Presented by, Abhi A IV BDS (Part II) Annoor dental college

INTRODUCTION
A significant number of prtients can never be made to use dentures effectively because of bone atrophy,soft tissue hypertrophy or localized soft and hard tissue problems or all of them. various treatment methods to improve patients denture foundation and ridge relations are: Nonsurgical Surgical Combination of both

Nonsurgical methods

Rest for denture supporting tissues Occlusal correction of the old prosthesis Good nutrition Conditioning of the patients musculature

Characteristic of ideal denture bearing area

Adequate bone support. 2. Adequate firm soft tissue coverage. 3. No bony or soft tissue undercut or prominences. 4. No sharp ridges. 5. No high muscle or frenal attachments. 6. No presence of peripheral fibrous tissue bands to prevent proper seating. 7. No soft tissue hypertrophies on the ridges or in the sulci. 8. No intraoral or extraoral pathology. 9. Proper alveolar ridge relationship in all three planes.
1.

Preprosthetic surgery.
Preprosthetic surgery is carried out to reform/redesign soft / hard tissues by eliminating biological hinderness to receive comfortable & stable prosthesis.

Aims of preprosthetic surgery

1.To provide adequate bony tissue support for the placement of rpd /cd. 2. Provide adequate soft tissue support ,optimum vestibular depth. 3. Elimination of the pre-existing bony deformities eg. Tori, promoinent mylohyoid ridge,genial tubercle. 4. Correction of mandibular and maxillary ridge relationship. 5. Elimination of preexisting deformities.eg. epulis,flabby ridges, hyperplastic tissues. 6. Relocation of frenal or muscle attachments. 7. Relocation of mental nerve. 8. Establishment of correct vestibular depth.

Preprosthetic surgical procedures .

Alveolar ridge correction Alveolar ridge extension Alveolar ridge augmentation.

Alveolar ridge correction

Bony surgeries.

Labial alveolectomy. Primary alveoplasty. Secondary alveoloplasty. Excision of tori. Reduction of genial tubercle. Reduction of mylohyoid ridges. Maxillary tuberosity reduction

Soft tissue surgeries:

Removal of redundant crestal soft tissue.

Frenectomy labial & lingual. Excision of epulis fissuratum & palatal hyperplasia.

ALVEOLECTOMY.
Surgical removal or trimming of the alveolar process. Trimming done with roungeur or round bur and smoothened with bone file. Use in the presence of sharp margins at interseptal or labiobuccal alveolar ridge. Too much bone loss will result in poor denture base.

Single tooth alveolectomy

Simple Alveoloplasty
Refers to surgical recontouring of the alveolar process. Primary alveoloplasty always done at the time of multiple extraction or single extraction. Minimum amount of alveolar bone resorption occurs if after simple extraction ,digital compression of the aqlveolar cortices done immediately.

Intraseptal alveoloplasty deans alveloplasty with repositioning of labial cortical bone.

Used in maxilla. Used to reduce gross maxillary overjet. To reduce the volume of Cancellous bone , maintaining stress bearing cortical bone intact. Not require for raising mucoperiosteal flap. Carried following extraction of anterior teeth immediately. Maintain periosteal attachment to the labial plate of bone. It will reduce buccal undercut or labial prominence without reducing the height of residual alveolar ridge. Best long time result. Indicated in cases , in which the adequate bone height exists.

Indications 1.Multiple extraction 2.Early initial post extraction period. Steps 1.removal of bone followed by 2.repositioning of the labial corttical bone. Technique Teeth should be extracted avoiding trauma to the labial cortex. Interdental septal bone is cut from canine to canine region with the straight fissure bur attached to surgical handpiece or with rongeur. With the same bur ,vertical cuts are made only in the labial cortex at distal end of the canine extraction sockets bilaterally without perforation of the labial mucosa in the deans technique.

With periosteal elevator /osteotome placed in the base of the canine socket bilaterally, labial cortex is fractured. Digital pressure is used to compress the fractured labial cortex into the palatal direction. Labial and palatal plate will come into approximation with each other. Interrupted continous suturing is carried out.

Obwegessers modification for interseptal alveoloplasty

Indication Gross max.overjet.( when compression of the labial cortex is not sufficient) After cutting the interseptal bone ,an inverted cone vulcanite bur is used to widen the socket. With small bur ,horizontal cuts are made at the base of the extraction socket in the labial and palatal cortices. Vertical cuts then made bilaterally in both the labial and palatal cortices in the area distal to the canine socket. With digital pressure,both the labial and palatal cortices are compressed together and sutures are given. Immediate denture delivery is planned ,used as a template to check for any pressure points.

