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Pre-prosthetic
surgery
Contents:
Introduction
Definition
Goals of Pre-prosthetic Surgery
Objectives of Pre-Prosthetic Surgery
Classification...
Definition:
According to the glossary of Prosthodontic
terms (GPT-8). The surgical procedures designed
to facilitate fabri...
Goals of Preprosthetic Surgery:
To modify the oral environment to render it free of
disease
Provide a broad and flat rid...
Objectives:
∆ Elimination of disease
∆ Conservation of oral structures
∆ Provide residual tissue to
withstand masticatory ...
The best denture support has the following 11
characteristics:
1.No evidence of intraoral or extraoral pathologic
conditio...
4. No bony or soft tissue protuberances or
undercuts
5. Adequate palatal vault form
6. Proper posterior tuberosity notchin...
9. Added strength where mandibular fracture
may occur
10. Protection of the neurovascular bundle
11. Adequate bony support...
Examination:
Assessment of existing tooth; if any tooth is
remaining.
Amount and contour of the remaining bone.
Quality...
Examination of inter-arch relationships in proper vertical
dimension often reveals lack of adequate space for
prosthetic r...
Radiograph demonstrating atrophic mandibular and
maxillary alveolar ridges. Pneumatization of maxillary sinus is
demonstra...
Cephalometric radiograph illustrating cross-sectional
anatomy of the anterior mandible (patient is overclosed,
giving the ...
Palpation reveals hypermobile tissue that will not
provide adequate base in denture-bearing area.
Classification of Pre-Prosthetic Surgical
Procedures (Modified From Peterson and
Kruger)
I) Basic preprosthetic surgical p...
B. Bony Recontouring of alveolar ridges:
•Simple alveoloplasty associated with
removal of multiple teeth.
•Intraseptal alv...
C. Tori Removal:
•Maxillary tori
•Mandibular tori
D. Soft Tissue Procedures:
•Maxillary tuberosity reduction (soft tissue)...
II) Advanced pre-prosthetic surgical
procedures:
A)Mandibular Augmentation:
•Superior Border Augmentation
•Inferior Border...
C)Soft tissue surgery for ridge extension of the
mandible
•Transpositional flap vestibuloplasty (Lip Switch)
•Vestibule an...
Basic Pre-prosthetic
Surgeries
Alveoloplasty
Surgical procedure which intends to recontour the
alveolar ridge
Alveolotomy : Partial removal of alveolar b...
Types of alveoloplasty :
1. Simple alveoloplasty
2. Labial and buccal cortical alveoloplasty
3.Dean’s interseptal or Thoma...
1) Alveolar compression1) Alveolar compression
∆ Easiest & quickest method
∆ Involves compression of cortical plates with ...
2) Simple Alveoloplasty2) Simple Alveoloplasty
 Indications:
∆ Reduction of
buccal/labial plate
∆ Extraction of
single/mu...
3) Labial & Buccal Cortical Alveoloplasty3) Labial & Buccal Cortical Alveoloplasty
Simple alveoloplasty eliminates buccal ...
A. Clinical appearance of
maxillary ridge after removal of
teeth.
B, Minimal flap reflection for
recontouring.
C, Proper a...
4) Dean’s Intraseptal /Intercortical/Crush4) Dean’s Intraseptal /Intercortical/Crush
TechniqueTechnique
Principles:
a)Redu...
Obwegeser’s modification
In case of extreme protrusion both cortical
Plates are fractured inwards.
Maxillary Tuberosity reduction
Indications:
1. Reduced interridge distance
2. To prevent displacement of denture.
3. To re...
Bony tuberosity
reduction.
A, Incision extended
along crest of
alveolar ridge distally
to superior extent of
tuberosity ar...
Buccal exostoses and excessive
undercuts
Commoner in the maxilla than the mandible.
Although large areas of bony exostos...
A, Gross irregularities of
buccal aspect of alveolar ridge. After
tooth removal, incision is
completed over crest of alveo...
Lateral palatal exostosis
Lateral palatal exostosis present a problem in
denture construction because of the undercut
crea...
Removal of palatal bony exostosis. A, Small palatal exostosis that interferes with
proper denture construction in this are...
Mylohyoid ridge reduction:
The mylohyoid ridge is one of the more common
areas interfering with proper denture constructio...
Mylohyoid ridge reduction. A, Cross-sectional view of posterior aspect of
mandible, showing concave contour of the superio...
Genial tubercle
Genial tubercles are neither exostoses nor tori but are
often prominent following advanced alveolar ridge
...
