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34 TEXTBOOK OF COMPLETE DENTURE PROSTHODONTICS

PREPROSTHETIC SURGERY 35

INTRODUCTION Indications for preprosthetic surgery in soft tissue defects


like:
The preprosthetic surgery is an important procedure 1. Bulbous maxillary tuberosity with normal underlying
done prior to prosthetic replacements in compromised bone.
condition of the hard and the soft tissues supporting the 2. Alteration of muscle attachment e.g. Mylohyoid
complete denture muscle attachment forms the floor of the mouth.
Geniohyoid and genioglossus which are attached to
AIMS genial tubercles.
Requirements of an ideal ridge:
1. To facilitate retention and stability of the denture.
1. No evidence of intraoral or extraoral pathologic
2. To improve the condition of the supporting tissues.
conditions.
2. Proper jaw relationship in the anteroposterior,
SCOPE transverse and vertical dimensions.
The scope of preprosthetic surgery includes the following: 3. Alveolar processes that are as large as possible and
1. Ridge preservation procedures as a preventive of the proper configuration (the ideal shape of the
measure alveolar process is a broad U-shaped ridge with
2. Corrective or recontouring procedures of the defects vertical components as parallel as possible).
and abnormalities. 4. No bony or soft tissue protuberances or undercuts.
5. Adequate attached keratinized mucosa in the primary
3. Ridge extension procedures
denture bearing area.
a. Relative methods, e.g. sulcus extension (vestibulo-
6. Adequate vestibular depth.
plasties)
7. Adequate form and tissue coverage for possible
b. Absolute methods, e.g. ridge augmentation
implant placement.
methods
8. Have no muscle fibers or frena that mobilize the
4. Reconstruction methods like correction of abnormal
prosthesis.
ridge relationships.
9. Have no neoplastic lesions.
5. Provision of accessory aids
a. Creating favourable undercuts The various types of preprosthetic surgeries are:
b. Dental implants 1. Ridge preservation
c. Onlay denture 2. Ridge augmentation
6. Modified denture construction procedures e.g. 3. Ridge extension
immediate denture where construction of the denture
precedes surgery. RIDGE PRESERVATION PROCEDURE
Hard Tissue Abnormalities
INDICATIONS Alveoloplasty
Indications for preprosthetic surgery in hard tissue defects It is a plastic surgical recontouring procedure that is done
like: on alveolar ridge to obtain a proper foundation and
1. Knife edge margins of alveolar ridge stability of a denture. Simplest forms of alveoplasty consist
2. Presence of any bony spicules of compression of lateral walls of extraction socket after
3. Presence of any root stumps or cysts simple tooth removal. In many cases of simple tooth
4. Presence of exotosis (bony overgrowth) occurs in extraction digital compressions of extraction site
maxilla in palate. adequately contours the underlying bone provided, there
5. Presence of tori-mandible is commonly involved in are no gross irregularities of bone in the area after
the lingual aspect. extraction.
36 TEXTBOOK OF COMPLETE DENTURE PROSTHODONTICS

Alveoplasty in case of multiple teeth extraction is done labial cortical plate of the alveolar ridge inward to
in two stages: approximate the palatal or lingual plate area more closely.
a. Immediately after extraction or Digital pressure on the labial aspect of the ridge is
b. After a certain level of healing has taken place necessary to determine when the bony cut is complete
and to ensure that the mucosa is not damaged.
Simple Procedure After positioning the labial cortical plate any residual
A conservative alveoplasty in combination with multiple bony irregularities can be contoured using a bone file
extractions is carried out after all the teeth in the arch and the alveolar mucosa can be re-approximated with
have been removed. interrupted or continuous sutures.
After local anesthesia is administered, reflect a proper Advantages:
mucoperiosteal flap exposing the bony protruberance. • Labial prominence of the alveolar ridge can be
A mucoperiosteal incision is given along the crest of the reduced without significantly reducing the height of
ridge with adequate extensions anterior and posterior the ridge in this area.
to the area to be exposed. Flap reflection allows • The periosteal attachment to the underlying bone
adequate visualization and access to the alveolar ridge. can also be maintained, thus reducing postoperative
If adequate exposure is not obtained, small vertical bone resorption and remodeling.
releasing incisions should be given. The objectives of
mucoperiosteal flap reflection are to allow for adequate
visualization and access to the bony structures that
require recontouring and to protect soft tissues adjacent
to this area during the procedure. Depending on the
degree of irregularity of the alveolar ridge area,
recontouring can be accomplished with a bone rongeur,
a bone file or a bone bur in a handpiece alone or in
combination. In any case copious saline irrigation should
be used throughout the recontouring procedure. After
recontouring, the flap should be reapproximated by
digital pressure and the ridge palpated to ensure that all
irregularities have been removed. After copious irrigation
the edges of the flap can be trimmed to remove excess
tissue and sutured with interrupted or continuous sutures.

