy
 Long term denture usage
Residual Ridge Resorption (RRR)

 ACCORDING TO GLOSSARY OF PROSTHODONTICS


TERMS (GPT 1999)

 Residual bone –
“That component of maxillary or mandibular bone, once
used to support the roots of the teeth that remains after
the teeth are lost.”
 Residual ridge – “The portion of the residual bone and
its soft tissue covering that remains after the removal of
teeth .’’

 Residual ridge resorption – “A term used for the


diminishing quantity and quality of the residual ridge
after teeth are removed.’’
 Rate of RRR depends on –
- Size ,shape ,density of alveolar ridge
-Cellular activity of osteoblast & osteoclast
-Duration , frequency & direction of any previous occlusal forces.
Atwood’s classification

Order – I II III IV V VI
Patterns of bone loss

 According to Tallgren study (1972) , most of bone loss occur


in the 1st year denture wearing & it is 10 times greater than
the loss seen in following years .
 Edentulous bone loss (EBL) is up to 1 mm/year ,with the
greatest loss occuring within 12-18 months after extractions .
 He also demonstrated that 4 times more bone loss in the
mandible , than in the maxilla
 MAXILLA -
The pattern of EBL results in upward & inward loss of structures .
In anterior maxilla –
less horizontal bone loss& posterior drift
of anterior crest .
In posterior maxilla –
Inward drift of posterior crest .
The width of maxilla is
Depth of palatal vault is
as resorption takes place .
 MANDIBLE –
Mandible resorbs downward & outwards causing flattening of the
ridge .
Resorption is faster in the labial & buccal parts of the ridge.

Patterns of bone loss


Features Of Ideal Denture Base Area
Bone support (U-shaped
ridge)

Adequate soft tissue

Proper alveolar maxillary &


mandibular relationship

Bony or soft tissue undercuts or


prominence

High muscle & frenal


attachment

Intraoral & extraoral


pathology
Examination

 Examination includes –

 Medical , surgical & dental history of the patient.


 Medical & dental clinical examination .
 Radiological examination & study of dental casts whenever indicated .
 Patients physical evaluation – vital signs & psychological status .
Continued

A good clinical examination will include assessment of both


hard & soft tissues & should include a good facial
esthetic examination & radiological examination .
Intraoral examination

 Examination of the alveolar ridges of the both maxillary &


mandibular should be carried along with the soft tissue
examination including posterior pharynx.
 Inspection & palpation should be carried out.
Continued

 Ridge form & contour


 Height & width of the ridge – whether flabby , mobile
tissue is present over the ridge
 Presence of gross irregularities in the ridge .
 Buccal & labial as well as lingual vestibules evaluation
for depth & type of soft tissue .
 Interarch relationship.
Supporting soft tissue examination

 The amount of keratinized tissue firmly attached to the underlying


bone .
 Inflammatory areas ,scars , ulcers, hyperplastic tissue due to ill-
fitting denture should be looked for .
 Tongue size & movement is also important for the stability of
denture .Hence needs evaluation.
Radiological Evaluation

 Radiological assessment includes –


 OPG
 Lateral cephalograms
 Dental CT scan ,CBCT ( in difficult cases )
Radiographs should be studied to detect
any Presence of bony pathological lesions ,
presence of impacted teeth , cysts, root pieces , bony trabecular pattern
Treatment planning

 Treatment option for an edentulous patient –


Complete Denture

Partial Denture - Cast partial


Interim
Classification

Advanced
Basic
surgery
procedures
procedures
Basic procedures

A. Bony surgeries
- Labial alvectomy
- Primary alveoplasty
- Secondary alveoplasty
- Excision of tori- mandibular ,palatal
- Reduction of genial tubercle
- Reducton of mylohyoid ridge
- Maxillary tuberosity reduction
- Removal of undecuts in maxilla & mandible
B. Soft tissue surgeries
- Removal of flabby soft tissue
- Frenectomy – Labial & lingual
- Excision of –
Epulis fissuratum
Palatal papillary hyperplasia
Denture hyperplasia
Advanced surgery procedures

 Alveolar ridge correction


 Alveolar ridge extension
 Alveolar ridge augmentation
Bony abnormalities

 Irregular alveolar ridge –


- Found at the time of extraction or after healing .
- Requires recontouring before final prosthetic construction .

Irregular alveolar
ridge post extraction
 Ridge undercuts –
- Small undercuts & undercut only in anterior labial do not require
any surgical intervention
- If undercuts present both anteriorly & posteriorly , reduction of
posterior undercuts is preferred
- bilateral undercuts need correction at least in one side
 Prominent mylohyoid ridge
- It damages the mucosa covering , the muscular attachment in this
area dislodges the denture .
- Requires surgical recontouring along with detachment of posterior
muscle insertion of mylohyoid muscle.
 Sharp , spiny residual ridges –
- Knife – edged ridges commonly occur in lower anterior region
- Leads to hypermobile tissue that gets trapped between the
denture & sharp bony ridge.
- 3 types of sharp ridges given by Meyer –
1. Saw- tooth
2. Razor - like
3. Discrete spiny projection
- Surgical treatment requires reshaping of bone & soft tissue & closure
of epithelium with sutures.
- If surgery is contraindicated –
 selective pressure impression technique
 permanent resilient liners
 Reduction of occlusal table with maximum denture base extension
 Tori & exostoses
- Relatively common , benign , slowly growing bony projections of
maxilla & mandible .
- When it occurs midline palate it is called as ‘torus palatinus’
- When it occurs in the lingual aspect of mandible called as ‘torus
manibularis’
- Covering mucosa is thin
 Maxillary tuberosity interfernce
- pendulous tuberosity with undercuts .
- unilaterally or bilterally
- Interfernce with interarch space , denture insertion & extension ,
mandibular movements .
Soft tissue abnormalities

