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Goals of Pre-prosthetic Surgery
Objectives of Pre-Prosthetic Surgery
Classification of Pre-Prosthetic
Description of clinical Pre-Prosthetic
According to the glossary of Prosthodontic
terms (GPT-8). The surgical procedures designed
to facilitate fabrication of a prosthesis or to
improve the prognosis of prosthodontic care.
According to Bruce Donoff, preprosthetic
surgery is that part of the oral and
maxillofacial surgery designed to establish
the best hard and soft tissue bases for
Goals of Preprosthetic Surgery:
To modify the oral environment to render it free of
Provide a broad and flat ridge form with vertical
height (minimum 5 mm)
Provide a firm resilient mucosal covering
Provide ideal interarch distance (minimum 16-18 mm)
Provide post tuberosity (hamular) notching to
enhance the posterior border seal and resistance of the
denture to anterior dislodging forces.
∆ Elimination of disease
∆ Conservation of oral structures
∆ Provide residual tissue to
withstand masticatory forces
∆ Maintain function
The best denture support has the following 11
1.No evidence of intraoral or extraoral pathologic
2. Proper interarch jaw relationship in the
anteroposterior, transverse, and vertical
3. Alveolar processes that are as large as
possible and of the proper configuration (The
ideal shape of the alveolar process is a broad U-
shaped ridge, with the vertical components as
parallel as possible
4. No bony or soft tissue protuberances or
5. Adequate palatal vault form
6. Proper posterior tuberosity notching
7. Adequate attached keratinized mucosa in the
primary denture bearing area
8. Adequate vestibular depth for prosthesis
9. Added strength where mandibular fracture
10. Protection of the neurovascular bundle
11. Adequate bony support and attached soft
tissue covering to facilitate implant placement
Contemporary Oral and Maxillofacial Surgery,
Sixth Edition- Hupp, James R
Assessment of existing tooth; if any tooth is
Amount and contour of the remaining bone.
Quality of soft tissue overlying the primary
denture bearing area.
Location of muscle attachment.
Jaw relationship and presence of soft tissue
or bony pathologic condition.
Physical and mental health status.
Examination of inter-arch relationships in proper vertical
dimension often reveals lack of adequate space for
In this case, bony and fibrous tissue excess in tuberosity
area must be reduced to provide adequate space for partial
Radiograph demonstrating atrophic mandibular and
maxillary alveolar ridges. Pneumatization of maxillary sinus is
Cephalometric radiograph illustrating cross-sectional
anatomy of the anterior mandible (patient is overclosed,
giving the relative appearance of a Class III jaw relationship
Palpation reveals hypermobile tissue that will not
provide adequate base in denture-bearing area.
Classification of Pre-Prosthetic Surgical
Procedures (Modified From Peterson and
I) Basic preprosthetic surgical procedures
A. Removal of Teeth
• Partially erupted
• Root stumps
B. Bony Recontouring of alveolar ridges:
•Simple alveoloplasty associated with
removal of multiple teeth.
•Maxillary tuberosity reduction
•Buccal exostosis and excessive undercuts
•Lateral palatal exostosis
•Mylohyoid ridge reduction
•Genial tubercle reduction
C. Tori Removal:
D. Soft Tissue Procedures:
•Maxillary tuberosity reduction (soft tissue)
•Mandibular retromolar pad reduction
•Lateral palatal soft tissue excess
•Unsupported hypermobile tissue
•Inflammatory fibrous hyperplasia
•Inflammatory papillary hyperplasia of the palate.
II) Advanced pre-prosthetic surgical
•Superior Border Augmentation
•Inferior Border Augmentation
•Pedicled or Interpositional Grafts.
