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Soft tissue changes in preprosthetic surgery
- 1. SOFT TISSUE CHANGESIN PREPROSTHETIC SURGERY By – Dr. Chirag Patil M.D.S in oral and maxillofacial surgery
- 2. CONTENTS • History • Introduction •Unfavorable situation • Goals of preprosthetic surgery • Intraoral soft tissue examination • Soft tissue preprosthetic surgey technique • VESTIBULOPLASTY • Obwegeser’s Submucous Vestibuloplasty • Open view submucosal vestibuloplasty • Maxillary pocket inlay vestibuloplasty • Vestibuloplasty by Secondary Epithelization •Kazanjian Technique •Godwin Technique •Cooley Technique •Collett Technique •Lipswitch technique •Clark’s Technique •Obwegerser’s modification •Obwegeser Secondary Epithelization Vestibuloplasty • Lingual Sulcoplasty •Trauner Technique •Obwegeser technique for skin grafting • Moore modification of Obwegeser technique •caldwell’s technique
- 3. CONTENTS • Frenectomy •Labial frenectomy - Z- plasty - v-y type incision • Lingual frenotomy • Double lip • Inflammatory papillary hyperplasia of the palate • Inflammatory hyperplasia of the vestibular mucosa • Denture granuloma • Unsupported and hypermobile gingiva • Mandibular retromolar pad reduction
- 4. HISTORY Willard (1853)was the first person to recommend preprosthetic surgery as an aid in preparation of the patient for complete dentures. Preprosthetic surgery emerged from a ridge trimming service to a truly reconstructive service.
- 5. PREPROSTHETIC SURGERY Dealswith preparation of oral tissues and structures favorable to placement of subsequent prosthesis for their proper placement, retention, stability, function and cosmesis. Elimination of pathology in the denture- bearing soft and hard tissue, and making the edentulous ridges and supporting structures favorable for receiving prosthesis.
- 6. UNFAVORABLE SITUATIONSSUCH AS- Bone loss with inregularities High frenal attachments Sharp bony ridges Undercuts Abnormal muscle attachments Flabby soft tissue Hypertrophied maxillary tuberosity Exostosis Tori Superficial location of mental nerve & foramen
- 7. GOALS OF PREPROSTHETIC SURGERY Satisfy aesthetic concern of patient To provide adequate residual tissue with ridge & withstand masticatory stress Proper speech & deglutination Remove all hard & soft tissue protuberance & undercuts Adequate vestibular depth
- 8. GOALS OF PREPROSTHETIC SURGERY •Appropriate frenal attachments • Proper jaw relationship • Relocate the mental nerve • Reduce pain & discomfort
- 9. INTRAORAL SOFT TISSUE EXAMINATION •Quantity & quality of overlying tissue • Mucosa should be firm (Not flabby) • Palpation of vestibule- - Adequate depth - Self cleansability - Inflammation - Ulceration - Growth • Muscle & frenal attachement with alveolar crest
- 10. INTRAORAL SOFT TISSUE EXAMINATION •Lingual vestibular depth and attachment • Movement of tongue • Soft tissue & bony pathologies if present • Through examination- - Palatal vault - Soft palate for lesion - Papillary hyperplasia - Abnormalities interfering with denture placement
- 11. Vestibuloplasty (Ridge extension procedure) Surgical procedure where oral vestibule is deepened by changing the soft tissue attachments or Deeping of the vestibule without any addition of the bone
- 12. Types of Vestibuloplasty Mucosaladvancement (submucous) vestibuloplasty: The mucous membrane of the vestibule is undermined and advanced to line both sides of the extended vestibule Secondary epithelization (reepithelization) vestibuloplasty: The mucosa of the vestibule is used to line one side of the extended vestibule, and the other side heals by growing a new epithelial surface
- 13. MOUTH MIRROR TEST Obwegeser 1967 Simple clinical test Adequancy of mucossa available Lips in a relaxed position Mouth mirror is inserted into the sulcus If the upper lip is not displaced upward or inward then , there is sufficient mucosa for an advancement procedure Can be used in the lower labial vestibule
- 14. Obwegeser’s Submucous Vestibuloplasty Macintosh & Obwegeser 1959 Closed submucosal vestibuloplasty Applicable to the entire maxillary sulcus and anterior mandibular sulcus Can be performed with local anesthesia A vertical incision is made, extending from the mucogingival junction Blunt spreading dissection carried out A tunnel is formed between the mucosa and the submucosa, till zygomatic buttresses on either side Incison in vestibule Blunt dissection by scissors;