Dean’s Intraseptal Procedure (Fig. 5.1)


It is done at the time of extraction. This technique is best
used in an area where the ridge is of relatively regular
contour and height but presents an undercut at the depth
of the labial vestibule because of the configuration of
the alveolar ridge.
After exposure of the crest of the alveolar ridge by
reflection of the mucoperiostium, a small rongeur can
be used to remove the intraseptal segment of the alveolar FIGURES 5.1A to G: Dean’s intraseptal (intercortical) alveolo-
plasty. (A) Pre-extraction, (B) Post extraction, (C) Bur used to
bone. After adequate bone removal has been accomp- remove interdental base, (D) Smoothening, (E,F) Compression
lished digital pressure should be sufficient to fracture the of cortices, (G) Primary closure
PREPROSTHETIC SURGERY 37

Maxillary Tuberosity Reduction reflected which exposes mylohyoid ridge area and
Horizontal and/or vertical excess of the maxillary mylohyoid muscle attachments. Mylohyoid muscle fibres
tuberosity may be a result of excess bone, an increase in are removed by sharply incising the muscle attachments
the thickness of soft tissue overlying the bone or both. at the area of bony origin. A rotary instrument or bone
Recontouring of the maxillary tuberosity area may be file can be used to remove sharp prominence of the
necessary to remove bony ridge irregularities / create mylohyoid ridge.
adequate interarch space, which will allow proper
construction of the prosthesis in the posterior area. Genial Tubercle Reduction
Anesthesia may be obtained by local infiltration or Local anesthesia infiltration and bilateral lingual nerve
by posterior superior alveolar nerve block and greater blocks should provide adequate anaesthesia. A crestal
palatine nerve blocks. Crestal incision is made that incision is made from each premolar area to midline of
extends up to the posterior aspect of the tuberosity area. the mandible. A full thickness mucoperiosteal flap is
Reflection of a full thickness mucoperiosteal flap is dissected lingually to expose the genial tubercles. The
completed both in the buccal and palatal directions to genioglossus muscle attachment can be removed by a
allow adequate access to the entire tuberosity area. Bone sharp incision. Smoothening with the bur or a rongeur
is removed either by a side cutting rongeur or rotary followed by a bone file reduces the genial tubercles.
instrument by carefully avoiding perforation of the floor Genioglossus muscle is left to reattach in a random
of the maxillary sinus. After appropriate amount of bone fashion. If the areas of irregularity are small, recontouring
has been removed, the area is smoothened with a bone with a bone file can be done. If the areas of irregularity
file and copiously irrigated with saline. Mucoperiosteal are large, use of a rongeur or a rotary instrument may
flaps can be readapted and excess, overlapping soft tissue be necessary. After the completion of the bone
resulting from the bone removal is excised in an elliptical contouring soft tissue is readapted and visual inspection
fashion. Sutures are allowed to remain in place for seven and palpation assure that no irregularities or bony
days. undercuts exist. Interrupted or continuous sutures are
used to close soft tissue incisions. Sutures removed in
Buccal Exostosis and Excessive Undercuts seven days.
Excessive bony proturberances and resulting undercut
areas are common in maxilla than in mandible. Lateral Palatal Exostosis
Local anesthesia should be infiltrated around the area This presents problems in denture construction because
requiring bony reduction. A crestal incision extends 1 to of the undercut created by exostosis and the narrowing
1.5 cms beyond each end of the area, requiring contour of the palatal vault. Local anaesthesia is adsministered
and a full thickness mucoperiosteal flap is reflected to by greater palatine nerve block and infiltration. A crestal
expose the areas of bony exostosis. Vertical incision can incision is made from the posterior aspect of the
be given for proper access and visibility and the ridges tuberosity extending slightly beyond the anterior area
prepared to give suitable foundation to the prosthesis of exostosis. Reflection of mucoperiosteal flap in the
that is fabricated palatal direction is accomplished with careful attention
to the area of palatine foramen to avoid damage to the
Mylohyoid Ridge Reduction blood vessels as they leave the foramen and extend
Inferior alveolar, buccal and lingual nerve blocks are forward. After adequate exposure, a rotary instrument
required for mylohyoid ridge reduction. Linear incision or bone file can be used to remove excess bony
is made over the crest of the ridge in the posterior aspect projection in this area. The area is irrigated with sterile
of the mandible. Extension of incision too far to the saline and closed with continuous or interrupted sutures.
lingual aspect is avoided as this may cause trauma to No surgical splint or packing is generally required after
lingual nerve. Full thickness muco-periosteal flap is this procedure.
38 TEXTBOOK OF COMPLETE DENTURE PROSTHODONTICS