Alveoloplasty with post extraction healing

Crestal incision is taken not to tear the mucoperiosteal flap, but the reflection Side ways separation with the periosteal elevator will help the smooth reflection. Sharp areas or large undercuts should be trimmed with rongeur. And suturing done.

Elimination of unfavourable undercut

Usually done in the mandibular lingual aspect (genial tubercle , sharp mylohyoid ridge prominence.) Seen in patients wearing old dentures, due to resorption over the years,the denture become unstable

Reduction /resection of the genial tubercle

Are bony attachments of genioglossus muscle. Are seen on the crestal level on the lingual aspect.

Technique

Crestal incision is made from the lower canine to canine region , after infilteration of the LA. No reflection of flap done on the labial side. Full thickness flap is reflected to expose the genial tubercle. Excision of tubercle is done by rotary instruments . Smoothening can be done by a bone file. Irrigation should be done before suturing.

Reduction of mylohyoid ridges

Done with IFAN block. Crestal incision taken in the posterior ridge region. Mucoperiosteal flap reflected on the lingual side to expose the medial surface of the mandible at the mylohyoid ridge region. Tissue from the floor of the mouth and lingual mucoperiostium are protected by inserting the flat blade of the tongue depressor . The reduction of the mylohyoid ridge is carried with osteotome or round bur ,after dissecting mylohyoid fibres away. Bone is smoothened with bone file. Soft tissue flap is returned back and the complete lingual vestibule checked with digital pressure for any sharp areas. After complete smoothening sutures are given.

Excision of tori
Indications Large torus ,filling the palatal vault. Large torus extending beyond the postdam area. Ulceration or traumatisation or hyperkeratinisation of the overlying mucosa. Deep bony undercut. Interference with function. Psychological consideration. Food lodgement.

Technique

Under LA ( bilateral grater palatine and incisive nerve block) A-P linear incision in the midline of the palate. Y shaped releasing incision at one or both the ends of the incision. Two mucoperiosteal flaps raised with periosteal elevator from th midline sideways. Retraction sutures placed on both the flaps to minimize the exposure. Division of the torus into the multiple segments should be done with the bur. Small pieces removed with chisel and mallet. Conyinous over and under type suturing using fine absorbable suture material. Prefabricated acrylic stent or splint or iodoform pack can be given to prevent heamatoma.

Mandibular tori removal.

Technique IFAN block is given. Incision over alveolar ridge in lower premolar region. Mucoperiostral flap is raised Make a purchase point or groove with bur on medial aspect of the tporus. Cleavage taken with a osteotome. Smoothen with roud bur or bone file. Irrigatre band suture.

Maxillary tuberosity reduction and exostosis removal

Technique Under infilteration or PSA nerve & GPN block. Crestal elliptical incisions from tuberosity to premolar area. Periostium is reflected and tissue present b/w the crestal incision removed with chisel mallet or bur. Flap is sutured and stent is placed.

Soft tissue surgeries

Removal of redundant crestal soft tissue - eg . enlarged tuberosity, enlarged retromolar pad. Denture granuloma or hyperplasia. To reduce this elliptical incision taken on either sides of the tissue . Excision of epulis fissuratum. Sharp excision Electrocauterisation Cryosurgery Laser excision Palatal papillary hyperplasia. Supraperiosteal excision.

Frenectomy
Indications High attachment of frenum. Ulceration at the frenal attachment a due to overuse of the denture

TECHNIQUE Crosssdiamond excision. Base of the frenum at the alveolar crest is grasped with the hemostat and incision is taken below and above the hemostat. Surgical defect created by excision of fibrous bands. Z plasty procedure can be done.

Lingual frenectomy
Indication Tongue tie Technique Bilateral lingual nerve block Submucosal dissection done on either side . Dissection of genioglossus muscle and suture it.