- 15. Obwegeser’s Submucous Vestibuloplasty Supraperiosteal tunneling is done. A strip of connective tissue remains between the two tunnels. Strip of connective tissue is excised Freely movable mucosa is adapted into the deepened sulcus Blood is milked out of the surgical field. Repositioned superiorly New depth is maintained A new denture can be made after 2 or 3 weeks Tunnel formed Denture/splint with extended flanges secured to alveolar bone
- 16. Open view submucosalvestibuloplasty Wallenius (open-view) technique (1963) He used an ‘open view’ procedure instead of a ‘tunneling’ technique. Horizontal incision is made along the mucogingival junction Supraperiosteal dissection is performed Not to cut or tear the periosteum A thin mucosal flap is elevated by submucosal dissection Excision of muscle & subcutaneous tissue Stay suture are used to fix the flap to the periosteum deep in vestibule Free margin of the flap is then returned to its original position and sutured
- 17. Maxillary pocket inlayvestibuloplasty Used for extension of ridge in atrophic maxilla Pockets are created on either side of the pyriform aperture & denture flanges are extended into these pockets for stability preoperatively patients upper denture is modified with extended labial flanges Advantages- - Better retention of the denture - Deficiency in the nasolabial fold can be improve
- 18. Maxillary pocket inlayvestibuloplasty Technique- Intraoral insicion is made along the vestibule from one zygomatic buttress to the other supraperiosteal dissection to creat two pockets on either side of pyriform apperture Extended superiorly to the level of the attachment of levator anguli oris muscle Medially to base of pyriform apperture Perforation of the nasal cavity should be avoided Impression of the newly created pouches is taken The labial flanges of the denture are then covered with split thickness skin graft ( Raw surface facing pyriform aperture) Denture is then into the place Bilateral circumzygomatic wires Wound margin sutured to the graft Wire remain for a week New denture are constructed after a period of 6 weeks To prevent contraction of the pouches denture should be worn for an year
- 19. Vestibuloplasty by SecondaryEpithelization • Inflammatory hyperplasia and scar tissue are present • Secondary epithelization techniques should be considered as the first alternative. • Raw surface is heals by secondary epithelialization
- 20. Kazanjian Technique 1935 •Incision is made in the mucosa of the lip • Large flap of labial and vestibular mucosa retracted • Supraperiosteal dissection to deepen the sulcus • The flap of mucosa was turned downward from its attachment on the alveolar ridge and placed directly against the periosteum to which it was sutured. • The labial donor site was left raw to granulate and heal by secondary epithelization • Disadvantage • Raw area is in the soft tissue • Scarring of the vestibule and relapse is common
- 21. Godwin Technique 1947 •Similar to kazanjian method • Labial mucosa flap raised • Sulcus is deepened & subperiosteal stripping. • Periosteum and the attached connective tissue was either excised or pushed downward • Labial and vestibular mucosa directly placed against the bone and sutured it to the connective tissue beyond the deepened sulcus, using absorbable suture • Godwin exposed the bone and was able to smoothen the bone • Raw tissues healed by granulation and secondary epithelization • Disadvantage – - Scar on the labial side of sulcus. - Bone resorption by removing the periosteum
- 22. Cooley Technique 1952 •Deepening the mandibular and maxillary sulcus • To smooth any bony irregularities on the crest of the ridge and reposition the mental nerve. • Incision on the crest of the mandibular ridge from second molar area on one side to other side • Short lateral relaxing incisions at the posterior ends of the primary incision. • A full thickness labiobuccal mucoperiosteal flap was reflected down • Mental nerve was repositioned inferiorly on each side. • Three drill holes were placed through the alveolar ridge, one in the midline and one in each cuspid area
- 23. Cooley Technique 1952 •The gingival margin of the labial flap was sutured through the peralveolar holes to the lingual mucoperiosteum leaving the crest of the ridge bare. • previously prepared acrylic splint with extended flanges was secured to the mandible for 6 days with circumferential wires • Cooley’s maxillary sulcoplasty where primary incision, was made to the palatal side of the crest. Advantages- • Bony irregularities on the crest and labial surface of the ridge can be corrected • No scar contracture over bone • Mental nerve can be repositioned bilaterally, if indicated.