Excision of Tori
Maxillary tori (Fig. 5.2): Local anaesthesia by bilateral
greater palatine and incisive blocks or local infiltrations
provides the necessary anesthesia for tori removal. A
linear incision in the midline of the torus with oblique
vertical releasing incisions at one or both ends is necessary.
Raise the mucoperiosteal flap carefully. When tori with a
small pedunculated base are present, an osteome and
mallet may be used to remove the bony mass. For larger
tori, it is usually best to section the tori into multiple
fragments with a bur in a rotary handpiece. After
sectioning, individual portions of the tori can be removed
with a mallet and osteotome or a rongeur and area can
be smoothened with a large bone bur. Tissue is readapted
by finger pressure and inspected to determine the
amount of excess mucosa that may need to be removed.
The mucosa is reapproximated and sutured by
interrupted suture technique. Vaseline gauze formed into
a pack and adapted to the palate can be sutured in place
with a 2-0 silk suture tied to the lateral aspects of the
palatal vault, which suspends the Vaseline pack in place
under pressure against the palatal bone. Major compli-
cations of maxillary tori removal include postoperative
hematoma formation, fracture or perforation of the floor
of the nose and necrosis of the flap.
Mandibular tori (Fig. 5.3): They are bony protuberances
FIGURES 5.2A to E: Technique for removal of palatal torus: (A)
on the lingual aspect of the mandible that usually occur Median palatal incision (B) Dental bur used to cut grooves (C)
in the premolar area. Bilateral lingual and inferior alveolar Sharp chisel used to remove small pieces (D) Bone bur used
injections provide adequate anesthesia for tori removal. to smooth the stump (E) Palatal incision sutured
An incision on the crest of the ridge should be made
extending 1-1.5 cm beyond each end of the tori to be smoothen the lingual cortex. The tissue should be
reduced when bilateral tori are to be removed readapted and palpated to evaluate contour and
simultaneously, It is best to leave a small band of tissue elimination of undercuts. An interrupted suture or
attached to midline between the anterior extents of the continuous suture technique is used to close the incision.
two incisions. When the torus has a small pedunculated Gauze packs placed in the floor of the mouth and retained
base, a mallet and osteotome may be used to cleave the for 12 hr are helpful in reducing postoperative hematoma
torus from the medial aspect of the mandible. The line and edema formation.
of cleavage can be directed by creating a small trough
with a bur and a handpiece before using an osteotome. Soft Tissue Abnormalities
It is important to ensure that the direction of the initial Abnormalities of the soft tissue in the denture bearing
bur trough is parallel with the medial aspect of the and peripheral tissue areas include:
mandible to avoid an unfavourable fracture of the lingual • Abnormal muscular and frenal attachments (Figs 5.4
or inferior cortex. A bone bur or file can be used to and 5.5).
PREPROSTHETIC SURGERY 39