Ridge extension procedure

Vestibuloblasty or sulcoplasty It is a deepening procedure of vestibule. Mandibular techniques done on labial side done on lingual side labial vestibular procedure transpositional flap vestibuloplasty or lip switch procedure Indications Used when patient has a bone ht of 15mm or more in the ant region

Techniques
kazanjian technique (1924) oldest technique use mucosal flap from the inner aspect of lower lip. Carried out in premolar to premolar region. Procedure

submucosal dissection is done and directed inferiorly to remove muscle and connective tissue attachments. Raised mucosal flap is adapted to the new vestibule and Suture is done

Godwin s modification (1947)

Mucosal incision in inner aspect of lip is longer than the proposed vestibular depth . Labial periosteal margin is sutured to the incised lip mucosa. Stent is placed.

Clarks technique

Supraperiosteal flap on the inner aspect of lip leaves a raw surface on the bone covering the inner lips surface . Incision started labial to the crest Supraperiosteal dissection is done along the labial surface till the vestibular depth. Edge of the mobilized flap is pushed into the new vestibular area and held in position by sutures . Alveolar bone is covered by periosteal layer.

Obwegessers modification

Similar to clarks method except the area of alveolar bone with its periosteal attachment covered with split thickness graft. Advantages Covers the bone and ensures fast healing Less bone loss and scarring .

Lingual vestibuloplasty
Indication In case where mylohyoid and genioglossus close to the alveolar ridge. Trauners technique Incision is done from 2nd molar to 2nd premolar region Supraperiosteal dissection is done Instrument paseed below mylohyoid muscle and separate it from bony attachment. Fixation of mylohyoid muscle to new desired vestibular depth by sutures.

Caldwells technique

Here mylohyoid muscle superficaial fibrees of genioglossus muscle pushed inferiorly. Rubbertubing placed in the lingual vestibule and flap is held in position by sutures

Obwegessers technique
Lingual vestibuloplasty + buccal vestibuloplasty Edges of buccal and lingual flaps are raised and sutured below the inferior border of the mandible. Skin graft is placed over the entire alveolar ridge. Acrylic stent or denture placed and fixed to mandible with circummandibular wiring.

Submucosal vestibuloplasty technique Indication Shallow vestibular depth with good underlying bone height and contour. Technique Vertical midline incision is made in the labial vestibule. Supraperiosteal tunnel from one premolar to other . Intervening submucosal tissue excised or repositioned superiorly.

Max.pocket inlay vestibuloplasty (obwegesser)

Procedure involves surgical creating pockets in the max,mattress and pyriform aperture region helps in the denture extension into the pockets. Intraoral incision is taken just above the attached gingiva from one maxillary buttress to the other buttress. Supraperiosteal dissection is performed to create two pockets on either side of pyriform aperture. Dissection is extended superiorly to the level of attachment of the levator anguli oris. Also continued in the midline upto the base of the pyriform aperture. Impression is taken with the impression compound. Labial flanges of the dentures then covered with split thickness skin graft. Bilateral circumzygomatic wires and pyriform margin wires used to stabilize the denture.

Mental nerve transposition

Patients with severe mandibular atrophic ridges. Complain of pain after wearing denture because of superior position of the mental neurovascular bundle. Repositioning of the mental nerve should be done. A crestal incision is taken with buccal releasing incision in the region of premolars. Mucoperiosteal flap is reflected inferiorly to locate the nerve. Dissection below the foramen till the inferior border of the mandible should be done and the nerve is freed lightly and held with hook upward. Bony groove is cut below the mental foramen,only in the buccal cortex. Nerve is positioned inferiorly and secured in place with the gelfoam and flaps is sutured.

Ridge augmentation procedures

Alveolar ridge resorption is so extreme that the alveolar bone is completely disappeared., in this case vestibuloplasty is not done. Two appointments are available Augmentation of alveolar bone. Place the implants.

Procedures
Mandibular augmentation 1. Superior border augmentation Bone grafts cartilage graft

alloplastic grafts

2.inferior border augmentation bone grafts . cartilage grafts

3.interpositional or sand witch bone grafts Bone grafts cartilage grafts hydroxyapatite blocks

4. visor osteotomy 5.onlay grafting autogenous allogenous alloplastic B. maxillary augmentation. Onlay grafting Onlay grafting of alloplastic material Interpositional or sandwitch grafs Sinus lift procedure

Augmentation in combination with orthognathic surgery mandibular osteotomy procedure maxillary osteotomy procedure Combination Materials for augmentation of alveolar ridge autogenous grafts iliac crest rib graft allogenic bone freeze dried cadaver bone. Alloplastic material Hydroxyapatite

Mandibular augmentation Superior border grafting or augmentation Use 15 cm rib graft . Fixed to mandibvle with trans osseous wiring of circum mandibular wiring. Disadvantage Donor site morbidity Continued resorption of grafted sites. Soft tissue dehiscence or limitation.