•Hydroxyapatite Augmentation of the mandible
•Onlay Bone Grafting
•Interpositional Bone Grafts
•Maxillary Hydroxyapatite Augmentation
C)Soft tissue surgery for ridge extension of the
•Transpositional flap vestibuloplasty (Lip Switch)
•Vestibule and floor of the mouth extension
•Relocation of the mental nerve
D)Soft tissue surgery for maxillary ridge extension
•Maxillary skin grafting vestibuloplasty
Surgical procedure which intends to recontour the
Alveolotomy : Partial removal of alveolar bone
Alveolectomy : Complete removal of alveolar bone.
Alveoloplasty : Shaping of the alveolar bone.
Indications : 1.Presence of sharp bony margins
2.Knife edge ridge
3. Sever undercuts
4 . Maxillary protrusion alveoloplasty.
5. Reduction of Mylohyoid ridge and lingual
6. Elimination of labial mandibular undercut
Types of alveoloplasty :
1. Simple alveoloplasty
2. Labial and buccal cortical alveoloplasty
3.Dean’s interseptal or Thoma’s
4. Obwegeser technique
1) Alveolar compression1) Alveolar compression
∆ Easiest & quickest method
∆ Involves compression of cortical plates with fingers
∆ Reduction in socket width
2) Simple Alveoloplasty2) Simple Alveoloplasty
∆ Reduction of
∆ Extraction of
∆ Single tooth extraction
∆ Multiple teeth extraction
∆ Over erupted teeth
3) Labial & Buccal Cortical Alveoloplasty3) Labial & Buccal Cortical Alveoloplasty
Simple alveoloplasty eliminates buccal irregularities and
undercut areas by removing labiocortical bone
A. Clinical appearance of
maxillary ridge after removal of
B, Minimal flap reflection for
C, Proper alveolar
ridge form free of irregularities and
bony undercuts after recontouring
4) Dean’s Intraseptal /Intercortical/Crush4) Dean’s Intraseptal /Intercortical/Crush
In case of extreme protrusion both cortical
Plates are fractured inwards.
Maxillary Tuberosity reduction
1. Reduced interridge distance
2. To prevent displacement of denture.
3. To reduce severe bilateral undercuts.
Incision placed on the lateral side rather on the crest.
In case of thick fibrous tissue - excised.
Care should be taken not to perforate into the sinus.
A, Incision extended
along crest of
alveolar ridge distally
to superior extent of
exposure to all areas
of bony excess.
C, Rongeur used to
Buccal exostoses and excessive
Commoner in the maxilla than the mandible.
Although large areas of bony exostosis
generally require removal.
Small undercut areas are often best treated by
filling with either autogenous or allogenic bone
material or with an alloplastic material such as
A, Gross irregularities of
buccal aspect of alveolar ridge. After
tooth removal, incision is
completed over crest of alveolar ridge.
(Vertical-releasing incision in
cuspid area is demonstrated.)
B, Exposure and removal of buccal
exostosis with rongeur.
C, Soft tissue closure using continuous
Lateral palatal exostosis
Lateral palatal exostosis present a problem in
denture construction because of the undercut
created by the exostosis and the narrowing of the
palatal vault. Occasionally they are large enough
that the mucosa covering the area becomes
PRECAUTION : Avoid damage to the blood
vessels as they leave the palatine foramen and
NO SURGICAL SPLINT OR PACK REQUIRED
Removal of palatal bony exostosis. A, Small palatal exostosis that interferes with
proper denture construction in this area. B, Crestal incision and mucoperiosteal
flap reflection to expose palatal exostosis. C, Use of bone file to remove bony
excess. D, Soft tissue closure.
Mylohyoid ridge reduction:
The mylohyoid ridge is one of the more common
areas interfering with proper denture construction.
In addition to the actual bony ridge, which easily
damages thin covering of mucosa, the muscular
attachment to this area often is responsible for
dislodging the denture when this ridge is extremely
sharp, denture pressure may produce significant
pain in this area.
