oral and maxillofacial surgery surgical techniques of maxilla surgical procedures flowchart diagrams

1. Dr.Gladwin James

2. • INTROUCTION
• GOALS
• TECHNIQUES:
Hard tissue
 Soft tissue

3. • Preprosthetic surgery is concerned with the surgical
modification of alveolar process and its surrounding
structures to enable the fabrication of a well fitting,
comfortable and esthetic dental prosthesis.

4. Adequate height,length,breadth,shape and width of residual
tissue
• Speech and deglutition
• Esthetic concern
• Remove all hard tissue and soft tissue protuberances and
undercuts
• Adequate vestibular depth
• Appropriate frenal attachment
• Proper jaw relationship
• Reduce pain and discomfort

5. HARDTISSUE SOFTTISSUE
•ALVEOLAR RIDGE
PRESERVATION
•ALVEOLAR RIDGE
AUGMENTATION
•ALVEOLAR RIDGE
CORRECTION
•FRENECTOMY
•VESTIBULOPLASTY
•REDUNDANTTISSUE
EXTENDS
•MENTAL NERVE
REPOSITIONING

6. • Techniques:
 Conservative extraction techniques using periosteotomes
to maintain alveolar continuity,Orthodontic guided tooth
or root extraction.
 Immediate grafting of extraction site
 Relief of undercuts using bone graft or Hydroxyapatite
augmentation
 GTR

7. (R/E done)
a) Extraction technique
•Use of appropriate forceps
•Avoid improper soft tissue handling,extreme forces in
extraction that causes fracture.
•When multiple teeth are extracted in a quadrant, primary
alveoloplasty is required.
•Canine extraction is done prior to premolar
•After extraction compressing of the socket should be done.
•Bony spicules should be removed prior to suturing.
•Fractured root should be removed with minimum
manipulation.
•Fractured tooth root with normal surrounding pdl and vital
pulp should be left as such.
•Periodontally involved teeth should be extracted.

8. a) Preservation of uninfected root stumps

9. • Achieved by building up atrophied jaw bone using
autogenous bone,allogenic bone or alloplastic material
• Criteria
• Gross atrophy of the jaws with the risk of mandibular
fracture.
• Atropy of the jaws with knife edge ridge causing
prosthetic difficulties.
• Insufficient alveolar dimension for implant placement

10. A. Onlay bone grafting
B. Onlay grafting of alloplastic material
C. Interpositional or sandwich graft
D. Sinus lift procedures
E. Bone graft and rhBMP-2
F. Alveolar transport DO-Alveolar reconstruction by
means of bone transport technique where by
transport segment would have moved using distractor

11. •Onlay grafting- Bone Height adequate and
inadequate width
• Autogenous bone graft from mandible or costochondral rib
graft
• Hydroxyapetite crystals used

13. • Due to excessive pneumatisation of the maxillary antrum
and atrophy of the maxillary ridge.
•Sinus lift(Tatum 1977)-To lift floor of sinus lining by placing
graft in between sinus lining and floor of antrum
Materials-Illiac crest,ribs,HA
SINUS LIFT

14. 2)Modified Caldwel-Luc lateral window approach:
vertical releasing incision from canine to tuberosity
-Full thickness flap-
Horizontal bony cut is made inferiorly 2-4mm above the
floor of the sinus
vertical bone cut parallel to lateral nasal wall
Another vertical cut is made perpendicular to the inferior
horizontal cut in the region of maxillary buttress.

15. Two vertical cuts are joined
Currette placed b/w bone
Bone is gently peeled from inside
Graft inserted in the floor
Closed with interrupted sutures

17. A. ALVEOLOPLASTY
• Well contoured smooth ridge for proper
construction of denture
• The procedure of contouring should be
limited to the excision of the irregular
sharp ridges and unfavourable undercuts
which are unsuitable for the denture
construction.

18. GOALS
•To provide optimal ridge contour quickly
•Alveolar ridges should be broad :maximum
distribution of forces
•Smoothening of ridge.
•Mucosa covering ridge should have uniform
thickness,density and compressibility.
•In younger patients lesser amount of bone should
be removed.

19. • Trimming and removal of labiobuccal alveolar bone along
with someinterdental and interradicular bone.
• Carried out at time of extraction of teeth
INDICATION- Prior to immediate denture,Prominent and
dence alveolar ridge
TECHNIQUE

20. Crevicular incision along gingival margin
full thickness envelope or triangular flap
Rongeur forceps is held with one beak beneath the bony
rim of the socket and other on the crest of the ridge
Bone file used
Suturing done
If immediate denture,note pressure points under acrylic
plate-trim

23. •Helps in eliminating anterior maxillary undercuts and
reducing large amount maxilla by removing the interseptal
bone between the teeth
•Involves the preparation of six anterior teeth and
sometimes the premolars.
INDICATIONS
•To decrease gross maxillary overjet
•Adequate bone height
•Multiple extraction

24. Crevicular incision made
Envelope flap raised as conservatively as possible
Teeth extracted from canine to incisors
Removal of intraradicular bony septa

25. V shape excision of bone in labial cortical plate distal and
posterior to the canine eminence
Finger pressure to labial cortex which is collapsed towards
socket.
Suture to stabilize tissue.