Inferior border grafting It is indicated when the arch less than 58 mm in height. Procedure Supraclavicular incision followed by subplatysmal incision till the inferior boredr of the mandible. Freeze dried alloogenic cadaver mandible is hollowed out and multiple perforations made into it and it is used as atray. It is then filled with autogenous cancellous graft particles fixed to the inferior border with 2-0 vicryl sutures by cicummandibular fixation

Interpositional bone grafting ( sandwitch bone grafting) Horizontal osteotomy is performed Splitting is done and bone graft is grafted into this gap In mandible , autogenic or allogenic bone or hydroxyapatite grafts can be used. Delivery of aplliance is delayed for 3-5 months.

Onlay grafting

Used in case of inadequate width but adequate height for the maxilla or mandible Oldest technique Onlay augmentation with hydroxyapatite is advocated by obwegessor via submucosal vetibuloplasty technique. After creating a tunnel via a midline a putty is formed of hydroxyapatite crystals is mixed with saline or blood and is injected via syringe into the submucosal tunnel. Solid or porous blocks of hydroxyl apatite is used. Split thickness ribgraft or iliac crest can be used.

Technique High vestibular incision is taken , mucoperiosteal flap is reflected to expose the defect. Small perforations made in this external cortex by using small round bur. Grafting material is placed or mounted over the external cortex.

Visor osteotomy To increase the height of mandibular ridge for denture support. Consists of central splitting of the mandible in buccolingual dimension and the superior positioning of the lingual section of mandible wired in position Cancellous bone grafting material placed at the outer cortex over the superior labial junction for improving the contour.

Modified visor osteotomy Consists of splitting of the mandible buccolingually by vertical osteotomy only in the posterior region and a horizontal osteotomy in the anterior region. Posterior lingual segments are then pushed superiorly on both sides. Anterior fragment is also pushed superiorly and fixed with wires. Corticocancellous bone graft particles with hydroxyapatite granules placed in the gap between the superior , inferior and anterior segments.

Sinus lift procedure or sinus grafting Sinus lining at the floor of the mouth is lifted up surgically and the bone graft is placed between the sinus lining and the inner aspect of the alveolar crest or floor of the maxillary sinus in the posterior maxilla. Totum was the first surgeon who used this method. Materials used are autogenous bone allogenic bone. tricalcium phosphate hydroxyapatite. calcium phosphate. ceramics calcium deficient carbonate apatite from bovine bone.

Technique Intraoral incision is taken on maxillary crest or slightly on the palatal aspect with vertical incision from canine to tuberosity area Antrolateral wall of maxilla is exposed by reflecting the mucoperiosteal flap Bony windows made with trap door type osteotomy , lateral and posterior to the caine fossa. 15 20 mm lomg inferior osteotomy cut placed 3mm above the sinus floor Anterior vertical cut parallel to the lateral nasal wall and perpendicular to the horizontal osteotomy. Posterior vertical cut is at the maxillary tuberosity. Vertical cuts are joined superiorly by placing the small bur holes placed at small intervals without completing the superior cut.

Trap door type of bony window is lifted up superiorly o expose the schineiderian membrane. Gap between lifted sinus membrane and the floor is filled with graft material. One stage implant Coticocancellous iliac crest bone block Otherwise 6-9 months before implant placement

Augmentation in combination with orthognathic surgery 1.anterior maxillary osteotomy. 2.total lefort osteotomy used along with interpositioning of grafts. Limitation of augmentation technique 1.inadequate soft tissue coverage. 2.rejection of autografts. 3.dehiscence of overlying mucosa. 4. migration of graft material. 5..resorption of graft.

conclusion
Preprosthetic surgery offers a sigificant contribution in patients with bone atrophy,soft tissue hypertrophy or localized soft and hard tissue problems or all of them. Pre existing stuctures like frenal attachments,exostosis,tori are insignificant while teeth are present in the oral cavity. But these non significant structures cause hindrences for denture stability and resultant reduced masticatory function after tooth loss. Preprosthetic surgery plays an important role in providing a better anatomic environment and to create proper supporting structures for denture construction.