Preprosthetic surgical procedures

1. PREPROSTHETIC SURGERY
(Preparation of Mouth for Dentures)
Based on Chapter 11 of Principles of
Oral and Maxillofacial Surgery- 5th edition
by MOORE

2. Specific Learning outcomes
List the objectives of preprosthetic surgical procedures and
describe the preoperative patient selection(C1)
Give the classification of preprosthetic surgical procedures (C2)
Apply the knowledge to plan the treatment for patients requiring
alveolar ridge correction procedures (C3)
Explain various alveolar ridge extension and alveolar ridge
augmentation procedures (C2)

3. LECTURE OUTLINE
Aims & Objectives of Pre Prosthetic Surgery
Bone Loss- Causes, Patterns
Preservation of Alveolar Ridge
Preprosthetic Surgical Techniques
Surgery involving bony irregularities
Surgery involving soft tissue irregularities

4. The prosthetic replacement of lost teeth frequently
involves surgical preparation of the remaining oral tissues.
Aims
To leave a satisfactory base for subsequent placement of
prosthetic appliances.
To provide a better anatomic environment and to create proper
supporting structures for denture construction.
Ideally treatment for these procedures should be planned jointly
(by a prosthodontist and oral surgeon)

6. Objectives
• Provide adequate bony tissue support for the
placement of the prosthesis.
• Provide adequate soft tissue support.
Optimum vestibular depth.
• Elimination of pre-existing bony and soft
tissue deformities.
• Relocation of frenal/muscle attachments.

7. CAUSES OF BONE LOSS
Causes of bone loss :
1.Metabolicfactors:osteoporosis,osteomalacia.
2. Aging.
3. Trauma.
4. Periodontal disease.
5. Disuse atrophy.
6. Long term denture use.

8. PATTERNS OF BONE LOSS
• Tallgren in 1972 stated that most of the bone loss
occurs in the first year of denture wearing (ten
times).
• Four times more bone loss in the mandible.
• Usual resorption of the maxilla is on the buccal and
inferior portion of the alveolar ridge.
• Anterior maxilla less horizontal bone loss.

9. • In the posterior maxilla there is inward drift of
the posterior crest.
• The width of the maxilla is reduced.
• Decrease in the palatal vault.
• Mandible resorbs downwards and outwards.
• Edentulous bone loss is upto 1mm per year
with greatest loss within 18 months after
extraction.

10. Bone height loss can be up to 1.5 mm in 3 months and decrease in the width of
alveolar ridge can be as much as 50% within12 months.

11. MERCIER 1995. RESORPTIVE PATTERN
OF THE EDENTULOUS RIDGE.
• TYPE 1 : minor ridge modelling.
• TYPE 2 : sharp atrophic residual ridge.
• TYPE 3 : basal bone ridge.
• TYPE 4 : basal bone resorption.

12. Preservation of alveolar ridge at time of extraction
Preservation of alveolar ridge for prosthesis starts – when
the first permanent tooth is extracted itself.
Careful planning to be done during removal of buried teeth
and lesions.
Difficult extractions (multirooted teeth)---best removed—
by transalveolar extraction----to avoid alveolar fracture.

13. Preservation of alveolar ridge at time of extraction– contd
Access to deeply buried roots----made through lateral
aspect of alveolus---leaving the ridge intact.
Bone cutting to be limited to one side----leaving palatal
or lingual plate with its mucoperiosteum untouched.
More conservative approach is important where
periodontal disease has already caused more bone loss.

14. Preservation of alveolar bone in edentulous patients
Resorption-----makes alveolar ridge more weak
Symptomless root fragments in thin
mandibles
Buried teeth unlikely to come to surface
during their life time
Use of Blunt burs
Failure to provide irrigation SHOULD BE AVOIDED
Those teeth lying superficially
Those associated with cysts and granulomas
NEED NOT BE
EXTRACTED
need to be
EXTRACTED

15. IDEAL DENTURE BASE AREA
• Adequate bone support.
• Adequate firm soft tissue coverage.
• No bony or soft tissue undercuts or
prominences.
• No sharp ridges.
• No high muscle or frenal attachments.

16. Classification of Surgical
Techniques
• 1.Alveolar ridge correction.
• 2.Alveolar ridge extension.
• 3.Alveolar ridge augmentation.

17. SURGERY INVOLVING BONE IRREGULARITIES
 Alveoloplasty
 Tori Removal
 Maxillary Tuberosity reduction
 Mylohyoid Ridge Reduction
 Genial Tubercle Reduction
Alveolar Ridge Correction Procedures

18. SURGERY INVOLVING SOFT TISSUE IRREGULARITIES
Maxillary Tuberosity Reduction (soft tissue)
Frenectomy
Denture irritation hyperplasia
Flabby ridge

19. ALVEOLOPLASTY
Minor surgical procedure done to smoothen irregular ridges,
bony spicules and to remove undercuts
Horizontal incision is made on the alveolus with (vertical
release incision if needed) under LA
Flap is reflected to expose the alveolar crest
Primary
Secondary

20. Bone ---- trimmed with large
rosehead bur or rongeur
smoothen----with bone file
Operator then replaces the flap
and runs his finger over the
ridge to check—smoothness
Followed by irrigation with
saline and suturing

21. REMOVAL OF PALATAL TORI
Torus is exostosis/overgrowth of cortical/cortico-cancellous
Bone.
Palatal tori should be removed if they cause denture instability
or repeated fracture or where there is soft tissue trauma.

