The denture-wearing history should provide information on the age of existing dentures, the frequency of denture replacement, the patient's experiences and expectations. It is important to identify whether any previous dentures have been successful as it may be suitable to copy features from a previously successful set. It will be important to manage expectations for those patients with a history of denture intolerance, yet technically satisfactory prostheses. Clinical examination Clinical examination should fully evaluate both the patient's anatomy and previous dentures to anticipate challenges and the potential to improve upon retention, stability, support, appearance and/or other factors. This should be undertaken in a systematic manner and would typically involve assessment of anatomy followed by an assessment of any existing dentures. This should follow a diagnostic process to determine if the patient presents with: Technically adequate dentures on a favourable tissue base Technically adequate dentures on an unfavourable tissue base Technically inadequate dentures on a favourable tissue base Technically inadequate dentures on an unfavourable tissue base.

1. SURGICAL MANAGEMENT OF
COMPLETE DENTURE PATIENT
Presented by- Dr. Nikita
Chhabariya. Pg II year

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.  Preprosthetic surgery refers to the surgical procedures that
can modify the oral anatomy to facilitate the retention of
conventional dentures.
• According to the Glossary of Prosthodontic Terms - preprosthetic surgery is
defined as surgical procedures designed to facilitate fabrication or to
improve the prognosis of prosthodontic care.
DEFINITION

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. Elimination of disease
Conservation of oral structures
Provide residual tissue to withstand
masticatory forces
Maintain function
Esthetics
Lawson, W. A. (1972). Objectives of pre-prosthetic surgery. British Journal of Oral Surgery, 10,

6. Classification of Pre-Prosthetic Surgical Procedures
(Modified From Peterson and Kruger)
A. Removal of Teeth
•• Erupted
•• Unerupted
•• Partially erupted
•• Root stumps
•• Cysts
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
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
I) Basic preprosthetic surgical procedures

7. 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
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

8.  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.
 Jawrelationship and presence of soft tissue or bony pathologic
condition.
 Patient’s age.
 Physical and mental health status.
 Financial constraint.

9. Basic Pre-prosthetic
Surgeries

10.  Surgical procedure which intends to recontour the alveolar ridge.
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
Types of alveoloplasty :
Simple
alveoloplasty
Labial and
buccal cortical
alveoloplasty
Dean’s
interseptal or
Thoma’s
intracorticular
Obwegeser
technique

11. Easiest & quickest method
Involves compression of cortical plates with fingers
Reduction in socket width
• Indication
Reduction of buccal/labial plate
Extraction of single/multiple teeth
Technique:
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3), 459–472. doi:10.1016/j.coms.2015.04.002

12. 3) Labial & Buccal Cortical Alveoloplasty
alveoloplasty eliminates buccal irregularities
and undercut areas by removing
labiocortical bone
B, Minimal flap
reflection for
recontouring.
A. Clinical
appearance of
maxillary ridge after
removal of teeth.
C, Proper alveolar
ridge form free of
irregularities and bony
undercuts after
recontouring
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3), 459–472. doi:10.1016/j.coms.2015.04.002

13. 4)Dean’s Intraseptal /Intercortical/Crush Technique
Principles:
a)Reduction of labial/alveolar
prominences
b)Muscle attachments are
undisturbed
c)Intact periosteum
d)Preserve cortical bone
e)Less post-op resorption
Maxillary ridge present with undercut to the depth of labial
vestibule.
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3), 459–472. doi:10.1016/j.coms.2015.04.002

14. Obwegeser’s modification
In case of extreme protrusion both cortical Plates are
fractured inwards.
Inward compression of
labial cortex
Obwegeser H. Die submukose vestibulumplastik. Dtsch Zahnarztl Z 1959;14:629, 749

15. Maxillary Tuberosity
reduction
Indications:
1. Reduced interridge distance
2. To prevent displacement of denture.
3. To reduce severe bilateral
undercuts.
A, Incision extended along crest of alveolar ridge
distally to superior extent of tuberosity area.(lateral)
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
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3), 459–472. doi:10.1016/j.coms.2015.04.002

16. Buccal exostoses and
excessive undercuts
• Common 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).
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