- 24. Collett Technique 1954 •Previously prepared denture with overextended flange borders to support full-thickness labiobuccal mucoperiosteal flaps • An incision is made on the crest of the maxillary ridge from one tuberosity to the other. • Large full-thickness flap is reflected. • Transparent template is inserted to reposition the flaps higher in the vestibular sulcus. • Position of the flaps can be observed through the template. • No sutures are placed. • Denture is inserted to support the newly deepened sulcus. • Bone is protected by the denture until granulation tissue forms and surface epithelization occurs. • Disadvantage- • Entire external surface of the maxillary ridge is left bare • Infection • Additional bone resorption of a previously resorbed ridge.
- 25. LIPSWITCH TECHNIQUE • Kethley& gamble. • Mucosal flap containing labial and vestibular mucosa is similar way as kazanjian’s & Godwin’s technique • Free margin in the lip & base attached to crest of alveolar ridge • Periosteum is incised high in alveolar ridge below the crest & reflected from bone • Flap consisting of periosteum, connective tissue & muscle is turned outwardly & sutured to the margins of the raw labial surface • Mucosal flap is turned downwards againts the bare bone & sutured to the periosteum deep in the vestibule
- 26.
- 27. Clark’s Technique 1953 •Reverse of Kazanjian technique • Based on following principles- 1) Raw surfaces on connective tissue contract, whereas the same surfaces undergo minimal contraction when covered with epithelium. 2)Raw surfaces overlying bone cannot contract. 3) For repositioning & fixation, epithelial flap must be undermined adequately 4) Soft tissues which are repositioned have a tendency to return to their former position so that overcorrection and firm fixation are necessary. • The raw surface on bone is left exposed
- 28. Clark’s Technique 1953 •Incision is made on the alveolar ridge • Supraperiosteal dissection is done • Mucosa of the lip is undermined to the vermilion border • Free edge of the mucosal flap is secured to the periosteum deep in the sulcus • The raw surface on the bone heals by granulation tissue formation and epithelialisation without contracture Flap harvested from alveolar mucosa Flap sutured to
- 29. Obwegeser Secondary EpithelizationVestibuloplasty1967 • Used secondary epithelization in cases in which there is enough bone, but insufficient healthy mucosa • Incision is made at the mucogingival junction • Supraperiosteal dissection is extended to the infraorbital foramen. • Labial and buccal mucosa are undermined. • Mucosal flap is sutured to the periosteum. • Denture flange be shortened so there is no contact with the raw periosteal surface • Irritation from the flange that could cause proliferation of an excessive amount of granulation tissue • Tissues healed upto 3 or 4 weeks. • 4 to 5 weeks postoperatively a flange is added to the denture • Better results with this procedure in cases of maxillary vestibuloplasty than in mandibular.
- 30. Obwegerser’s modification 1963,1967 • Similarto clarks method except the area of the alveolar bone with its periosteal attachment is covered with a split thickness skin graft & held in position by suture or stent • Covers the bone & ensure faster healing • Reduced chances of postoperative infection • Less bone loss & scaring
- 31. Lingual Sulcoplasty • Grosslyresorbed mandible • Extend the denture foundation and improve the stability, surface area and retention of the mandibular denture. • Mylohyoid , genioglossus muscles and the mucosa of the floor of the mouth can be repositioned inferiorly without undue impairment of function.