22. REMOVAL OF PALATAL TORI

23. Steps involved
A) Reflection of mucoperiosteal flaps---Y shaped incision
B) Sectioning of torus with fissure bur
C) Small osteotome used to remove sections of torus
D) Large bone bur used to produce final desired contour
E,F) Removal of excess soft tissue and closure

24. REMOVAL OF LINGUAL TORI - Steps involved
Step1
Incision
Step 2
Exposure of torus
Step 3
Trough created between mandible and
torus using fissure bur

25. Step 4
Removal of torus en mass
is done with osteotome
Step 5
Burs are used to get final desired contour
Step 6
Soft tissue closure

26. MAXILLARY TUBEROSITY REDUCTION
Technique
Step 1
Administration of LA
Incision extended along the crest of
alveolar ridge distally to superior extent
of tuberosity area
Step 2
Elevation of mucoperiosteal flap

27. Step 3
Elimination of bony excess
using rongeur (avoid
perforation to floor of sinus)
and suturing.
Cross sectional view of
posterior tuberosity area
showing vertical reduction of
bone and reapposition of
mucoperiosteal flap

28. MAXILLARY TUBEROSITY REDUCTION----contd
If perforated and sinus floor NOT violated, no specific treatment
required
Initial denture impressions can be made 4 weeks after surgery
In case of sinus infections-----antibiotics (penicillin) ,sinus
decongestants (pseudoephedrine) should be given 7-10 days
post operatively.
Patient has to be cautioned against creating excessive sinus
pressure, such as nose blowing or sucking with a straw for
10-14 days.

29. MYLOHYOID RIDGE REDUCTION
Is needed when ridge is sharp and denture pressure can
cause significant pain in that area.
Technique
Administration of LA ----inferior alveolar,
buccal, lingual
Incision, exposure and removal of sharp
bone with rongeur in mylohyoid ridge area
Bone file used to complete recontouring of
mylohyoid area

30. GENIAL TUBERCLE REDUCTION
They can become prominent in floor of mouth due to
alveolar recession.
Occasionally the upper part of prominent genial tubercle
may require excision to facilitate denture wearing.

31. SURGERY INVOLVING SOFT TISSUE IRREGULARITIES
 Maxillary Tuberosity Reduction (soft tissue)
 Frenectomy
 Denture irritation hyperplasia
 Flabby ridge

32. SURGERY INVOLVING SOFT TISSUES
FRENECTOMY
Musculo -fibrous band attached to alveolus
Labial, Buccal, Lingual frenum are most prominent
When they become prominent they lift the denture and
break peripheral seal

33. LABIAL FRENECTOMY
Diamond shaped incision is
made round the margins deep
enough.
Extent of frenum is noted by
drawing the upper lip forward.

34. Excision of
fibrous band
Suturing

35. LINGUAL FRENECTOMY
An abnormal lingual frenal attachment usually consists of mucosa, dense fibrous
connective tissue, and occasionally superior fibers of genioglossus muscle.
This attachment binds the tip of the tongue to the posterior surface of the
mandibular alveolar ridge.
Such attachments can affect speech and after teeth loss they interfere with
denture stability.

36. Step1
Retraction suture placed in tip of tongue
Diamond shaped incision
Step 2
Undermining of lateral borders of wound margin
Step 3
Soft tissue closure

37. MAXILLARY TUBEROSITY REDUCTION (SOFT TISSUE)
The primary objective for soft tissue tuberosity is to provide adequate interarch
space for proper denture construction
Amount of soft tissue reduction can be determined by presurgical OPG or the
thickness can be measured with a sharp probe after administration of LA
Technique
Step 1
Elliptical incision over the tuberosity
area requiring reduction
Step 2
Soft tissue are excised with initial
incision

38. Step 3
Undermining of buccal and palatal
flaps to provide adequate soft tissue
contour and tension –free closure
After tissue removal
Step 4
Soft tissue closure

39. DENTURE IRRITATION HYPERPLASIA
Fibroepithelial overgrowth in response
to chronic trauma
Because of overextended denture
flange
Presents as one or series of folds like leaves of a book
Management includes removal of irritation (denture)--- by
leaving out.
Review after one month and if still hyperplasia persist ---do
surgical excision.

40. Surgical correction of localized area of fibrous
hyperplasia
Step 1
Simple excision
Step 2
Closure of wound margins

41. Surgical correction of large areas of fibrous
hyperplasia
Large multi leaved hyperplasia require excision
Raw area present covered with a split thickness skin graft
Cryosurgery /Co2 laser are other alternatives available.

42. Surgical correction of large areas of fibrous hyperplasia----contd
Surgical splint is placed with soft tissue conditioner for 5-7 days
Oral hygiene should be maintained in this period with saline
rinses
Secondary epithelization usually takes place and denture
impressions can be made after 4 weeks.

43. Alveolar Ridge Extension Procedures
(Vestibuloplasty or Sulcus deepening procedures)
Whenever there is an inadequate vestibular depth present, (due to
mandibular atrophy and high muscle and soft tissue attachments) to increase
the retention and stability of the denture, deepening of the vestibule
is considered.

44. Clark’s vestibuloplasty
Kazanjian vestibuloplasty

45. Alveolar Ridge Augmentation Procedures
When there is extreme alveolar ridge resorption , the ridge augmentation
procedures are advised.
Superior Border
Inferior Border
Visor Osteotomy
Sandwich Grafting

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