Complete removal of the genial tubercles should be avoided
as lack of attachment of the genioglossus and geniohyoid
could ...
Removal of Tori
Grouped under exostosis
No pathological significance.
Misdiagnosed as tumors.
No signs and symptoms
Proble...
Technique of removal of maxillary Tori
Maxillary Tori : Seen in the midline of the palate with
different shapes.
1.Spindle...
Removal of palatal torus.
A, Typical appearance of maxillary torus
B, Mucoperiosteal flaps retracted with silk sutures to ...
D and E, Sectioning of torus using fissure bur. F, Small osteotome used to remove sections of torus.
G and H, Large bone b...
Technique of removal of Mandibular Tori
Mandibular Tori :
Lingual premolar area.
Bulbous or nodular
Incision:
Placed on th...
After block, local anesthetic is
administered; ballooning of thin
mucoperiosteum over area of tori can
be accomplished by ...
Use of bone bur
and bone file to
eliminate minor
irregularities.
Tissue closure
Soft tissue procedures
Maxillary tuberosity reduction (Soft Tissue)
The amount of soft tissue available for reduction can often be
determine by e...
A, Elliptical incision around soft tissue to be
excised in tuberosity area.
B, Soft tissue area excised with initial
incis...
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 thinne...
•Retromolar pad
reduction
Rarely is it required to perform
this procedure. LA infiltration in the
area requiring excision ...
Excess removal of tissue in the submucosal
area of the lingual flap may result in damage
to the lingual nerve and artery.
...
•Lateral palatal soft tissue excess
LA infiltrated in the greater palatine area and anterior
to the soft tissue mass is su...
Following removal of this tissue, a surgical
splint lined with a tissue conditioner (5-7
days) can be inserted to aid heal...
•Unsupported hypermobile tissue.
Excessive hypermobile tissue on the alveolar ridge is
generally the result of resorption ...
A periosteal elevator is used to remove the excessive
soft tissue from the underlying bone
A possible complication of this...
•Inflammatory fibrous hyperplasia
In the early stages, when fibrosis is minimal
nonsurgical treatment with a denture in co...
Labial Frenectomy
Indication : 1. Frenum is close to crest of the ridge
2. Irritated by the flange of the ridge.
3. Diaste...
V-Y Technique
The V-Y type of incision can be used for lengthening localized
area.
Broad frenum in premolar molar area can...
•Lingual frenectomy
Technique
•The tip of the tongue is controlled by placing a traction suture.
•The lingual frenum is re...
Advanced Pre-prosthetic
Procedures
•Superior border augmentation
Indications
•When severe resorption of the mandible results in
inadequate height and contour...
•Inferior border augmentation.
Indications
•Atrophy of the alveolar ridge area.(less than 5-8mm)
•Prevention and managemen...
•Pedicled or Inter positional grafts
(Sandwich Technique)
A pedicle graft is designed to minimize resorption after
healing...
•Because of the viability of the repositioned segment, and the
immediate vestibuloplasty performed at the time of surgery,...
Visor osteotomy consists of central splitting of
mandible in buccolingual dimension.
The lingual segment is raised along...
A, Intraoperative view of the chin region, with the
incision line.
B,The visor osteotomy is performed.
C-D, The bone fragm...
Modified Visor Osteotomy
 The combination of the ‘visor’ and ‘sandwich’ techniques was designed to over come the
disadvan...
•Onlay bone grafting
Indications:
•Severe resorption of the maxillary alveolar resulting in the
absence of a clinical alve...
Inter positional bone grafts
Indications
•In a bony deficient maxilla where there is adequate form to the palatal
vault bu...
The lateral maxillary and lateral nasal walls and pterygoid maxillary
suture area separated using surgical saws and osteot...
•Maxillary hydroxyapatite augmentation
Hydroxyapatite grafting has become the primary method of
maxillary augmentation.
Pr...
•Tuberoplasty
The tuberosity – hamular notch area prevents denture
displacement and aids the peripheral seal of the maxill...
Ridge extension procedure
Vestibuloplasty :Vestibuloplasty has become most popular
method for improving denture-retention ...
Indication:
1. Obliteration of the sulcus with high muscle
attachment.
2. Extensive mandibular bone atrophy with
mental ne...
•Transpositional flap vestibuloplasty (Lip
switch)
A lingually based flap vestibuloplasty was first described by
Kazanjian...
A, Incision is made in the labial mucosa, and a thin mucosal flap is dissected from
underlying tissue. B, The flap of the ...
Advantages
•Provides adequate results in many cases.
•And generally does not require hospitalization
•Donor site surgery o...
