Pre prosthetic surgery

PRE PROSTHETIC
SURGERY
Dr. Saleh Bakry
Assistant Professor of Oral and
Maxillofacial Surgery

Definition
Corrective operations performed
before denture construction and
placement.

Objectives (goals - Aims) of
preprosthetic surgery
• Improvement of masticatory function.
• Reconstruction of acceptable facial and dental
esthetics.
• Creation of broad ridge form for denture and
implant.
• Adequate fixed soft tissue over denture bearing area.
• Adequate vestibular depth.
• Proper inter arch relationship.
• Protection of neurovascular bundle.

PATIENT EVALUATION BEFORE
CORRECTIVE SURGERY
1. History:
• Pt. chief complaint.
• Pt. expectations of surgical and preprosthetic
treatment.
• Esthetic and functional goal of the pt.
• Psychological factors and adaptability of the pt. to
function with P.D or C.D. dentures.
• Systemic diseases that may affect bone or soft tissue
healing.

2. Intra oral and extra oral clinical
examination:
A. Evaluation of supporting hard bony
tissue
• This occur by visual inspection, palpation,
radiographic examination and evaluation of
models.
I. Evaluation of denture bearing area of maxilla
• No bony undercuts or gross bony protuberance.
• Adequate post-tuberosity notching for denture
stability and seal.

II- Evaluation of mandibular ridge
• Gross ridge irregularities, tori and buccal
exostosis.
• Moderate to severe resorption of alveolar bone.
• Muscular and mucosal attachments near the
crest of ridge.
• The location of mental nerve.

B-Evaluation of supporting soft tissue
to detect
• Quality of tissue in denture bearing area.
• Degree of keratinization.
• Degree of tissue mobility.
• Presence of inflammation.
• Presence of irregularities at depth of vestibule.
• Inspection of lingual aspect of mandible by
mirror to determine level of mylohyoid and
Geniohyoid.
• Depth of lingual vestibule through different
tongue position.

C. Evaluation of interarch
relationship:
• This includes antro-posterior and vertical
relationship and skeletal asymmetries that may
exist between maxilla, and mandible.
• Proper radiographs like panoramic views and
cephalometric radiograph are important for
initial diagnosis and treatment plan

3. Lab. Investigations:
• Serum (calcium level - phosphate level)
• Alkaline phosphatase enzyme.
4. Radiographic examination:
• Panoramic radiograph provides information
about: (Pathological lesions — impacted teeth
— remaining roots)

CLASSIFICATION OF RIDGE
ACCORDING TO RESORPTION
BEHAVIOR (LEVEL)
• Class I: adequate height but inadequate
width.
• Class II: inadequate height and width.
• Class III: at the level of basal bone.
• Class IV: resorption of basal bone.

Factors affect ridge resorpation
General factors:
• Systemic bone diseases.
• Osteoporosis
• Endocrine dysfunction.
Local factors:
• Alveoloplasty.
• Surgical removal of teeth.

Characteristics (criteria) of an
ideal denture support ridge
1. Adequate bony support:
• No irregularities.
• No sharp edge.
• No undercuts.
• No exostosis.
2. Bone covered by adequate attached keratinized mucosa:
• Not flabby.
• Adequate vestibular depth.
• No hypertrophy.
• No ulceration.
3. Freedom from pathologic or neoplastic disease.
4. Satisfactory relationship of the maxillary and mandibular
alveolar ridge.

TREATMENT
PLANNING OF THE
PREPROSTHETIC
SURGERY

1. Basic (Traditional)
Operations:
• Soft tissue operations.
• Bony operations.
2. Advanced (contemporary)
operations:
• Ridge augmentation.
• Ridge extension (vestibuloplasty).
• Ridge relationships.