 Hypertrophic frenum –
- Fibrous bands of tissue frequently attached to superficial muscle
attachments in maxilla & mandible
- -Hypertrophic lingual frenum interfering with denture extension &
denture stability .
 Hypertrophic maxillary labial frenum prevents
ideal extension of denture borders & peripheral
seal .
 Providing relief in the labial notch of the
denture will decrease the incidence of midline
fracture of denture.
 Treatment – frenectomies
Alveolar ridge correction

 A. Bony surgeries – ALVEOPLASTY


ALVEOECTOMY
Ridge extension procedures
 Includes – VESTIBULOPLASTIES

TYPES - For Maxilla


1. Submucosal vestibuloplasty
2. Secondary epithelization procedure
 Lipswitch technique
 Kazanjian’s technique
 Godwin’s modification
 Clark’s technique
 Obwegeser’s modification
 Lingual vestibuloplasty
3. Tissue / alloplastic grafts vestibuloplasty
For mandible

1. submucosal vestibuloplasty
2. Secondary epithelization procedure –
 Trauner’s technique
 Caldwell’s technique
 Obegser’s technique
3. Tissue/ alloplastic grafts vestibuloplasty
Ridge augmentation procedures

A. Mandibular ridge


augmentation
1. Superior border augmentation
2. Inferior border augmentation
3. Interpositional or sandwitch bone grafts
4. Visor osteotomy
5. Onlay grafting
6. Pedicled augmentation
7. Ridge split technique
B. Maxillary augmentation
1. Onlay bone grafting –autogenous / allogenic grafts
2. onlay grafting of alloplastic material
3. Interpositional or sandwitch grafts
.

C. Augmentation in
combination with
orthognathic surgery –
1. Mandibular osteotomy procedure
2. Maxillary osteotomy procedure
3. Combination procedure
D. Distraction osteogenesis –
Vertical
anterioposterior vector ( recent)
SURGICAL
INTERVENTIONS
ALVEOLOPLASTY

Refers to surgical recontouring of the alveolar process.

Alveoloplasty maintainence of bone and soft tissue

Better Denture Support

Simple
(Conservative)

Intraseptal
Simple Alveoloplasty

Removal and smoothing of bone margins


Interseptal Alveoloplasty
Dean’s alveoloplasty
Clinical Presentation of Dean’s alveoloplasty
Obwegeser’s Modification:

•Obwegeser in 1966 suggested further


modification of Dean’s technique for cases
of extreme premaxillary protrusion. He
fractured both the labial and palatal
cortices
ALVEOLECTOMY

 Surgical Removal or trimming of the alveolar


process.

 Post-Extraction presence of sharp bony ridges


are trimmed with a ronguer and smoothened
by bonefile.
Reduction Of Genial Tubercles

Crestal incision from lower canine to canine


region.

Flap elevation (full thickness mucoperiosteal


flap)

Excision of muscle attachment

Osteoplasty
(flame shaped bur or using a bone file)
Reduction Of Mylohyoid Ridge
Crestal incision with oblique release incision in posterior
ridge region

Mucoperioseteal flap reflection on lingual side

Dissection of mylohyoid muscle

Reduction of mylohyoid ridge

Closure of the soft tissue flap


Excision of Tori

 Torus is the exostosis/overgrowth of the cortical/corticocancellous


bone which is localized to a particular area, usually benign,
asymptomatic and slow growing.
 Origin is unknown

 INDICATIONS
• Deep bony undercuts
• Ulcerations/ Traumatization/ hyperkeratinization of mucosa
• Interference in function
Maxillary
Tori
Surgical Technique
Possible Complications
 Intraoperative :
1) Bleeding- Injury to greater palatine vessels.
2) Fracture of palatal shelf
3) Oronasal/ oroantral perforation

 Postoperative :
1) Hematoma formation
2) Sloughing or Necrosis of palatal mucosa
3) Gaping/ Nonhealing wound
4) Oronasal/ oroantral fistula
Mandibular
Tori
Possible Complications

 Intraoperative :
1) Injury to the submandibular salivary gland structures
2) Excessive bleeding
3) Laceration of the mylohyoid muscle
4) Tearing of the flap

 Postoperative :
1) Life threatening hemorrhage in the floor of the mouth
2) Airway obstruction due to infection
Maxillary Tuberosity And
Exostosis removal
Enlarged tuberosities due to bony overgrowth interfere
with denture construction.