Vestibule and Floor of the mouth extension procedure
Labial vestibuloplasty, floor-of-mouth lowering procedure, and skin
g...
D, Graft held over the supraperiosteal dissection with a stent
stabilized with circum-mandibular wires.
E, Postoperative v...
Vestibuloplasty, floor of the mouth lowering, and palatal
soft tissue grafting.
A, Preoperative photograph showing lack of...
Relocation of the mental nerve
In cases of severe atrophy of the alveolar bone and
superior aspect of underlying basal bon...
•The cortical bone and underlying medullary bone can be
removed with curettes and the NV bundle relocated to a
more inferi...
•Submucous vestibuloplasty
Procedure of choice for correction of soft tissue attachment
on or near the crest of the alveol...
An anterior vertical incision is used to create a submucosal tunnel
Excision of submucosal soft tissue layer.
Splint in pl...
Advantages
•This technique provides a predictable
increase in vestibular depth and attachment of
mucosa over the denture b...
Conclusion
It is always hoped that the results of Preprosthetic surgery
are acceptable both surgically and prosthodontical...
References
Contemporary Oral and Maxillofacial Surgery, Sixth
Edition- Hupp, James R
Syllabus of Complete Dentures., C. ...
Thank you…
Pre prosthetic surgeries
Pre prosthetic surgeries
Pre prosthetic surgeries
Pre prosthetic surgeries
Pre prosthetic surgeries
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Pre prosthetic surgeries
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Pre prosthetic surgeries

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surgical aspects prior proceeding to prosthetic replacements

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Pre prosthetic surgeries

  1. 1. Pre-prosthetic surgery
  2. 2. Contents: Introduction Definition Goals of Pre-prosthetic Surgery Objectives of Pre-Prosthetic Surgery Classification of Pre-Prosthetic Surgical Procedures Description of clinical Pre-Prosthetic Surgical Procedures Conclusion References
  3. 3. Definition: 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 prosthetic appliances
  4. 4. Goals of Preprosthetic Surgery: To modify the oral environment to render it free of disease 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.
  5. 5. Objectives: ∆ Elimination of disease ∆ Conservation of oral structures ∆ Provide residual tissue to withstand masticatory forces ∆ Maintain function ∆ Esthetics
  6. 6. The best denture support has the following 11 characteristics: 1.No evidence of intraoral or extraoral pathologic conditions 2. Proper interarch jaw relationship in the anteroposterior, transverse, and vertical dimensions 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
  7. 7. 4. No bony or soft tissue protuberances or undercuts 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 extension
  8. 8. 9. Added strength where mandibular fracture may occur 10. Protection of the neurovascular bundle 11. Adequate bony support and attached soft tissue covering to facilitate implant placement when necessary Contemporary Oral and Maxillofacial Surgery, Sixth Edition- Hupp, James R
  9. 9. Examination: Assessment of existing tooth; if any tooth is remaining. Amount and contour of the remaining bone. Quality of soft tissue overlying the primary denture bearing area. Vestibular depth. Location of muscle attachment. Jaw relationship and presence of soft tissue or bony pathologic condition. Patient’s age. Physical and mental health status. Financial constraint.
  10. 10. Examination of inter-arch relationships in proper vertical dimension often reveals lack of adequate space for prosthetic reconstruction. In this case, bony and fibrous tissue excess in tuberosity area must be reduced to provide adequate space for partial denture construction
  11. 11. Radiograph demonstrating atrophic mandibular and maxillary alveolar ridges. Pneumatization of maxillary sinus is demonstrated.
  12. 12. Cephalometric radiograph illustrating cross-sectional anatomy of the anterior mandible (patient is overclosed, giving the relative appearance of a Class III jaw relationship
  13. 13. Palpation reveals hypermobile tissue that will not provide adequate base in denture-bearing area.