I. BASIC
PREPROSTHETIC
SURGICAL
TECHNIQUES

A. SOFT TISSUE OPERATIONS:
• Labial frenectomy.
• Lingual frenectomy.
• Denture fissuratum.
• Flabby ridge.
• Maxillary tuberosity soft tissue reduction.
• Inflammatory papillary hyperplasia of the
palate

B. BONY OPERATIONS:
I. Alveolar ridges recontouring (Alveoloplasty)
• Alveolar compression.
• Simple Alveoloplasty.
• Intra septal Alveoloplasty.
 Dean’s alveoloplasty.
 Obwegeser’s modification.
II. Tori removal:
• Maxillary tori.
• Mandibular tori.

B. Bony operations:
III. Maxillary tuberosity reduction:
IV. Buccal exostosis
V. Mylohyoid palatal reduction

II. ADVANCED OR
CONTEMPORARY
PREPROSTHETIC
PROCEDURE

A. RIDGE AUGMENTATION
I. MANDIBULAR AUGMENTATION:
• Superior border augmentation.
• Inferior border augmentation.
• Pedicle or interpositional bone graft (visor
osteotomy augmentation).
• Hydroxyapatite (HA) augmentation.

A. RIDGE AUGMENTATION
II. MAXILLARY AUGMENTATION:
• Onlay bone grating.
• Interpositional bone grafting.
• Hydroxyapatite (HA) augmentation.
• Tuberoplasty.

B. RIDGE EXTENSION (VESTIBULOPLASTY)
I. MANDIBULAR VESTIBULOPLASTY:
• Lingually based flap vestibuloplasty
(Kazanjian).
• Transpositional flap vestibuloplasty (Lip
switch).

B. RIDGE EXTENSION (VESTIBULOPLASTY)
II. MAXILLARY VESTIBULOPLASTY:
• Submucosal vestibuloplasty.
III. Grafted vestibuloplasty.
• Full thickness skin.
• Split thickness skin.
• Palatal mucosa.
• Cheek mucosa.

I. BASIC
PREPROSTHETIC
SURGERY (SOFT
TISSUE
OPERATIONS)

1. LABIAL FRENECTOMY
Indication for removal:
• A highly attached frenum interfering
with the peripheral seals of the
denture and dislodge the denture.

2. LINGUAL FRENOTOMY
• It is a congenital condition. The patient is
unable to protrude the tongue.
Indications for removal
• Speech difficulty.
• Prevents seating and retention of the
mandibular denture during speech or
mastication.

Intraoperative possible complications
• Injury to superior lingual vessels.
• Injury to Wharton’s duct/papilla.

3. DENTURE FISSURATUM (DENTURE
GRANULOMATA)
Etiology
• Ill-fitting denture.
Treatment
1. Early stages
• The lesion may shrink and even disappear if the
offending denture is either not worn for a period.
• New denture should then be constructed.
2. Late stages
• The lesion should be excised before new dentures are
constructed.
• Challenge: Great care and skill are required to
preserve the shallow sulcus that remains after their
excision.

4. FLABBY RIDGE (UNSUPPORTED HYPER
MOBILE TISSUE)
By definition it is a pendulous gingival ridge
with lack of bony support.
Etiology
• Excessive occlusal trauma due to lack of
posterior support, which causes bone
resorption.

5. MAXILLARY TUBEROSITY REDUCTION
(SOFT TISSUE EXCESS)
It is a fibrous tissue accumulates in the
maxillary tuberosity region.
Causes
• Periodontal disease around natural
maxillary molars.
• Overgrowth of the soft tissues distal to an
over erupted unopposed maxillary molar.

FIBROUS HYPERPLASTIC MAXILLARY TUBEROSITY

6. INFLAMMATORY PAPILLARY
HYPERPLASIA OF THE PALATE
Causes:
• Chronic irritation by a denture.
• Poor oral hygiene
• Fungal infection.
Clinically:
• This condition usually appears as multiple
nodular projections in the palatal tissue.

