GOOD

MORNING
Introduction
Preprosthetic surgery is carried out to reform or
redesign the soft/hard tissues, by eliminating the
biological hindrances to receive a comfortable and
stable prosthesis and to create an oral environment to
support a functional prosthetic appliance.
Pathophysiology of edentulous
bone loss
Causes Physiologic, environmental, pathologic or
combination of any of the above
Patterns of bone loss
Most of the bone loss occurs during the first year of
the denture wearing
It is 10 times greater in the first year than that seen in
the following years
Bone loss in mandible 4 times greater than in maxilla
Resorption in maxilla on buccal and inferior portion
of the alveolar ridge--- resulting in reduced width of
maxilla
Mandible resorbs downwards and outwards causing
rapid flattening of the ridge.
Average bone loss 1mm per year

Aims of preprosthetic surgery
To provide adequate support for the placement of
RPD/CD
To provide adequate soft tissue support/vestibular
depth
Elimination of pre existing bony deformities eg: tori,
prominent mylohyoid ridge etc
Correction of maxillary and mandibular ridge relations
Elimination of pre existing soft tissue deformities eg:
epulis, flabby ridges etc
Relocation of frenal or muscle attachments
Relocation of the mental nerve
Establishment of the correct vestibular depth
Treatment Planning
Conventional dentures:
1. History taking and physical examination including
radiographs
2. Facial esthetic examination for unsupported upper
lip, poor vermillion show, poor/obtuse nasolabial
angle, loss of nasolabial forld etc
3. Intraoral examination Ridge form and contour,
quality and quantity of the overlying tissues, frenal
and muscle attachments, presence /absence of bony
or soft tissue pathologies and relationship of
maxillary ridge to mandibular ridge
Preprosthetic surgical procedures
Alveolar ridge correction
Bony surgeries
1. Compression alveoplasty
2. Simple Alveoplasty
3. Labial/ buccal cortical alveoplasty
4. Reduction of Tori and exostoses
Soft tissue surgeries
Ridge extension procedures/Vestibuloplasty
Augmentation
Alveoplasty

Alveoplasty: Recontouring of the alveolar process
Alveolectomy: The excision of a portion of the alveolar
process
Objectives and principles of
alveoplasty
Immediate goal in performing an alveoplasty is to
provide optimal ridge contour quickly, this should be
counterbalanced with ultimate goal of preserving as
much bone as possible for continued denture stability
Alveolar ridges should be left as broad as possible for
maximum distribution of the masticatory load
All undercuts especially the opposing ones should be
removed
Sharp edges should be rounded and gross irregularities
should be reduced
Mucosa covering the ridge should be uniform in
thickness
The younger the patient less amount of the bone
should be removed during alveoplasty
Types of alveoplasty
Compression alveoplasty:
a. Easiest and quickest
b. Compression of outer and inner cortical plates
between the fingers
c. Done after extractions
d. Compression reduces the width of the socket and
many otherwise troublesome bony undercuts
Simple alveoplasty:
a) Usually used to reduce sharp buccal or labial cortical
and occasionally lingual or palatal cortical margins.
b) Usually an envelop flap is used
c) With a rongeur or bone cutting forceps held parallel
to the bone margin of the alveolar bone, just the
right amount of bone can be removed

Labial or buccal cortical alveoplasty:
a) Incision made in the gingiva and full thickness
mucoperiosteal flap elevated
b) A sharp side cutting/Blumenthal forceps is held with
one beak beneath the bony rim of the socket and
other on the crest of the ridge.
c) Small bits of the bone can thus be bitten off
d) A bony file can be used to smoothen and perfect the
contour.
This type of alveoplasty is most commonly performed
after the tooth removal
Labial / Buccal
cortical alveoplasty
A. Pre op
B. After removal of
teeth the labial
gingiva is elevated
C. Rongeur is used
to reduce the bone
D. Condition after
bone trim
E. Suturing
Deans intraseptal(intercortical) alveoplasty:
a) After extraction of the teeth , the interradicular bony
septa should be removed with a rongeur forceps.
b) Dean used a chisel to make an inverted V shaped
excision of the bone in the labial cortex of the cuspid
socket, thus three sides of the labial cortical flap are
freed
c) Finger pressure is then applied to reduce the labial
cortical plate
d) This plate recieves its blood supply from the
overylying periosteum
Deans Intraseptal
alveoplasty
A. For cases with
moderate inclination of
the teeth
B. After removal of
teeth, gingival papillae
are removed
C. Bone bur is used to
remove the
interradicular medullary
bone
D. Bone cut is made in
the labial cortex at the
distolabial aspect of
each cuspid socket
E. Broad, flat
instruments are inserted
into the bone trough and
outward force is used to
fracture the labial cortex
F. Finger pressure is used
to compress the socket
G. Suturing

