Prepostetic Surgery PDF
Prepostetic Surgery PDF
Prepostetic Surgery PDF
PREPROSTHETIC SURGERY 35
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.
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
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
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
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?