  14. 14. Classification of Pre-Prosthetic Surgical Procedures (Modified From Peterson and Kruger) I) Basic preprosthetic surgical procedures A. Removal of Teeth • Erupted • Unerupted • Partially erupted • Root stumps • Cysts
  15. 15. B. Bony Recontouring of alveolar ridges: •Simple alveoloplasty associated with removal of multiple teeth. •Intraseptal alveoloplasty •Maxillary tuberosity reduction •Buccal exostosis and excessive undercuts •Lateral palatal exostosis •Mylohyoid ridge reduction •Genial tubercle reduction
  16. 16. C. Tori Removal: •Maxillary tori •Mandibular tori 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. •Labial frenectomy •Lingual frenectomy
  17. 17. II) Advanced pre-prosthetic surgical procedures: A)Mandibular Augmentation: •Superior Border Augmentation •Inferior Border Augmentation •Pedicled or Interpositional Grafts. •Hydroxyapatite Augmentation of the mandible B)Maxillary Augmentation •Onlay Bone Grafting •Interpositional Bone Grafts •Maxillary Hydroxyapatite Augmentation •Tuberoplasty
  18. 18. C)Soft tissue surgery for ridge extension of the mandible •Transpositional flap vestibuloplasty (Lip Switch) •Vestibule and floor of the mouth extension procedure •Relocation of the mental nerve D)Soft tissue surgery for maxillary ridge extension •Submucous vestibuloplasty •Maxillary skin grafting vestibuloplasty
  19. 19. Basic Pre-prosthetic Surgeries
  20. 20. Alveoloplasty Surgical procedure which intends to recontour the alveolar ridge 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 alveolar crest. 6. Elimination of labial mandibular undercut
  21. 21. Types of alveoloplasty : 1. Simple alveoloplasty 2. Labial and buccal cortical alveoloplasty 3.Dean’s interseptal or Thoma’s intracorticular 4. Obwegeser technique
  22. 22. 1) Alveolar compression1) Alveolar compression ∆ Easiest & quickest method ∆ Involves compression of cortical plates with fingers ∆ Reduction in socket width
  23. 23. 2) Simple Alveoloplasty2) Simple Alveoloplasty  Indications: ∆ Reduction of buccal/labial plate ∆ Extraction of single/multiple teeth  Technique: ∆ Single tooth extraction ∆ Multiple teeth extraction ∆ Over erupted teeth
  24. 24. 3) Labial & Buccal Cortical Alveoloplasty3) Labial & Buccal Cortical Alveoloplasty Simple alveoloplasty eliminates buccal irregularities and undercut areas by removing labiocortical bone
  25. 25. A. Clinical appearance of maxillary ridge after removal of teeth. B, Minimal flap reflection for recontouring. C, Proper alveolar ridge form free of irregularities and bony undercuts after recontouring
  26. 26. 4) Dean’s Intraseptal /Intercortical/Crush4) Dean’s Intraseptal /Intercortical/Crush TechniqueTechnique Principles: a)Reduction of labial/alveolar prominences b)Muscle attachments are undisturbed c)Intact periosteum d)Preserve cortical bone e)Less post-op resorption
  27. 27. Obwegeser’s modification In case of extreme protrusion both cortical Plates are fractured inwards.
  28. 28. Maxillary Tuberosity reduction Indications: 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.
  29. 29. Bony tuberosity reduction. A, Incision extended along crest of alveolar ridge distally to superior extent of tuberosity area. B, Elevated mucoperiosteal flap provides adequate exposure to all areas of bony excess. C, Rongeur used to eliminate bony excess. D, Tissue reapproximated with continuous suture technique
  30. 30. Buccal exostoses and excessive undercuts 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 Hydroxyapatite (HA).
  31. 31. 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 suture technique
  32. 32. 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 ulcerated. PRECAUTION : Avoid damage to the blood vessels as they leave the palatine foramen and extend forwards. NO SURGICAL SPLINT OR PACK REQUIRED
  33. 33. 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.
  34. 34. 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.
  35. 35. 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
  36. 36. Genial tubercle 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.
  37. 37. 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 left free.
  38. 38. 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
  39. 39. Technique of removal of maxillary Tori Maxillary Tori : Seen in the midline of the palate with different shapes. 1.Spindle shape 2. Nodular 3. Lobulated 4. Flat 5. Multiple 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.
  40. 40. 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.
  41. 41. 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
  42. 42. Technique of removal of Mandibular Tori Mandibular Tori : Lingual premolar area. Bulbous or nodular Incision: Placed on the crest for edentulous and on gingival margin for dentulous. Should not be placed on the Tori. Complications: Post operative hematoma formation Wound dehiscence.
  43. 43. 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 subperiosteally.
  44. 44. Use of bone bur and bone file to eliminate minor irregularities. Tissue closure
  45. 45. Soft tissue procedures
  46. 46. Maxillary tuberosity reduction (Soft Tissue) The amount of soft tissue available for reduction can often be determine by evaluating a presurgical panoramic radiograph – 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.
  47. 47. A, Elliptical incision around soft tissue to be excised in tuberosity area. B, Soft tissue area excised with initial incision.
  48. 48. Undermining of buccal and palatal flaps to provide adequate soft tissue contour and tension-free closure.
  49. 49. 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 sutures
  50. 50. •Retromolar pad reduction 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
  51. 51. 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.
