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1. Preprosthetic Surgical
Procedures
John Beumer III, DDS, MS
Division of Advanced Prosthodontics,
Biomaterials and Hospital Dentistry
UCLA School of Dentistry
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2. Conventional preprosthetic surgery
v Tuberosity reduction
v Elimination of boney undercuts
v Removal of palatal papillary hyperplasia
v Frenectomy
v Removal of epuli (fibrous hyperplasia
secondary to denture irritation
v Displacing the inferior alveolar nerve

3. Ideal Bearing Surfaces - Maxilla
l Ridge form – rounded crest with vertical sides
l Ample keratinized attached mucosa
l Displaceable tissues in the posterior palatal seal area
l Accessible vestibules

4. Ideal Bearing Surfaces - Mandible
l Broad, rounded ridge crest form with vertical sides
l Ample amounts of keratinized, attached mucosa
l Favorable floor of mouth posture
l Anterior tongue position

5. Mandibular Bearing Surfaces
v Severe ridge resorption
Consequences:
a) Impaired stability of the denture
b) Impaired support for the denture
c) Pathologic fracture of the mandible

6. Severe Resorption - Mandible
v Definition: Loss of the mandible to the extent where 10
mm or less of the vertical height of the mandibular body
remains.
v Precipitating factors
a) Loss of the teeth
b) Ill fitting dentures
c) Hormonal influences?
d) Wearing dentures at night
e) Edentulous mandible opposing
dentate maxilla

7. Severe Resorption - Mandible
Prevention
a) Retention of roots
b) Well adapted dentures with
a coordinated occlusion
c) Leaving out dentures at night
d) Use of osseointegrated implants
e) Removing opposing dentition

8. Mandibular Arch – Common Problems
l Unfavorable floor of mouth posture and
retruded tongue position
Consequences: Result:
Length of lingual flange a) Impaired stability
is minimized b) Impaired control

9. Mandibular Arch – Common Problems
l Reduced amounts of attached, keratinized
Consequences: Note: Usually occurs
a) Impaired Support coincident with moderate
to severe resorption of the
alveolar ridge

10. Mandibular Arch – Common Problems
l Thin, knife edged ridge crest
Consequence:
a) Impaired support
b) Pain and discomfort

11. Mandibular Arch – Common Problems
Inferior alveolar nerve exposed on the ridge crest
Consequences:
a) Severe discomfort upon application of pressure
b) Inability to tolerate the lower denture

12. Maxillary Arch – Common Problems
Severely resorbed, flat ridges and lack of vertical sides
Precipitating Factors:
a) Loss of teeth
b) Hormonal influences?
c) Ill fitting dentures
d) Wearing dentures at night
e) Opposing arch with natural
dentition
Consequences:
a) Impaired stability
b) Difficulty in maintaining seal

13. Severe Resorption - Maxilla
Prevention:
v Retention of roots
v Well adapted dentures with coordinated
occlusion
v Leave dentures at night
v Use of osseointegrated implants
v Removing opposing dentition

14. Redundant tissues - Premaxilla
The entire premaxillary segment is fibrous connective
tissue in this patient. The underlying bone has
resorbed. It is not advisable to remove this cushion of
tissue, however, because the residual ridge crest
beneath these soft tissues is likely to be knife edged.

15. Maxillary Arch – Common Problems
Bilateral undercuts*
Consequence: *Can be prevented during
a) Impaired extraction by alveolar
adaptation and compression and primary
retention closure (Obwegeser, 1966)

16. Maxillary Arch – Common Problems
Low frenum attachments
Consequences:
a) Seal
b) Fracture of denture

17. Maxillary :Arch – Common Problems
Inflammatory palatal papillary hyperplasia
Consequences:
a) Prevents proper adaptation of the denture
base compromising support

18. Preprosthetic Surgery
v Goals– Improve the denture foundation
area so as to facilitate the support,
retention, and stability provided for
removable prostheses
a) Minor soft tissue procedures
b) Minor osseous procedures
c) Vestibuloplasty
d) Bone augmentation
e) Implants

19. Conventional Preprosthetic Surgery
v Epulisfissuratum removal
v Frenectomy
v Treatment of palatal papillary hyperplasia
v Tuberosity reduction
v Removal of maxillary and mandibular tori
v Removal of boney undercuts
v Displacing the inferior alveolar nerve

20. Epulis Fissuratum (Inflammatory Fibrous
Etiology
a) Persistent denture irritation that is not resolved
Treatment
a) Surgical excision and primary closure*
*These lesions are generally pedunculated and
are easily removed with scissors.