AIM: To remove bony/ soft tissue irregularities


To create adequate inter-arch space for proper
construction of prosthesis in the posterior area.
Surgical technique
Frenectomy

 Frenal Attachment :is a thin band of fibrous tissue and


few muscle fibers covered by mucuous membrane.

 Indications :
1) High frenal attachments
2) Fibrous bands attached near the alveolar crest which
often displace the dentures during function.
Techniques
Maxillary Labial Frenectomy
Z-Plasty

Technique :
1) 2 releasing incisions creating a Z shape precede
undermining of the flap.
2) The two flaps are eventually undermined and rotated to
close the initial vertical incision horizontally.
Lingual Frenectomy

 Attachment : crest of alveolar ridge and connected to


the tongue below the tip or behind mandibular incisors.

 Aim : To correct speech, prior to denture construction ,


to improve tongue mobility
T
E
C
H
N
I
Q
U
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Complications

 Intraoperative ;
1) Injury to superior lingual vessels
2) Injury to Warthin’s duct/papilla

 Postoperative:
1) Hematoma in the floor of the mouth
2) Pain
3) Restricted tongue movements
Why Correction ?

Decreased
Inadequate Deepening of
retention and
vestibular depth vestibule considered
stability of denture
Vestibuloplasty
KAZANJIAN TECHNIQUE (1924)

Submucosal disection on inner aspect of lower lip to


Mucogingival junction

Supraperiosteal dissection

Removal of muscle and connective tissue attachments in


the vestibule

Fixed with sutures or stent


(RAW AREA left on the LIP)
CLARK’S TECHNIQUE

Incision is taken slightly labial to the crest

Mucosal flap on inner aspect of lip is undermined till


vermillion border

Edge of mobilized flap pushed into the vestibular depth

Suturing done
RAW AREA on the BONE
OBWEGESER’S TECHNIQUE

Similar to Clark’s technique except the area of alveolar


bone with periosteum is held in place with a split thickness
skin or mucosal graft.
Other Modifications

 Godwin’s Technique
 Lipswitch Technique
Lingual Vestibuloplasty

TRAUNER’S TECHNIQUE

Incision on the lingual side of the alveolar ridge bilaterally

Subperiosteal dissection to identify mylohyoid muscle

Muscle separated from bone

Fixation of the insical border of the muscle to a newly


derived depth

Suturing extraorally
Placement of skin graft or stent.
CALDWELL’S TECHNIQUE

Reflection of entire lingual mucoperiosteal flap

Mylohyoid ridge reduced along with genial tubercle

Mylohyoid muscle and fibers of genioglossus pushed


inferiorly

Rubber tubing placed in the vestibule

Sutures passed through with a skin graft


OBWEGESER’S TECHNIQUE

Incision on the alveolar ridge

Mucosal flap raised buccally and lingually

Mylohyoid muscle attachment and sup. Fibers of genioglossus


seperated

Edges of both flaps sutured to each other on inferior border of mandible

Skin graft over the ridge

Stent placed along with circummandibular wiring


Materials Used

 Autogenous bone grafts – iliac crest, rib grafts


 Allogenic bone grafts – freeze dried cadaver bone
 Alloplastic material – hydroxyapatite
 Metal mesh with autogenous corticocancellous bone
 Metal mesh with hydroxy apatite
Interpositional Augmentation

Horizontal osteotomy done by splitting in maxilla or mandible

Allogenic ,autogenous or hydroxyapatite graft is placed in gap

Delivery of prosthodontic appliance is after 3-5 months

Secondary vestibuloplasty procedures done if necessary


Advantages-
Lesser resorbtion rate
More predictable prognosis
Risk of nerve paraesthesia less
Can be accompanied with implants
Onlay Grafting

Indications
When the width of alveolar ridge inadequate
Oldest technique by Obwegeser

Submucosal tunnelling done via midline

Hydroxyapatite crystals mixed with blood or saline is loaded Into


syringe and injected into tunnel

Alternatively split thickness illiac or rib graft can also be placed in


one piece
Technique
high vestibular incision

mucoperiosteal flap reflected

Cortex perforated to induce bleeding ,clot formation and


ultimately neovascularization

Graft moulded over cortex

Barrier membrane placed to secure graft and to ensure


regeneration

Advantage
improved ridge height and width
uniform ridge is created
VISOR OSTEOTOMY

Indication

to achieve adequate hieght of mandibular ridge

Method

centrally split ridge buccolingually and position lingual section superiorly


Mould with graft material and secure with wiring
MODIFIED VISOR OSTEOTOMY
year
Method
vertical splitting of posterior segment of ridge

horizontal split done in anterior segment

Position the posterior lingual and anterior sections of ridge


superiorly

place graft in the gaps

closure done
Advantage

80% height maintained after 3-5 years

Disadvantage

1) Nerve paraesthesia
2) Donor site morbidity
3) Need for hospitalization
4) Inability to wear dentures for 3-5 months
Distraction Osteogenesis

 Wassmund,Rosenthal in 1927 - 1st osteodistraction


 Tension is created in the surrounding soft tissues leading
to distraction histogenesis
 Indication:
Conclusion
Refernces

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