FIGURES 5.3A and B: Technique for removal of mandibular


torus: (A) Mucoperiosteal flap reflected to expose large torus
and sharp chisel used to remove it. (B) Large bone bur used
to smoothen the stump

FIGURES 5.5A to E: Lingual frenectomy (A) Preoperative view


(B) Transverse incision made with scalpel or scissor through
the frenum. Deeper dissection with scissor is continued in
the midline until the tip touches the maxillary teeth (C)(D)
FIGURES 5.4A to D: Maxillary labial frenectomy (A) Narrow Margins of the diamond shaped wound undermined with
‘v’shaped incision made around the frenum (B) Fibres of scissors (E) Sutured as a median palatal incision
frenum stripped away from bone and retracted into lip (C)
Small tag of labial mucosa and redundant connective tissue
removed with scissor (D) Wound closed with suture a. Horizontal osteotomy (sandwich technique)
b. Vertical osteotomy (visor’s technique)
• Excessive fibrous or hypermobile tissue (Figs 5.6 and
5.7). Rib Graft Augmentation to the Superior
• Inflammatory lesions such as inflammatory fibrous Border of Mandible (Fig. 5.9)
hyperplasia of the vestibule (Fig. 5.8).
Indications:
• Inflammatory papillary hyperplasia of the palate.
i. Atrophic mandible with decreased vertical height.
ii. Atrophic mandible susceptible to fracture.
ADVANCED PREPROSTHETIC SURGERY iii. Atrophic mandible where there is possibility of
Ridge Augmentation Procedures neural disturbances.
Types Procedure: Incision is made within the fixed crestal
1. Rib graft augmentation to the superior border of tissue after general anaesthesia is administered. Muco-
mandible. periosteal flap is reflected. Grooves in the anterior area
2. Rib graft augmentation to the inferior border of are placed as lingually as possible. Ribs are used for the
mandible. procedure. Rib is adapted to shape of arch and grooved
3. Residual ridge augmentation by pedicled bone flap prior to placement. Ligature with stainless steel wire is
procedure. adapted.
40 TEXTBOOK OF COMPLETE DENTURE PROSTHODONTICS

FIGURES 5.8A and B: Excision of hyperplastic vestibular


mucosa: (A) Excision of inflammatory hyperplasia of the
vestibule (B) Wound healed by granulation

FIGURES 5.6A to F: Excision of fibrous tissue on maxillary


ridge (A)(B) Elliptical incisions made around the hyperplastic
soft tissue masses (C) Block of tissue removed (D) Blocks of
submucous connective tissue are removed so the buccal and
palatal flaps are thinned and mobilized (E)(F) Wound margins
are approximated and sutured

FIGURES 5.9A to E: Rib graft augmentation to the superior


border of mandible: (A) Incision made within the fixed crestal
tissue (B) Periosteum releasing incision (C) Groove in the
anterior area is placed lingually as much as possible (D)
Ligation of the rib strut-the position of the three ligating wires
(E) Final configuration after the graft is placed and the wound
FIGURES 5.7A to B: Excision of fibrous tissue on mandibular sutured
ridge: (A) Thin freely moveable mucosa on the resorbed ridge
(B) Partial excision of the moveable portion of the mucosa with
scissors
Advantage
Disadvantages
• Increase in vertical height.
• Morbidity associated with removal of ribs.
• 70 percent of chance that graft is going to get Other materials used
resorbed. • Illiac crest
• Done under general anaesthesia. • Freeze dried bone
PREPROSTHETIC SURGERY 41

Rib Augmentation to Inferior Border of Mandible


Indications
• Atrophy of alveolar ridge area.
• Prevention and management of fractures of the
atrophic mandible.
Disadvantages
• Increased inter arch distance is not achieved.
• Morbidity of rib harvesting.
• Superior border irregularities.
• Exposed position of the mental nerve, which results
from mandibular atrophy.
• Need for hospitalization.