6. PAPILLARY PALATAL HYPERPLASIA

II. Basic
preprosthctic
surgery (Bony
operations)

1. Alveoloplasty
TYPES
Alveolar
compression
Simple
alveoloplasty
Dean’s
intraseptal
Obwegesser’s
technique

1. ALVEOLAR COMPRESSION
• Easiest & quickest method
• Involves compression of cortical plates
with fingers
• Reduction in socket width

2. SIMPLE ALVEOLOPLASTY
• It is simply reshaping the alveolar process by
removal of all sharp and rough bony
projections.
Indications:
• Facilitate removal of teeth.
• Correct irregularities of the residual alveolar
ridge following removal of teeth.
• Removal of undercuts for denture
reconstruction.
• Removal of excessive ridge height to ↓ inter-
maxillary space.

Types:
• Alveoloplasty after Extraction of Single
Tooth.
• Alveoloplasty after Extraction of Two or
Three Teeth or multiple extractions.
• Recontouring of Edentulous Alveolar
Ridge.

A. Alveoloplasty after
Extraction of Single
Tooth

Slide Title
B. Alveoloplasty after
Extraction of Two or
Three Teeth or multiple
extractions.

C. Recontouring of
Edentulous Alveolar
Ridge.

3. DEAN’S INTERSEPTAL ALVEOLOPLASTY
• Only done in maxillary anterior region to
reduce gross maxillary overjet.
• Mostly done immediately after extraction
of anterior teeth.

4. OBWEGESER’S MODIFICATION OF
DEAN’S ALVEOLOPLASTY
• In this both the labial and palatal cortices
are repositioned.
• This is done when the anterior overjet is
too gross that cannot be reduced by labial
plate repositioning.
Procedure:
• Procedure is same as dean’s alveoloplasty
but the only addition is that, here palatal
plate is fractured too at its base and
repositioned with labial plate in palatal
direction.

Slide Title
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• Alveoloplasty: means Bone contouring of
the alveolar ridge.
• Alveolectomy: means Removal of
projecting interseptal bone.
• Alveolotomy: means cutting through the
alveolar process as in surgical removal of
R.R or impacted tooth.

A. MAXILLARY TORI (TORUS PALATINUS)
• It is a congenital exostosis usually situated in the
midline of the palate.
• An extremely large torus, filling the palatal vault.
• Ulceration/traumatization/hyperkeratinization of
the overlying mucosa.
• Deep bony undercuts.
• Interference with the function—speech-deglutition.
• Psychological consideration—malignancy/cancer
phobia.
• Food lodgment under the folds and projection of
the tori.

Complications of maxillary tori removal:
Intra-operative complication
• Fracture of the palatal process and nasal
floor
• Injury to the greater palatine nerve.
• Oronasal/ oroantral bleeding.
Post-operative complication
• Necrosis of the palatal mucosa.
• Hematoma formation.
• Oronasal/ oroantral fistula.

B. MANDIBULAR TORI (TORUS
MANDIBULARIS)
• It is a congenital exostosis situated on the
lingual surface of the mandible in the canine -
premolars area, and is usually bilateral.
• If they cause pain, ulceration or difficulty to
denture wearers.

Possible complication
1. Intra-operative complication:
• Injury to the submandibular salivary gland
duct.
• Excessive bleeding.
• Laceration of the mylohyoid ridge.
• Tearing of the flap complication.
2. post-operative complication:
• Life threatening hemorrhage in the floor of
the mouth.
• Infection.
• airway obstruction.

3. MAXILLARY TUBEROSITY REDUCTION
(BONE EXCESS)
Horizontal and/or vertical excess of the
maxillary tuberosity area may be the result of
excess bone, excess thickness of the soft
tissue overlying bone or both.

Complications:
Perforation in the floor of the sinus:
• No specific treatment is required.
• Tension free water tight seal closure over
the area for 10- 14 days.
• Postoperative antibiotics and
decongestants should be given for 7 - 10
days postoperatively.
• Ask pt. to avoid creation of excessive
sinus pressure such as nose blowing for
10 - 14 days.