28. • When bone correction surgery is done on edentulous ridge
for irregularity after initation of extraction socket healing.
• Incision at crest of alveolar ridge
• Envelope flap
-Bony contouring with bone files burs and rongeurs
Digital palpation to determine uniformity of ridge
Irrigate region with saline and flaps closed.

30. TORI REMOVAL
•Tori are small developmental anomalies that occur
in constant sites on the jaw bones
1)Maxillary tori or Torus palatinus
•Torus palatinus is an exostosis found along the
suture line of hard palate
•Removed only if there is prosthetic difficulty

31. Technique:
Impression taken and acrylic stent made.
Y incision for small and double Y for large tori.
Full thickness mucoperiosteal flap
Tori divided by transverse and anteroposterior bur cuts to
a depth of 1-2mm above the level of horizontal palatal
shelf.

32. Cut sections removed with chisel and mallet.
Surface smoothened using large bone files.
Area copiously irrigated and mucoperiosteal flap
trimmed and sutured back.
Acrylic stent inserted.

35. Complications
Oronasal fistula

36. MAXILLARY TUBEROSITY
REDUCTION
Crestal approach and Lateral
approach

37. CRESTALAPPROACH
For proper construction of denture 1cm should exist
between max and mand arches.
Combined procedure require hard and soft tissue removal
PROCEDURE
Wedge shaped incision made on the crest of the alveolar
ridge to the depth of the bone.
This piece is then removed
Rongeur used to remove the bony undercut

38. Smoothened using bone files
Irrigated with saline
Buccal and palatal flap trimmed for
approximation.
Wounds are closed

39. LATERALAPPROACH
Done when tuberosity is very narrow and overlying
keratinised mucosa required to be preserved for
vestibuloplasty.
Incision made on the lateral side of the maxillary ridge .
Two relaxing incisions are made on either side of the
crestal incision anteriorly and posteriorly and flap is
retracted.
Submucosal excision of the fibrotic tissue is done.

40. Sulcus extended superiorly from the lateral incision
to deepen the sulcus
Palatally based flap is advanced to cover the bone.
Sutured to the new periosteum
Maxillary denture splint used to stabilise the tissue

42. A crestal elliptical incision from tuberosity to
premolar area
Mucoperiosteum undermined
Section of tissue between the elliptical incisions
removed
Excess bone is then removed from the crest of the
ridge and from the buccal plate ( with chisel, mallot
or burs)

43. Excess soft tissue trimmed
Flap is sutured
Stent placed

45. 1. FRENECTOMY

47. Anesthetise the area
Upper lip everted
Two hemostats are used to lock the frenum
(First :parallel to the labial surface of the alveolar
ridge and mucosa covering the labial surface.
Second :parallel to lip and perpendicular to first)

48. Tips of hemostat touch each other (the entire
frenum lies within the hemostat)
Excised using No.11 BP blade
Lateral margins of the wound undermined
Sutured without tension.

50. VESTIBULOPLASTY OR RIDGE EXTENSION
PROCEDURES

51. mucous membrane of vestibule is undermined and
advanced to line both sides of extended vestibule-Closed
and open view

52. CLOSED SUBMUCUOS VESTIBULOPLASTY
Vertical incision is made in the midline of the vestibule
extending till the mucogingival junction
Creation of submucosal tunnel extending till the zygomatic
buttress on either side
Supraperiosteal dissection is done freeing the underlying
muscles from periosteum
Vertical incision closed
Stent is placed.

53. Pocket inlay vestibuloplasty-Extension of ridge in atrophic
maxilla-Pockets on sides of pyriform aperture and denture
flanges
Grafting vestibuloplasty
When the available bone is inadequate to compensate for
relapse
When bone graft has been previously placed.
When large surgical defect is present
Graft used
Skin graft
Mucosal graft
Xenograft
amnion

54. REDUNDANT TISSUE
EXCISION
A)Alveolar flabby ridge (Hypermobile soft tissuesof the
alveolar ridge)
Resorption of residual alveolar bone or illfitting dentures
or both excessive hypermobile tissues present on the
residual alveolar ridge.

56. B)DENTURE GRANULOMA

57. C)EPULIS FISSURATUM(Inflammatory fibrous
hyperplasia,Denture fibrosis)

58. Small lesion
Base of growth held with Allis forceps.
Sharp submucosal dissection is done to form a flap
followed by sharp submucosal excision of the
growth and the flap is sutured back
Severely scarred tissues excision followed by
supraperiosteal placement of free mucosal palatal
graft.

60. EPULIS FISSURATUM

61. D)Reactive inflammatory hyperplasia of palate

62. THANK YOU..