17. Mylohyoid ridge reduction:
The mylohyoid ridge is one of the more common areas interfering with proper
denture construction.
Gilles – same level of alveolar process
Roberts – reduction of mylohyoid ridge and the extension of posterior lingual denture flanges into
retromylohyoid fossa- denture stability
Bone file used smoothen the area
Rongeur is used –reduce sharp bony margin
Mucoperiosteum is raised
Incision is made- crest of alveolar ridge
Roberts, B. J. (1977). Mylohyoid ridge reductions as an aid to success in complete lower dentures. The Journal of Prosthetic Dentistry, 37(5), 486–493.

18. 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.

19. Technique of removal of maxillary Tori
Maxillary Tori : Seen in the midline
of the palate with different shapes.
Spindle shape Nodular Lobulated Flat 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.
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3),.2015.04.002

20. 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
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3),.2015.04.002

21. Technique of removal of Mandibular Tori
•Lingual premolar area.
•Bulbous or nodular
Mandibular
Tori :
•Placed on the crest for edentulous and on
gingival margin for dentulous.
Should not be placed on the Tori.
Incision:
Complications:
Post operative hematoma formation Wound
dehiscence.

22. SOFT TISSUE PROCEDURES

23. Fibrous Hyperplasia Of Maxillary Tuberosity
A, Elliptical incision around soft tissue to be excised
in tuberosity area.
B, Soft tissue area excised with initial
incision
Undermining of buccal and palatal flaps to provide
adequate soft tissue contour and tension-free closure.
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3), 459–472. doi:10.1016/j.coms.2015.04.002
Fonseca RJ, Davis WH. Reconstructive preprosthetic oral and maxillofacial surgery. St Louis (MO): W.B. Saunders; 1986

24. 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
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3), 459–472. doi:10.1016/j.coms.2015.04.002

25. pad
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
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.
Retromolar reduction

26. Lateral palatal soft tissue excess
Tangential excision of excess soft
tissue

27. •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.
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.

28. 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.
Inflammatory fibrous hyperplasia

29. Labial Frenectomy
Indication
• Frenum is close to crest of the ridge
• Irritated by the flange of the ridge.
• Diastema in the midline (in dentulous)
Method of Frenectomy :
1. Diamond type
2. Z plasty
3. V-Y plasty
Ephros, H., Klein, R., & Sallustio, A. (2015). Preprosthetic Surgery. Oral and Maxillofacial Surgery Clinics of North America, 27(3),.2015.04.002

30. 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.
Use of prefabricated stent is
necessary Disadvantage-
Excessive bulk of the tissue at the depth of the vestibule

31. •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

32. Advanced Pre-prosthetic
Procedures

33. •Superior border augmentation
Indications
•When severe resorption of the mandible results in
inadequate height and contour and potential risk 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.

34. •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.

36. 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.
• 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.
Indication
•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.

37. Visor osteotomy
Goal:
To increase the height of the mandibular ridge for denture support.
Visor osteotomy consists of central splitting of mandible in buccolingual dimension.
thelingual 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.
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.
-

38. 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.

39.  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
Indications:
severe resorption of the maxillaryalveolar-- absence of a clinical alveolar
ridge and loss of adequate palatal vault form

40. 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
This technique effectively increases the ridge height
from the lateral maxillary area to the crest of the ridge.

41. •Maxillary hydroxyapatite augmentation
Hydroxyapatite grafting has become the primary method of maxillary
augmentation.

42. •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.

43. 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
Indication:
1. Obliteration of the sulcus with high muscle attachment.
2. Extensive mandibular bone atrophy with mental nerve emerging at the crest
Brons R, Boskar H,dijk LV visor osteotomy and vestibuloplasty a one stage procedure a preliminary report. Int.J.Oral Surg 1977;6(3):127- 130

44. 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.
Transpositional flap vestibuloplasty (lip switch)

45. 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

46. 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.

47. 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

48. 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.