Mylohyoid ridge reduction. A, Cross-sectional view of posterior aspect of
mandible, showing concave contour of the superior aspect of
ridge from resorption. Mylohyoid ridge and external oblique lines form
highest portions of ridge. (This can generally best be treated by alloplastic
augmentation of mandible but, in rare cases, may also require mylohyoid
ridge reduction.) B, Crestal incision and exposure of lingual aspect of
mandible for removal of sharp bone in mylohyoid ridge area. Rongeur or bur
in rotating handpiece can be used to remove bone. C, Bone file used to
complete recontouring of mylohyoid ridge
Genial tubercles are neither exostoses nor tori but are
often prominent following advanced alveolar ridge
resorption in the anterior area of the mandible.
They are covered by thin tissue which will not bear the
pressure of a denture flange located in this area.
Complete removal of the genial tubercles should be avoided
as lack of attachment of the genioglossus and geniohyoid
could lead to impaired tongue function That portion of the
genioglossus muscle which is attached in the area is usually
Removal of Tori
Grouped under exostosis
No pathological significance.
Misdiagnosed as tumors.
No signs and symptoms
Problem with Tori:
1.Denture failure because of rocking
2. Lead to ulceration, infection when impinged by prosthesis
3. Constant irritation may lead to malignant change.
4. Difficult in eating and speaking
Can occur in mandible - Torus mandibularis
Technique of removal of maxillary Tori
Maxillary Tori : Seen in the midline of the palate with
Maxillary Tori should not be excised enmass, to prevent
entry into the sinus.
Incisions : 1.Single midline incision.
2. Double ended ‘Y’ incision.
3. Elliptical incision.
Stent can be prepared prior to surgery to prevent
hematoma and to support the flap.
Removal of palatal torus.
A, Typical appearance of maxillary torus
B, Mucoperiosteal flaps retracted with silk sutures to improve
access to all areas of torus. Removal of palatal torus.
D and E, Sectioning of torus using fissure bur. F, Small osteotome used to remove sections of torus.
G and H, Large bone bur used to produce the final desired contour. I, Soft tissue closure
Technique of removal of Mandibular Tori
Mandibular Tori :
Lingual premolar area.
Bulbous or nodular
Placed on the crest for edentulous and on gingival
margin for dentulous. Should not be placed on the
Post operative hematoma formation
After block, local anesthetic is
administered; ballooning of thin
mucoperiosteum over area of tori can
be accomplished by placing bevel of
local anesthetic needle against torus
and injecting local anesthetic
Use of bone bur
and bone file to
Maxillary tuberosity reduction (Soft Tissue)
The amount of soft tissue available for reduction can often be
determine by evaluating a presurgical panoramic
– If a radiograph is not necessary to determine soft tissue
thickness, this depth can be measured with a sharp probe
after local anesthesia is obtained at the time of surgery.
A, Elliptical incision around soft tissue to be
excised in tuberosity area.
B, Soft tissue area excised with initial
Undermining of buccal and palatal flaps to provide adequate
soft tissue contour and tension-free closure.
An initial elliptical incision is
made over the tuberosity .
The medial and lateral margins
of the excision must be thinned
out to remove excess soft tissue
A tension free closure made
with Interrupted or continuous
Rarely is it required to perform
this procedure. LA infiltration in the
area requiring excision is sufficient.
An elliptical incision is made,
excising the greatest area of tissue
in the posterior mandibular area.
Slight trimming of the margins is
carried out with the majority of
tissue reduction on the facial aspect
Excess removal of tissue in the submucosal
area of the lingual flap may result in damage
to the lingual nerve and artery.
The tissue is approximated with
interrupted or continuous sutures.
•Lateral palatal soft tissue excess
LA infiltrated in the greater palatine area and anterior
to the soft tissue mass is sufficient.
With a sharp scalpel blade in a tangential manner, the
superficial layers of mucosa and underlying fibrous
tissue can be removed to the extent necessary to
eliminate undercuts in soft tissue bulk.
excision of excess
Following removal of this tissue, a surgical
splint lined with a tissue conditioner (5-7
days) can be inserted to aid healing.