- 32. Trauner Technique 1952 • Incisionis given in the floor of the mouth • From the third molar region of one side to opposite side • Connective tissue was separated from the periosteum • Till inferior border of the mandible • Mucosa of the floor of the mouth and the mylohyoid muscle were sutured with heavy nylon mattress sutures through the skin to buttons under the mandible. • Medial periosteal surface of the mandible was left bare to granulate and epithelized. • Healing period- 2 months • Trauner also suggested that split- thickness skin grafts could be used to cover the raw periosteal surfaces.
- 33. Obwegeser technique for skingrafting • Obwegeser (1963, 1967) modified trauner technique. • Combined a ridge skin grafting vestibuloplasty with a lingual sulcoplasty Obwegeser’s modified linguosulcoplasty: (A) Incision sparing mucosa at crest of ridge; (B) Labial and lingual ridge extensions; (C) Raw bone is skin grafted and covered with surgical stent; (D) Final result
- 34. CALDWELL’S TECHNIQUE 1955 • Incision ismade in the crest of the posterior mandibular ridge from molar to molar region • Subperiosteal dissection is carried out • Mylohyoid muscle is detached & mylohyoid ridge is removed or reduced along with reduction of genial tubercle • Mylohyoid muscle & superficial fibers of genioglossus muscles are pushed inferiorly • Sutured with precutaneous suture • Left in place for 7-10 days
- 35.
- 36. Frenectomy • Band offibrous connective tissue, covered with mucous membrane that binds the lip to the alveolar process. • Indiacation - • High frenum attachment • Displacement of denture • Ulceration due to impingement of denture • Midline diastema
- 37. Labial Frenectomy • Lipis elevated, everted and tensed • Frenum becomes prominent. • Using two hemostats the fibers of the frenum are locked • Frenum is excised by cutting the outer surface of both the hemostats • Frenectomy is performed to aid the orthodontic closure of a median diastema, the apex of the v should be at or near the incisive papilla on the palate V shaped incision Frenum detached from bone
- 38. Labial Frenectomy • Resultingdiamond-shaped defect • Closed with interrupted sutures. • First suture should be placed across the middle of the wound (widest part) • Should engage both mucosal margins and the periosteum at the midline • Helps to maintain the height of the vestibular sulcus • Sutures should be removed in 7 days. Diamond shaped defect Closure
- 39. Z- PLASTY • Frenumis broad & vestibule is short • Simultaneously eliminate the frenum and deepen the vestibule • The length of the secondary incision should be approximately two thirds that of the vertical incision • Vertical lengthing can be obtained • Lessen the tension on scar band
- 40.
- 41. V-Y TYPE INCISION •Lengthing of localized area • Broad area in premolar –molar area • Semilunar incision at mucogingival junction • Supraperiosteal dissection • Superior edge of the flap is sutured to the periosteum at the greatest possible depth. • Exposed area is allowed to granulate & heal by secondary intention. • Prefabrication stent is necessary
- 42.
- 43. LINGUAL FRENOTOMY • Ankyloglossia,or Tongue-tie • Dense fibrous septum that binds the tip of the tongue to the alveolar process. • AIMS- • To correct speech • Prior to denture construction • Improve tongue mobility
- 44. LINGUAL FRENOTOMY • Atraction suture is placed to elevate, improve visibility ,control & stability of tongue • Frenum become tensed. • Using two hemostats the fibers of the frenum are locked • Cross-diamound incision along the edge of both the hemostat is made • Dissection of genioglossus muscle is done if necessary • Care not to damage to submandibular duct orifices • Suture done in vertical manner
- 45.
- 46. DOUBLE LIP • Accessoryfold of redundant mucous membrane that is situated just inside the vermilion border of the lip • Uncommon congenital anomaly • Acquired by sucking the lip between the teeth • Usually the upper lip is involved • Noticeable when the lip is tensed in smiling.