49. 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

50. MUCOSAL ADVANCEMENT (submucous)
VESTIBULOPLASTY
CLOSED SUBMUCOUS VESTIBULOPLASTY.
OPEN VIEW SUBMUCOUS VESTIBULOPLASTY.
SECONDARY EPITHELIZATION(RE-EPITHELIZATION) VESTIBULOPLASTY
•Kazanjians technique
•Clarks technique

51. VESTIBULOPLASTY
 Vestibuloplasty should be performed in case of the shallow vestibule to widen
denture-bearing area. There vestibuloplasty should be performed in case of
the shallow vestibule to widen denture-bearing area. There are different
techniques of vestibuloplasty. Most of them provide access from the buccal
aspect of the mandible.
•For mandibular ridge:
•Kazanjian technique (1935)
•Godwin’s modification (1947)
•Clark’s technique(1953)
•Obwegeser’s modification(1959)
•for maxillary ridge:
•Maxillary pocket inlay vestibuloplasty
•Labial vestibuloplasty: Lingual vestibuloplasty
• Trauner’s technique
• Caldwell’s technique
Mental nerve transposition

52. KAZANJIAN VESTIBULOPLASTY
 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 epithelialization.

53. SECONDARYEPITHELIZATIONVESTIBULOPLASTY
53
(kazanjian’stechnique) 1935
LABIAL PEDICAL FLAP

54. CLARK1953- PEDICLEDFLAPFROMLIPNOTFROM ALVEOLAR
PROCESS.
54

55. HOWE1966 &KETHLEYGAMBLE1978- LIPSWITCH
PROCEDURE/MOD.KAZANJIAN.
09/19/16
09:16AM
55
PRE PROSTHETIC SOFT TISSUE SURGERIES/RT/6/51

56. MAXILLARYMUCOSALADVANCEMENT(closedsubmucous)
VESTIBULOPLASTY.OBWEGESER1959
PRE PROSTHETIC SOFT TISSUE SURGERIES/RT/6/51
56

57. REFERENCES
 Peterson LJ, Ellis E, Hupp JR,Tucker MR, Contemporary oral and maxillofacial surgery. 4TH ed.Mosby; 1988 :248-303
 Crabtree DG, Bell DH, Alexander JM.Surgical template as a guide for reduction of maxillary tuberosities. J Prosthet Dent.1986;
55(1):137-39
 Roberts BJ. Mylohyoid ridge reductions as an aid to success in complete lower denture. J Prosthet. Dent.1977;37(5) :486-93
 Golds L.The prosthetic treatment in the presence of gross resorption of the mandibular alveolar ridge. Journal of Dentistry.
1985;13(2):91-101
 Christopher JH, Christopher T, Vogel, G, Fisher R Simple Bone Augmentation for Alveolar Ridge Defects. Oral and Maxillofacial
Surgery Clinics of North America .2015;27(2);203-226
 Stoelinga PJ, koomen, HA,Tideman H,Hujibers TJ.Repraissal of the interposed bone graft augmentation of atropic mandible. J
Maxillofac.Surg.1983;11(3):107-112
 Sugar W, Thielens P, Stafford G. D, Willins M. J.Augmentation of the atrophic maxillary alveolar ridge with hydroxyapatite
granules in a Vicryl (Polyglactin 910) knitted tube and simultaneous open vestibuloplasty. Br J Oral and Maxillofac Surg.1995;
33(2):93-97
 Brons R, Boskar H,dijk LV visor osteotomy and vestibuloplasty a one stage procedure a preliminary report. Int.J.Oral Surg
1977;6(3):127- 130
 Mahdy FA,Belasy A. Mandibular Anterior Ridge Extension: A Modification of the Kazanjian Vestibuloplasty Technique.J Oral
Maxillofac Surg.1997; 55(10):1057-1059
 Burton DJ, Holton SH. A simplified two-stage mandibular ridge extension procedure. Oral Surgery, Oral
Medicine,OralPathology.1981;51(4):335-341
 Riley C., Surgical stents for vestibuloplasty and alveolar ridge skin grafts. J Prosthet Dent.1971; 26(5): 511-516
 Crabtree DG, Bell DH, Alexander JM.Surgical template as a guide for reduction of maxillary tuberosities. J Prosthet Dent.1986;
55(1):137-39

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