Pedicle Bone / Interpositional Graft


It was introduced by Haile, which was later modified by
Peterson and Scade.
Advantages
• There is decreased amount of resorption as
continuous blood supply is maintained. FIGURES 5.10A to D: Horizontal osteotomy: (A) Sagittal view
• Since relatively little cancellous bone is needed, donor showing the attachment of the genioglossus and suprahyoid
muscles,which can provide blood supply to a lingual
site morbidity can also be reduced. mandibular bone flap (B) Reciprocating saw inserted from
• As this augmentation repositions the lingual aspect the lateral ,is used to make the horizontal osteotomy in the
of the mandible, a correction of class III ridge body of the mandible (C) When the superior aspect of the
mandible is mobilized it remains attached to the lingual
relationship that can result from severe bony
mucosa and the musculature (D) Cortical struts of the
resorption may occur. mandible are used to stabilize the bone flap and cancellous
marrow is packed in the remaining space
Disadvantages
• Need for hospitalization.
• Allows for more predictable long-term results
• Done under general anaesthesia.
• Decreased incidence of nerve parasthesia.
• Donor site surgery and the inability to wear denture
for 3 to 5 months after surgery. Vertical Osteotomy (Visor’s Technique)
• Postoperative neurosensory deficit has also been (Fig. 5.11)
noted.
In this technique,the bucco lingual dimension of the
Horizontal Osteotomy (Sandwich Technique) mandible is split and lingual cortical plate is repositioned
(Fig. 5.10) superiorly. It extends from retromolar triangle to retro
molar triangle on the other side and from crest of the
It is done by splitting the superior – inferior dimension
ridge to the inferior border of mandible. Osteotomy must
of the residual jaw and bone is grafted into this osteotomy.
be angled laterally so that it will extend completely to
In maxilla, the Le Fort osteotomy with interpositional
inferior border of mandible. Mobilized lingual bone flap
grafting often is used. Useful for augmentation of anterior
is elevated in visor fashion and secured with sutures.
mandible
Cancellous marrow from the illium is placed on the lateral
Advantage aspect of the elevated bone flap. The periosteum may be
• Less resorption needed to be incised to prevent tension during the closure.
42 TEXTBOOK OF COMPLETE DENTURE PROSTHODONTICS

Hydroxyapatite Augmentation (Table 5.1)


It is a dense biocompatible material that can be produced
synthetically or obtained from biologic sources such as
coral. Granular or particle form is most commonly used
for alveolar ridge augmentation. When placed in sub-
periosteal environment adjacent to bone, hydroxyapatite
bonds physically and chemically to the bone.

Augmentation of Mandible with Hydroxyapatite


It can generally be performed on an outpatient basis
using local anaesthesia combined with conscious sedation
techniques.
Procedure: A subperiosteal tunnel technique is used,
which exposes entire superior aspect of mandible. After
tunnel is created, a preloaded beveled syringe containing
hydroxyapatite is inserted in most posterior aspect and
it is injected until the desired height and contour of
mandible is obtained. Insertion of hydroxyapatite from
each lateral incision area augments the anterior of the
mandible. Splints are preferred to minimize hydroxy-
appatite displacement and to improve vestibular form
during postoperative period. Vestibuloplasty and skin
grafting can be performed 8 to 12 weeks after
augmentation.
FIGURES 5.11A to E: Vertical osteotomy (A) Buccal muco-
periosteal flap is reflected,leaving the lingual soft tissue Advantages
attached. (B) Extension of vertial osteotomy (C) Osteotomy • The need for donor site surgery is eliminated.
should be angled laterally so that I will extend completely to
the inferior border of the mandible. (D) Mobilized lingual bone • Done under local anaesthesia.
flap is elevated in visor fashion and secured with sutures (E) • There is no postoperative loss of graft.
Cancellous marrow from the ilium is placed on the lateral • Vascular tissue ingrowth around hydroxyappatite
aspect of the elevated bone flap.the periosteum may need to
be incised to prevent tension during the closure. provides adequate vascular bed for future soft tissue
grafts.
Advantages
• There is decreased postoperative bone resorption. Disadvantages
• Good vertical bone augmentation. • It is difficult to contain the material within the tunnel
• Simultaneous vestibuloplasty procedures can be and obtain adequate absolute height augmentation.
performed. • Nerve dysesthesias.