•Unsupported hypermobile tissue.
Excessive hypermobile tissue on the alveolar ridge is
generally the result of resorption of the underlying bone, ill-
fitting dentures or both.
Two parallel full thickness incisions are made on the
buccal and lingual aspects of the tissue to be excised.
A periosteal elevator is used to remove the excessive
soft tissue from the underlying bone
A possible complication of this procedure is the
obliteration of the buccal vestibule as a result of tissue
undermining necessary to obtain tissue closure.
•Inflammatory fibrous hyperplasia
In the early stages, when fibrosis is minimal
nonsurgical treatment with a denture in combination
with a soft liner is frequently sufficient for reduction
or elimination of this tissue.
When this condition has existed for some time,
significant fibrosis occurs and then this will not
respond to non surgical treatment and excision is the
treatment of choice.
If tissue mass minimal- Electrosurgical technique
If tissue mass extensive- Simple excision.
Indication : 1. Frenum is close to crest of the ridge
2. Irritated by the flange of the ridge.
3. Diastema in the midline (in dentulous)
Method of Frenectomy : 1. Diamond type
2. Z plasty
3. V-Y plasty
The V-Y type of incision can be used for lengthening localized
Broad frenum in premolar molar area can be treated by taking
semilunar incision at the mucogingival junction and a
supraperiosteal dissection is done.
The superior edge of the incision is sutured at the depth of the
vestibule to the periosteum and the rest of the raw area is allowed
to heal by secondary epithelialization
Use of prefabricated stent is necessary
Excessive bulk of the tissue at the depth of the vestibule
•The tip of the tongue is controlled by placing a traction suture.
•The lingual frenum is released by incising the attachment of the
fibrous connective tissue at the base of the tongue in a transverse
A hemostat can be placed across the frenal attachment at the
base of the tongue for approximately 3 minutes providing
vasoconstiction and a nearlly bloodless field during the surgical
Care must be taken not to excise the blood vessels at the inferior
aspect of the tongue and floor of the mouth region and to the
submandibular ducts openings – during incising and suturing.
•Superior border augmentation
•When severe resorption of the mandible results in
inadequate height and contour and potential risk of
•Neurosensory disturbances from the location of the mental
•High morbidity associated with removal of ribs.
•Need for soft tissue surgery at a later date.
•Necessity of the patient to forego denture wearing to allow 6-
8 months of healing after surgery.
•Possibility of significant postoperative resorption of the graft.
•Inferior border augmentation.
•Atrophy of the alveolar ridge area.(less than 5-8mm)
•Prevention and management of fractures of the atrophic
•Does not address abnormalities of the denture bearing
areas such as
increased inter – arch distance
superior border irregularities
exposed position of the mental nerve which result in
These disadvantages combined with the morbidity of rib
harvesting make this a seldom used technique.
•Pedicled or Inter positional grafts
A pedicle graft is designed to minimize resorption after
healing by maintaining a vascular supply to the augmented
bony area through an attached soft tissue pedicle.
A horizontal osteotomy is performed , splitting the
residual mandible and bone is grafted into the osteotomy
Significant mandibular atrophy with absence of adequate
bone in the denture bearing area and a bucco lingual width
of the mandible of approximately 15mm.
Mainly used for augmentation of anterior mandible.
•Because of the viability of the repositioned segment, and the
immediate vestibuloplasty performed at the time of surgery,
denture construction can usually take place within 3-5
Visor osteotomy consists of central splitting of
mandible in buccolingual dimension.
The lingual segment is raised along a greater
length of the mandibular body and free chips of
bone are added to the lateral aspect of the raised
To increase the height of the mandibular
ridge for denture support.
A, Intraoperative view of the chin region, with the
B,The visor osteotomy is performed.
C-D, The bone fragment is mobilized and fixed in
Modified Visor Osteotomy
The combination of the ‘visor’ and ‘sandwich’ techniques was designed to over come the
disadvantages in bone grafting.