4. BUCCAL EXOSTOSIS
• Buccal exostoses are more common in
maxilla than in mandible.
• Buccal exostosis presents problems in
denture construction because of the
undercut created by exostosis.

5. MYLOHYOID RIDGE REDUCTION
(LINGUAL BALCONY REDUCTION)
• It is a prominent internal oblique ridge and
it is also called lingual balcony.
• These bilateral ridges result from advanced
resorption of the alveolar process.
Indications for removal
• pain when the lingual flange of the denture
compresses the intervening soft tissue
against it.
• Affecting the stability of the denture.

II. ADVANCED
PREPROSTHETIC
SURGERY

INDICATIONS OF RIDGE AUGMENTATION
• When there is extreme resorption of the alveolar
ridge i.e. when there is less than 2 cm of bone
height.
AIM OF RIDGE AUGMENTATION
• Restoration of ridge height and width, ridge form,
vestibular depth and denture bearing area.
• Protection of neurovascular bundle.
• Establishment of proper interarch relationship.
• Improvement of retention and stability of denture.

MATERIALS USED FOR AUGMENTATION
Graft:
• portion of a tissue or organ that after
removal from its origin or donor site is
positioned or inserted at a different place
with the objective of reinforcing the
existing tissues &/or correcting a
structural defect.

Classification
According to
structure
Cortical
Cancellous
Cortico-
cancellous
According to
source
Autograft
Allograft
Xenograft
Alloplast
According to
embryologic
origin
Membranous
Endochondral

Autogenous
Grafts
Distant sites
•Rib
•Iliac crest
•Calvarium
•Fibula
•Tibia
Local sites
•Chin
•Body and ramus
•ZM buttress
•Coronoid

1. SUPERIOR BORDER GRAFT:
• Source of graft material: ribs / iliac crest /
freeze dried bone.
• Fixation: Circumferential wiring or
Tranosseous wiring or Screws or Implants.
Advantages
• Adds strength / contour / height / preserve
mental nerve at the location of mental
foramen / decrease inters arch distance.

Disadvantages
• The morbidity associated with removal of
ribs.
• Significant postoperative resorption of
graft.

2. INFERIOR BORDER GRAFTS
Indication and advantage:
• Management of Severely atrophic alveolar ridge
in addition to prevention and management of
atrophic mand.
• This occurs by using a rib for augmentation of
inferior border of mand.
Disadvantage:
• This procedure can't solve the problems of:
• Wide interarch space
• Irregularities of superior border.
• Exposed position of mental nerve at superior
border.

3. MANDIBULAR AUGMENTATION;
PEDICLE GRAFT (VISOROSTEOTOMY)
• The mandible is split sagitally in the
buccolingual dimension and the lingual
cortex is moved vertically to gain height.

4. MANDIBULAR AUGMENTATION
INTERPOSITIONAL BONE GRAFT
• This technique involves a horizontal
osteotomy separating the residual ridge
of the maxilla or the mandible and bone
is grafted into this osteotomy.
• The bone graft can be autogenous or
allogenic bone.

4. MANDIBULAR AUGMENTATION
INTERPOSITIONAL BONE GRAFT

5. HA AUGMENTATION OF THE
MANDIBLE:
• HA augmentation is done by subperiosteal
tunnel technique.

6. ALVEOLAR SPLIT GRAFT (RIDGE SPLIT
OSTEOTOMY)
• Used to gain width for the alveolar ridge→
expanding the knife edge ridge in a B-L
direction.
• It is easier in the maxilla.
• Requires a minimum of 4 mm wide alveolar
crest.

6. ALVEOLAR SPLIT GRAFT (RIDGE SPLIT
OSTEOTOMY)

7. ALVEOLAR DISTRACTION
OSTEOGENESIS:
• Distraction osteogenesis (DO) is a biologic
process of new bone formation between
surfaces of bone segments which are
gradually separated by traction forces.