Disadvantage
Augmentation of Maxilla with Hydroxyapatite
• Need for hospitalization.
• Increased incidence of paresthesia of the mandibular Indications
nerve. • Alveolar ridge resorption results in an inability to
• Postoperative ridge form following visor osteotomy construct a denture.
is poor. • Elimination of undercut areas in maxilla.
PREPROSTHETIC SURGERY 43

Table 5.1: Classification of alveolar ridges and treatment protocol


Class Characteristics Treatment
I Alveolar ridge adequate in height but inadequate in width, usually Hydroxyapatite (HA) alone
with lateral deficiency or undercut areas.
II Alveolar ridge deficient in both height and width and has a knife-edge HA alone
appearance.
III Alveolar ridge resorbed to level of the basilar bone producing concave HA alone or mixed with autogenous
form on posterior areas of the mandible and sharp bony ridge form with cancellous iliac bone
bulbous, mobile soft tissue in the maxilla.
IV Resorption of basilar bone, producing pencil thin, flat mandible or flat HA mixed with autogenous
maxilla. cancellous iliac bone

Procedure: Incision made in mid-line is usually sufficient Goals


for adequate access to both sides of the maxillary ridge. • To provide adequate depth for lateral and buccal
Bilateral vertical maxillary incisions in the canine-premolar flange area.
area can be used to improve visibility. Subperiosteal • To have adequate amount of fixed tissue to form
tunnels are created over crest of the alveolar ridge and denture seal.
hydroxyappatite particles are injected and molded to
Techniques of vestibuloplasty
the desired height and contour of the maxillary ridge.
The incisions are closed with a horizontal mattress 1. Mucosal advancement or submucous vestibuloplasty.
suture. A. Closed submucous vestibuloplasty.
B. Open view submucous vestibuloplasty.
Ridge Extension Procedure 2. Secondary epithelialisation (repethelialisation)
A. Kazanjian’s technique
Vestibuloplasty
i. Godwin’s technique.
It is a sulcus deepening procedure, which is a selective ii. Lipswitch or transpositional vestibuloplasty.
method of ridge extension by deepening the vestibule B. Clarks technique
without any addition of bone. Only the soft tissue i. Periosteal fenestration (tortorelli).
attachments are shifted to a favorable zone in the 3. Grafting vestibuloplasty
jawbones so that more of denture bearing area is available i. Skin.
to increase the retention and stability of the denture. ii. Mucosal.
Indications 4. Lingual sulcoplasty
• High muscle attachments. i. Anterior lingual sulcoplasty.
• Inadequate depth in labial and buccal vestibule. ii. Posterior lingual sulcoplasty.
• Inadequate fixed tissue coverage in denture bearing A. Caldwell’s procedure.
areas. B. Trauner’s procedure.
C. Obwegeser’s technique.
Contraindications
• Patients diagnosed with hypertension, diabetes,
bleeding disorders (haemophilia thrombocytopenic Mucosal Advancement Vestibuloplasty (Fig. 5.12)
purpura). Indication
• Cardiac conditions like myocardial infarction. • Correction of soft tissue attachment on or near the
• Pregnancy. crest of the alveolar ridge of the maxilla.
44 TEXTBOOK OF COMPLETE DENTURE PROSTHODONTICS

Advantages: It provides a predictable increase in


vestibular depth attachment of mucosa and thus
increasing the denture bearing area.