A modification of the visor osteotomy has been recommended for patients with at least 8 mm of
bone height as measured at mental nerve region.
Frost and colleagues used a sagittal cut in the body region of the mandible, but changed to
horizontal cut anteriorly.
Nerve parasthesia and dysaethesia
Need for hospitalization
Donor site morbidity
Inability to wear dentures for 3-5 months post surgery.
•Onlay bone grafting
•Severe resorption of the maxillary alveolar resulting in the
absence of a clinical alveolar ridge and loss of adequate palatal vault
•Development of increased height and form of the alveolar ridge
and the palatal vault area.
•The anteroposterior position of the maxilla can be corrected.
•Need for a secondary donor site.
•Extensive post operative resorption.
•Postoperative secondary soft tissue procedures.
•Delay in wearing dentures for 6-8 months
Inter positional bone grafts
•In a bony deficient maxilla where there is adequate form to the palatal
vault but insufficient ridge height, particularly in the zygomatic buttress
and posterior tuberosity areas.
•Stable and predictable results by changing maxillary position in the
vertical, anteroposterior and transverse directions.
•May eliminate the need for secondary soft tissue procedures.
•Need to harvest bone from the iliac bone crest
•Possible secondary soft tissue surgery
The lateral maxillary and lateral nasal walls and pterygoid maxillary
suture area separated using surgical saws and osteotome and the maxilla
is down fractured.
Bone grafts obtained from the iliac crest are shaped and wired in place
in the lateral maxilllary areas.
This technique effectively increases the ridge height from
the lateral maxillary area to the crest of the ridge.
•Maxillary hydroxyapatite augmentation
Hydroxyapatite grafting has become the primary method of
•A single midline incision is usually sufficient. When
inadequate, bilateral vertical maxillary incisions in the
canine promolar area can be used.
•Subperiosteal tunnels are created over the crest of the
alveolar ridge and preloaded syringes are inserted into the
most posterior aspect of these tunnels.
•HA particles are injected and molded to the desired height
and contour, and the incision are closed with a horizontal
The tuberosity – hamular notch area prevents denture
displacement and aids the peripheral seal of the maxillary
Tuberosplasty is performed through a transverse
incision, approximately 5mm posterior to the hamular area
exposing the pterygomaxillary junction.
A curved osteotome inserted into the depth of the notch
fractures and displaces the pterygoid plate area from the
posterior aspect of the maxilla.
Exposed bone in the tuberosity pterygoid plate area is
allowed to heal by secondary intention.
Brisk heamorrhage may be encountered when
the pterygoid plates are fractured.
Ridge extension procedure
Vestibuloplasty :Vestibuloplasty has become most popular
method for improving denture-retention and stabilizing
capabilities of alveolar ridge. The technique makes no
attempt to ‘cure’ alveolar atrophy; rather it attempts to
expose and make available for denture construction that
bone which is still present. Procedure to increase the depth
of sulcus. Done when sufficient height of the ridge is
Aim : To uncover existing basal bone of the jaws by
the repositioning the overlying mucosa, muscle
1. Obliteration of the sulcus with high muscle
2. Extensive mandibular bone atrophy with
mental nerve emerging at the crest
•Transpositional flap vestibuloplasty (Lip
A lingually based flap vestibuloplasty was first described by
In this procedure, a mucosal flap pedicled from the alveolar
ridge is elevated from the underlying tissue and sutured to
the depth of the vestibule.
The inner portion of the lip is allowed to heal by secondary
intention / epithelialization.
•Adequate anterior mandibular height (min. 15mm)
•Inadequate facial vestibular depth from mucosal and
muscular attachments in the anterior mandible.
•Presence of an adequate vestibular depth on the lingual
aspect of the mandible.