21. Low Frenum Attachments
Problems:
a) Seal
b) Fracture
Treatment: Frenum are comprised of epithelium and
fibrous connective tissue, not muscle, so surgical
excision is quite effective.

22. Palatal Papillary Hyperplasia and Associated
Etiology
Candida Albicans Infection
a) Poorly adapted dentures
b) Candida albicans
*Corner of
mouth usually
Advanced infected with
Early
fungus as well
Worsened by:
a) Poor oral hygiene
b) Wearing dentures at night

23. Therapeutic Approaches – Palatal Papillary
Hyperplasia**with Associated Candida Albicans
Antifungal therapy*
a) Nystatin powder (100,000 units per gram) Apply to undersurface of
denture three times per day for 3-4 weeks
b) Nystatin cream – Best used for lesions associated with the corners of
the mouth
c) Reline denture with temporary reline material
d) Reline or remake denture
Surgical excision with electrosurgery (when antifungal
therapy has reached an end point)
*Nystatin rinse is generally ineffective. Nystatin oral or vaginal
suppositories used as an oral lozenge are reserved for fungal
infestations that extend beyond the denture bearing surfaces.
**Is this a premalignant lesion? No!!!!

24. Case Report
Note the chamber inscribed into the upper
denture(A) and the corresponding tissue
hyperplasia. Such chambers are ill advised.

25. Case Report – Palatal Papillary Hyperplasia
A severe case of palatal
papillary hyperplasia. A
combination of
antifungal therapy and
surgical excision is
recommended for this
patient.

26. Palatal Papillary Hyperplasia – Surgical
Removal
The preferred method for surgical
removal is with electrosurgery.
Following removal, islands of
epithelium remain which grow,
expand and eventually coalesce.

27. Hyperplastic Tuberosities
Etiologic factors
a) Combination syndrome -Edentulous
maxilla opposing distal extension RPD
where occlusion is not balanced
(Inflammatory fibrous hyperplasia)
b) Supereruption of unopposed molars
and upon extraction the bone
associated with the tuberosity is left
untrimmed (arrow)

28. Hyperplastic Tuberosities
When this patient assumes a
protrusive position, the maxillary
denture was tipped anteriorly
leading to resorption of bone of
the premaxilla and fibrous
hyperplasia of the maxillary
tuberosity

29. Enlarged Tuberosities – Criteria for Reduction
Fibrous Hyperplasia
v Lack of sufficient space at the proper vertical dimension of
occlusion to cover both tuberosities
v Inability to extend the maxillary denture base into the hamular
notch
v Inability to cover the retromolar pad.
v The preferred method is excision of the underlying fibrous

30. Conventional Preprosthetic Surgery –
Boney Procedures
Exostoses and tori
Indications for removal:
a) When they become so large as to interfere with speech
b) When the mucosa becomes traumatized, ulcerates, and fails to
heal because of its poor vascularity
c) When the torus interferes with the design and construction of a
removable partial denture or a complete denture

31. Palatal Tori - Criteria for Removal
v Height of torus exceeds that of the alveolar ridge
v Torus extends to the vibrating line preventing
development of posterior palatal seal
The palatal torus on the left should be considered
for removal while the small one on the right need not
be removed.

32. Removal of Palatal Tori
The torus is removed with a burr and chisel. Note that
the mucosal flaps are supported by a palatal stent
(arrow) so as to prevent formation of a hematoma.

33. Removal of Palatal Tori
This torus was removed with
a burr and chisel. The
mucosal flaps should be
supported by a palatal stent
so as to prevent formation of
a hematoma.

34. Mandibular Tori – Criteria for Removal
l Mucosa is thin and easily ulcerated and coverage
by a complete denture or a major or minor connector
of an RPD is usually not tolerated by the patient.
Removal is accomplished with burrs and chisels

35. Alveoloplasty
v Alveolar compression
v Reduction of the knife-edged or saw-tooth ridge
v Elimination of undercuts**
Study casts should be made to
properly plan the procedure
**Only half of the desired amount should
be removed because of the resorption that
follows reflection of the periosteum and the
surgical removal of bone

36. Repositioning the Inferior Alveolar Nerve
l Surgically possible, but there is risk of permanent injury to the
nerve. The resultant anesthesia, dysethesia, or hyperesthesia can
be quite debilitating to the patient.
Preferred solution: Placement of 4-5 implants anterior to the
mental foramen and fabrication of a fixed edentulous bridge

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