Secondary Epithelialisation
Kazanjian’s technique (Fig. 5.13)
Transpositional flap vestibuloplasty
Indication:
• Adequate mandibular height.
• Inadequate facial vestibular depth from mucosal and
muscular attachments in the anterior mandible.
FIGURES 5.12A to E: Mandibular mucosal advancement • Presence of adequate vestibular depth on the lingual
Vestibuloplasty: (A) Midline vertical incision is made in the aspect of mandible.
vestibule through the mucosa (B) Vertical incision is deepened
to bone and supraperiosteal dissection is performed. (C) Procedure: Incision is made on the labial vestibular
Connective tissue septum separating the submucosal and mucosa and large flap of labial and vestibular mucosa is
subperiosteal tunnels is excised. (D) Mucosa is adapted to reflected. Supra periosteal dissection is performed to
the deepened vestibule. (E) A surgical stent is placed by
circumferential wiring deepen the vestibule. Flap of mucosa is sutured to the
periosteum in the vestibule. Raw lip heals by granulation
• Useful when maxillary alveolar ridge resorption has and secondary epithelialisation. It can be combined with
occurred but the residual bony maxilla is adequate hydroxyapatite augmentation procedures.
for proper denture support. Advantages
• To provide adequate vestibular depth without • Provides adequate results.
providing an abnormal appearance of upper lip with • Do not require hospitalization.
adequate mucosal length available in this area.
Disadvantages
A simple test to determine whether adequate labial
• Unpredictability of the amount of relapse of vestibular
vestibular mucosa is present is performed by placing a
depth.
dental mouth mirror under the upper lip and elevating
the superior aspect of the vestibule to desired post-
operative depth. If no inversion or shortening of the lip
occurs, then adequate mucosa is present to perform a
proper submucosal vestibuloplasty.
Procedure: A midline vertical incision is made in the
vestibule through the mucosa with only mucosa
undermined into the lip and the cheek. Vertical incision
is deepened to bone and supra periosteal dissection is
performed. Connective tissue septum separating the
submucosal and subperiosteal tunnels is then developed.
Mucosa is adapted to the deepened vestibule. A surgical FIGURES 5.13A and B: Secondary epithelialisation vestibulo-
stent is placed and held in place by circumferential wiring. plasty (Kazanjian’s technique): (A) Incision is made on the
labial vestibular mucosa,large flap of labial and vestibular
Maxillary submucosal vestibuloplasty can also be mucosa is reflected.supraperiosteal dissection is performed
combined with hydroxyapatite augmentation of the to deepen the vestibule.(B) Flap of mucosa sutured to the
alveolar ridge area. periosteum in the vestibule
PREPROSTHETIC SURGERY 45

• Scaring in the depth of the vestibule.


• Problems with adaptation of peripheral flange area
of the denture to the depth of the vestibule.
Clark’s technique with Tortorelli’s periosteal fenestration
(Fig. 5.14): Horizontal incision at muco-gingival junction
and supra periosteal dissection done deep into vestibule.
At the base of vestibule, periosteum is incised horizontally.
FIGURES 5.15A to C: Skin grafting or mandibular vestibulop-
Inferior periosteal margin is elevated. Mucosal flap is lasty with mucosa: (A) Incision placed along mucogingival
transferred and sutured to the bone covered with junction. (B) Mucosal flap is sutured to the periosteum at the
periosteum that heals by epithelialisation. base of the vestibule. A skin or mucosal graft is used to cover
the raw periosteal surface and sutured to the wound margins
(C) Graft can be placed on the stent that is secured to the
mandible by circumferential wiring