7. ALVEOLAR DISTRACTION
OSTEOGENESIS:

1. ONLAY BONE GRAFTING:
• We use 2 ribs or iliac crest bone graft fixed
with screws to the atrophic maxillary arch.

2. INTER POSITIONAL BONE GRAFT
(LE FORT I OSTEOTOMY).
• We use iliac crest bone graft.
• Augmentation is completed by down
fracturing maxilla (le fort I osteotomy) and
placing interpositional graft using autogenous
iliac crest bone graft.

3. MAXILLARY HA AUGMENTATION:
• Subperiosteal tunnel technique is used.

4. TUBEROPLASTY
• Tuberoplasty is designedto deepen the
hamular notch by fracturing the pterygoid
plate and hamulus and positioning them in a
post. direction to deepen the notch and to
improve denture retention.
Indication:
• Adequate ridge and palatal vault but
inadequate notching in tuberosity hamular
area, so no peripheral seal of Max denture.
Disadvantage:
• Risk of hemorrhage.
• Unpredicted deptli.of nothcing after healing.

2. Ridge Extension
(Vestibuloplasty)

• By definition, it is surgical deepening of the
vestibule without any addition of bone.
Idea
• It is the repositioning the overlying mucosa, or
muscle attachments, to a lower position in the
mandible or to a superior position in the maxilla
leading to larger denture flange.
Requirements
• Adequate alveolar bone with sufficient height
remaining. i.e. 15 to 20 mm or greater of the
denture bearing area is present.
• If the bone is less than 15 mm ridge
augmentation is the treatment of choice.

A. MANDIBULAR
RIDGE EXTENSION
(MANDIBULAR
VESTIBULOPLASTY)

1. Lingually based flap vestibuloplasty
(Kazanjian) (secondary epithelialization
vestibuloplasty).

1. Lingually based flap vestibuloplasty
(Kazanjian) (secondary epithelialization
vestibuloplasty).
Indication:
• Adequate mandibular ridge height. (15
mm at least).
• Inadequate vestibular depth in buccal
side due to high mucosal and muscle
attachment.
• Adequate vestibular depth from lingual
side.

2. Trans positional flap vestibuloplasty
(lip switch):

2. Trans positional flap vestibuloplasty
(lip switch):
• It is a modified kazanjian procedure.
• Incising periosteum at crest of the alveolar
ridge and suturing free periosteal edge of
this periosteal flap to exposed labial tissue.
• Then mucosal flap is sutured over the
exposed bone to the periosteal junction at
depth of the vestibule.

Advantages
• Do not require hospitalization.
• There is no donor site surgery.
• Does not require prolonged periods without a
surgery.
Disadvantages
• Unpredictability of the amount of relapse of
the vestibular depth.
• Scarring at the depth of the vestibule.
• Problems with the adaptation of the peripheral
flange area.

3. SUB MUCOSAL VESTIBULOPLASTY

B) MAXILLARY
EXTENSION
(MAXILLARY
VESTIBULOPLASTY)

Indications
• Adequate underlying bone is present, but
the clinically apparent ridge is shallow.
Examination
• A useful test is to push a mirror superiorly
into the labial sulcus; if the lip is not
inverted or drawn by the mirror leading to
sufficient mucosa for this type of surgery.

C. GRAFTING
VESTIBULOPLASTY–
MUCOSAL VS. SKIN

• Donor sites of mucosal grafts are varied.
Such as the inside of the cheek (obtained by
the mucotome), a full thickness mucosa
could be removed from the palatal mucosa.
Types of grafts:
• Skin graft
• Palatal graft.
• Mucosal graft (cheek).
• Allogenic dermal grafts.

Skin graft vestibuloplsaty
Advantages:
• For cases which require more covering than mucosal
graft.
• Skin resists mechanical insult such as pressure
better than mucosa.
Requirements
• The graft should be obtained from a hairless area
(e.g.) the inner thigh, the medial side of the
forearm.
• A thin graft is preferable to a thick one.
• The recipient area should have a good blood supply
and be free from infection.
• The graft should cover all the raw area and should
be immobilized with great care under moderate
pressure.

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