  52. 52. •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. Tangential excision of excess soft tissue
  53. 53. Following removal of this tissue, a surgical splint lined with a tissue conditioner (5-7 days) can be inserted to aid healing.
  54. 54. •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.
  55. 55. 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.
  56. 56. •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.
  57. 57. Labial Frenectomy 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
  58. 58. V-Y Technique The V-Y type of incision can be used for lengthening localized area. 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 Disadvantage Excessive bulk of the tissue at the depth of the vestibule
  59. 59. •Lingual frenectomy Technique •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 fashion 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 procedure. 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.
  60. 60. Advanced Pre-prosthetic Procedures
  61. 61. •Superior border augmentation Indications •When severe resorption of the mandible results in inadequate height and contour and potential risk of fracture. •Neurosensory disturbances from the location of the mental foramen Disadvantages •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. Mandibular Augmentation
  62. 62. •Inferior border augmentation. Indications •Atrophy of the alveolar ridge area.(less than 5-8mm) •Prevention and management of fractures of the atrophic mandible. Disadvantages •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 mandibular atrophy. These disadvantages combined with the morbidity of rib harvesting make this a seldom used technique.
  63. 63. •Pedicled or Inter positional grafts (Sandwich Technique) 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 gap. Indication 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.
  64. 64. •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 months.
  65. 65. 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 bony segment. Visor osteotomy Goal: To increase the height of the mandibular ridge for denture support.
  66. 66. A, Intraoperative view of the chin region, with the incision line. B,The visor osteotomy is performed. C-D, The bone fragment is mobilized and fixed in correct position.
  67. 67. 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. Disadvantages: Nerve parasthesia and dysaethesia Need for hospitalization Donor site morbidity Inability to wear dentures for 3-5 months post surgery.
  68. 68. •Onlay bone grafting Indications: •Severe resorption of the maxillary alveolar resulting in the absence of a clinical alveolar ridge and loss of adequate palatal vault form. Advantages •Development of increased height and form of the alveolar ridge and the palatal vault area. •The anteroposterior position of the maxilla can be corrected. Disadvantages •Need for a secondary donor site. •Extensive post operative resorption. •Postoperative secondary soft tissue procedures. •Delay in wearing dentures for 6-8 months MAXILLARY AUGMENTATION
  69. 69. Inter positional bone grafts Indications •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. Advantages •Stable and predictable results by changing maxillary position in the vertical, anteroposterior and transverse directions. •May eliminate the need for secondary soft tissue procedures. Disadvantages •Need to harvest bone from the iliac bone crest •Possible secondary soft tissue surgery
  70. 70. 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. Procedure:
  71. 71. •Maxillary hydroxyapatite augmentation Hydroxyapatite grafting has become the primary method of maxillary augmentation. Procedure •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 mattress suture.
  72. 72. •Tuberoplasty The tuberosity – hamular notch area prevents denture displacement and aids the peripheral seal of the maxillary denture. 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.
  73. 73. 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 present. Aim : To uncover existing basal bone of the jaws by the repositioning the overlying mucosa, muscle attachment
  74. 74. Indication: 1. Obliteration of the sulcus with high muscle attachment. 2. Extensive mandibular bone atrophy with mental nerve emerging at the crest
  75. 75. •Transpositional flap vestibuloplasty (Lip switch) A lingually based flap vestibuloplasty was first described by Kazanjian. 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. Indications •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.
  76. 76. 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 vestibule. 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
  77. 77. Advantages •Provides adequate results in many cases. •And generally does not require hospitalization •Donor site surgery or •Prolonged periods without a dentures. Disadvantages •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.
  78. 78. 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 the mandible
  79. 79. D, Graft held over the supraperiosteal dissection with a stent stabilized with circum-mandibular wires. E, Postoperative view of newly created vestibular depth and floor-of-mouth area.
  80. 80. 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
  81. 81. 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 alveolar ridge.
  82. 82. •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.
  83. 83. •Submucous vestibuloplasty 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 denture support. 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.
  84. 84. 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
  85. 85. Advantages •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 surgery.
  86. 86. Conclusion 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 team. 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..
  87. 87. References Contemporary Oral and Maxillofacial Surgery, Sixth Edition- Hupp, James R Syllabus of Complete Dentures., C. M. Heartwell, 4th edition. Boucher – Prosthodontic treatment for edentulous patients. 13th edition. Sheldon Winkler – Essentials of complete denture prosthodontics. 2nd edition. Peterson – Contemporary oral and maxillofacial surgery. 2nd edition.
  88. 88. Thank you…

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