FIGURES 5.14A to C: Secondary epithelialisation vestibulo-


plasty (Clark’s technique): (A) Horizontal incision at the FIGURES 5.16A to C: Lingual sulcoplasty (Caldwell’s
mucogingival junction.supraperiosteal dissection done deep technique): (A) Incision placed on the crest of the ridge,
into the vestibule. (B) At the base of the vestibule,periosteum mylohyoid muscle is stripped away and the mylohyoid ridge is
is incised horizontally. (C) Inferior periosteal margins is removed. (B) Flap is sutured at the crest. (C) Denture or splint
elevated. Mucosal flap is transferred and sutured to the lower with elongated lingual flanges is fixed with circumferential
periosteal margin. The bone covered by periosteum heals by wires
secondary epithelialization

Skin Grafting or Mandibular Vestibuloplasty


with Mucosa (Fig. 5.15)
Incision is placed along muco-gingival junction and
vestibule is deepened by supraperiosteal dissection.
Mucosal flap is sutured to the periosteum at the base of
the vestibule. A skin or mucosal graft is used to cover FIGURES 5.17 A to C: Lingual sulcoplasty (Trauner’s technique):
(A) The medial surface of mandible is exposed he supra-
the raw periosteal surface and sutured to the wound
periosteal dissection. is severed and mylohyoid muscle is
margins. Graft can be placed on the stent that is secured placed inferiorly with sutures. (B) Periosteal surface is left raw
to mandible by circumferential wiring. (C) Periosteum is coverd with skin graft and stentis placed

Trauner’s technique (Fig. 5.17): By supraperiosteal


Lingual Sulcoplasty
dissection the medial surface of the mandible is exposed
Posterior Lingual Sulcoplasty and mylohyoid muscle is detached from the mylohyoid
Caldwell’s technique (Fig. 5.16): Incision is placed on ridge area and repositioned inferiorly by sutures, thus
the crest of the ridge. Mylohyoid muscle is stripped away effectively deepening the floor of mouth and relieving the
and mylohyoid ridge is removed. Flap is sutured at the influence of mylohyoid muscle on denture. Periosteal
crest. Denture or splinting with elongated lingual flange surface is left raw or periosteum is covered with skin grafts
is fixed with circumferential wirings. and stent is placed.
46 TEXTBOOK OF COMPLETE DENTURE PROSTHODONTICS

SELF-HELP QUESTIONS
1. Classify preprosthetic surgeries.
2. Mention the simplest forms of alveoloplasty.
3. Define vestibuloplasty.
4. What is Deans interseptal alveoloplasty.
5. What is Clarks procedure of vestibuloplasty.
FIGURES 5.18A to C: Obwegeser’s technique: (A) Incision on 6. Elaborate on Kazanjians procedure of vestibulo-
mucogingival junction on both facial and lingual surface supra-
periosteal dissection done mycohyoid and genioglossal
plasty .
muscle stripped (B) Split thickness skin graft secured to the 7. Elaborate on Obwegeser’s technique.
stent and are placed over mandible by circumferential wiring 8. Elaborate on Visor osteotomy.
(C) Skin adhered to raw periosteal surface
9. Elaborate on sandwich technique.
Obwegeser’s Technique (Fig. 5.18) 10. Elaborate on horizontal ridge augmentation
procedure.
Incision is done on mucogingival junction of both facial
11. Mention the common sites for mandibular tori
and lingual surfaces. Supraperiosteal dissection is done.
12. What are the types of vestibuloplasty?
Mylohyoid and genioglossus muscles are stripped. Split
13. Mention the recent advances in preprosthetic
thickness skin graft secured to the stent is placed over
surgery.
mandible by circumferential wiring.
14. What are the various alloplastic materials for ridge
Advantages augmentation?
• Early covering of the exposed periosteal bed, this 15. Mention the autogeneous bone graft sites.
improves patient comfort and allows earlier denture 16. What do you understand by superior border
construction. augmentation?
• Long-term results of vestibular extension are 17. What do you understand by inferior border
predictable. augmentation?
Disadvantages 18. Mention the various types of incisions for
• Need for hospitalization. alveoloplasty.
• Donor – site surgery combined with moderate 19. Elaborate on tuberoplasty.
swelling. 20. Mention the armamentarium for alveoloplasty
• Discomfort experienced postoperatively. 21. What are the indications for vestibuloplasty?

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