A, Incision is made in the labial mucosa, and a thin mucosal flap is dissected from
underlying tissue. B, The flap of the labial mucosa is sutured to the depth of the
C, Modification of technique by incising periosteum at crest of alveolar ridge and
suturing free periosteal edge to denuded area of labial mucosa
. D, The mucosal flap is then sutured over denuded bone to the periosteal junction at
the depth of the vestibule
•Provides adequate results in many cases.
•And generally does not require hospitalization
•Donor site surgery or
•Prolonged periods without a dentures.
•Unpredictable relapse to vestibular depth
•Scarring in the depth of the vestibule
•Occasional problems with adaptation of the peripheral
flange area of the denture to the depth of the vestibule
•Accelerated bone resorption of the alveolar crest.
Vestibule and Floor of the mouth extension procedure
Labial vestibuloplasty, floor-of-mouth lowering procedure, and skin
grafting (i.e., Obwegeser’s technique). A, Preoperative muscle and
soft tissue attachments near crest of remaining mandible. B, A crestal
incision is made. Buccal and lingual flaps are created by a supraperiosteal
dissection. C, Sutures are passed under the inferior border of the
mandible tethering the labial and lingual flaps near the inferior border of
D, Graft held over the supraperiosteal dissection with a stent
stabilized with circum-mandibular wires.
E, Postoperative view of newly created vestibular depth and
Vestibuloplasty, floor of the mouth lowering, and palatal
soft tissue grafting.
A, Preoperative photograph showing lack of facial
and lingual vestibular depth and absent keratinized tissue
adjacent to implant abutments.
B, Improved vestibular depth with sound attached tissue over
the alveolar ridge
Relocation of the mental nerve
In cases of severe atrophy of the alveolar bone and
superior aspect of underlying basal bone, the mental
neurovascular bundle may occupy a position at the superior
aspect of the mandible resulting in pain as a result of trauma
from the denture on the superior portion of the remaining
•The cortical bone and underlying medullary bone can be
removed with curettes and the NV bundle relocated to a
more inferior position.
•After the bone is exposed inferior to the mental foramen,
a groove is cut with a bur through the lateral cortex inferior
to the mental foramen area.
•Resorbable material, such as Gel foam, can be packed
around the bundle to help stabilize it at the inferior portion
of the newly created groove.
•Soft tissue closure with interrupted or continuous suturing
technique completes the procedure.
Procedure of choice for correction of soft tissue attachment
on or near the crest of the alveolar ridge of the maxilla,
particularly useful when maxillary alveolar ridge resorption has
occurred but the residual bony maxilla is adequate for proper
Underlying mucosal tissue is either excised or
repositioned, allowing for direct apposition of the labial
vestibular mucosa to the periosteum of the remaining maxilla.
To provide adequate vestibular depth without producing an
abnormal appearance of the upper lip, adequate mucosal
length must be available in this area.
An anterior vertical incision is used to create a submucosal tunnel
Excision of submucosal soft tissue layer.
Splint in place holding mucosa against periosteum at depth of vestibule
until healing occurs
•This technique provides a predictable
increase in vestibular depth and attachment of
mucosa over the denture bearing area.
•A properly relined denture can be worn
immediately after the surgery or after removal
of the splint.
•Impressions for final denture relining or
construction can be completed 2-3 weeks after
It is always hoped that the results of Preprosthetic surgery
are acceptable both surgically and prosthodontically.
In these instances, a team approach is needed with the
surgeon and prosthodontist serving as equal members of the
The various procedures which are described for
preprosthetic surgery may differ in each patient depending on
the overall evaulation of the patient (i.e. systemic and oral
conditions). Thus the final outcome may depend largely on an
accurate diagnosis, treatment plans and evaluation of patient
in discussion with the oral surgeries..
Contemporary Oral and Maxillofacial Surgery, Sixth
Edition- Hupp, James R
Syllabus of Complete Dentures., C. M. Heartwell, 4th
Boucher – Prosthodontic treatment for edentulous
Sheldon Winkler – Essentials of complete denture
Peterson – Contemporary oral and maxillofacial