- 47. DOUBLE LIP: Redundant foldsof labial mucosa are grasped gently with allis forceps Elliptical incisions are made around the masses Incisions are carried deep into the submucosa Wedge-shaped in cross section, are removed A few small bleeders are ligated/cauterized Wounds are closed in layers with 4 ‘0’ absorbable sutures
- 48. Inflammatory Papillary Hyperplasiaof the Palate • Painless, irreversible disease of the oral mucous membrane • Most commonly on the hard palate • Etiology- • Poorly fitting denture. • Wearing the denture 24 hours a day. • Poor oral hygiene. • Use of palatal relief.
- 49. Inflammatory Papillary Hyperplasiaof the Palate•Initial treatments involve Removal of the denture for several days •Split-thickness, supraperiosteal excision is the treatment of choice for most lesions •Small lesions can be removed with sharp curettes or by mucoabrasion with a rotary instrument •Use of electrocautery and cryosurgery by liquid nitrogen •Require several procedure for complete removal •patient’s denture or a specially prepared surgical splint should be used to cover the raw wound
- 50. Inflammatory Hyperplasia ofthe Vestibular Mucosa • Chronic irritation from a poorly fitting denture • Hyperplastic enlargement of the alveolar mucosa and the mucous membrane of the vestibular sulcus. • Composed of fibrous connective tissue with a mucous membrane covering • Inflammation is a common feature. • Excised with minimal scarring of the vestibule • Depth of the sulcus is maintained. • Wound margins cannot be sutured together without reducing the depth of the sulcus. • Many of these wounds heal by granulation and secondary epithelization
- 51. Inflammatory Hyperplasia ofthe Vestibular Mucosa
- 52. DENTURE GRANULOMA OR HYPERPLASIA •Ill fitting denture and flanges • Chronic denture irritation • Ulcers & granulation tissue • affect the stability & comfort of denture • Discontinue the denture for a period of 2 weeks • Elliptical incision are taken • Submucosal resection (excess tissue) • Two parallel incision are taken on buccal & lingual aspect of the tissue for excision • repositioned and sutured
- 53.
- 54. Unsupported and HypermobileGingiva • Denture becomes unstable ( rocking movement) • Treatment is providing a firm basal seat area for the denture. • surgery may done under local anesthesia. • MAXILLA- • Two incisions are made along the crest of the ridge, • labial and palatal side. • Incisions are carried to bone • long strip of gingiva is removed. • wound margins are approximated and sutured. • soft denture-lining material may be placed inside the denture to compensate for the change in tissue contour.
- 55. Unsupported and HypermobileGingiva MANDIBLE- • complicated by the presence of a very thin and short residual ridge. • deficiency of mandibular gingiva • not to excise too much of gingiva after hypermobile gingival crest is removed. • Sutures are rarely necessary. • soft denture-lining material may be placed • to improve the tissue-denture contact and to protect the tender mandibular ridge, • heals in a week. • Disadvantages – -does not give good results -short ridge with a soft mucosal covering. -Sulcus-deepening procedures
- 56. limitations of surgicalreduction of the hypermobile ridge, Laskin (1970) • Injected a sclerosing solution into the hypermobile gingiva • to produce fibrosis within the soft tissue • Result reduction in the mobility of the ridge. • He recommends that the patient should not wear his denture after the injections • lest tissue movement interfere with the fibrosis of the ridge. • After 4 to 6 weeks, the ridge should be sufficiently rigid that a new denture may be made.
- 57. Mandibular Retromolar PadReduction • Fibrous hyperplasia of mandibular retromolar pad region • infrequent • Complete excision permits excessive settling of the denture and ridge resorption. • can be performed with local anesthesia in the dental office. • Elliptical incisions are made around the soft tissue mass. • incisions should converge and be carried to bone • block of mandibular gingiva removed. • gingival flaps are approximated and sutured. .
- 58.
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