Obwegesers technique:
a) He suggested further modification of Deans
technique for extreme maxillary protrusion cases
b) He fractured both labial and palatal cortical plates as
follows-
1. The teeth are removed as usual
2. The sockets are connected, and rongeurs or burs are
used to remove the medullary interradicular bone
3. With a bur the sockets and their interconnections
trough id then enlarged.
4. Both labial and palatal plates are cut with burs in the
cuspid area to weaken the bone and to form three
sided bone flaps in both cortical plates
5. Palatal cortex usually needs to be scored
6. A pair of broad flat elevators are inserted into the
sockets and the labial plate is fractured labially and the
palatal plate palatally. Finger pressure is then used to
mould the alveolar process into the desired shape.
Sutures close the gingiva on the socket.
7. A Denture on splint is used to stabilize the fractures
alveolar process which heals in 4 to 6 weeks.
Obwegesers technique
A. For cases with
extreme labial
protrusion
B. A broad trough is
created with a bone
bur connecting all the
sockets
C. The labial and
palatal sockets are cut
with a bur
D. Palatal cortex is
partially cut
E. Labial and palatal
cortices fractured
F. Finger pressure used
to compress and mould
the socket
G. Suturing
Reduction of mylohyoid ridge and
lingual alveolar crest
Alveolar atrophy sometimes accentuates the
mylohyoid ridge, which can be plapated through the
lingual surface of the mandible
Mylohyoid ridge should be reduced whenever the
ridge is found to be at level or higher than the alveolar
process
Sometimes the overlying mucosa becomes
traumatized, ulcerates and fails to heal. In such cases
the bony edges should be removed to permit the
closure of the ulcerated tissues with sutures
Technique
Incision is made in the residual gingiva on the alveolar
crest of the alveolar process in the molar region.
Lingual mucoperiosteum is reflected carefully,
exposing the mylohyoid ridge and the muscle.
The mylohyoid muscle is attached to the edge and
inferior surface of the mylohyoid ridge and must be
incised with a scalpel
Once the muscle has been reflected, the bony edge can
be reduced with a chisel or rongeurs and bony file.
The detaches muscle will then reattach at a lower level
Reduction of Tori and Exostoses

Torus palatinus
It is a benign, slowly growing, bony projection of the
palatine processes of the maxillae and occasionally the
horizontal plates of the palatine bones.
It occurs bilaterally along the medial suture on oral
surface of the hard palate.
Slow growing
Females > males
Etiology - Unknown
Palatal tori removal is indicated when:
1. They become so large that they interfere with the
speech
2. The overlying mucosa becomes traumatized,
ulcerates and fails to heal because of its poor
vascularity
3. The torus interferes with the design and
construction of a removable dental prosthesis
Technique
Local anaesthesia is used to block the right and left
anterior palatine nerves and the nasopalatine nerve.
Median palatal incision is made in the mucosa the full
length of the torus with two short, diverging incisions
at the anterior and the posterior ends of the torus,
avoiding the vascular foramina.
Posteriorly care must be exercised to avoid accidental
perforation into the soft palate into the nasal cavity
Each flap is reflected with a periosteal elevator and
then sutured to the mucosa of the alveolar process to
keep it out of the operative field.
If the torus is small and pedunculated and the palatal
bone is thick then it can be cleaved from the palate
with a sharp blow of the mallet.
If the torus is thick and broad based then a 703 fissure
bur can be used to cut longitudinal and transverse
grooves in the torus to desired depth.
Once the torus has been grooved, the pieces can be
removed using the rongeur forceps or mallet and chisel
The stump of the torus can be smoothened with bone
files, chisels or large bone burs.
Prevention of post operative hematoma formation is
very important by use of rubber drain splint or stent
Removal of palatal torus
A. Pre op
B. Right and left
mucosal flaps
reflected. Dental bur
used to cut grooves into
the torus
C. Sharp chisel used to
remove the small
pieces of the torus
D. A bone bur used to
smoothen the stump of
the torus
E. Suturing
COMPLICATIONS:
1. Haemorrhage
2. Hematoma
3. Necrosis and sloughing of the palatal mucosa
4. Perforation of the floor of the nose
5. Fracture of the palate
Torus Mandibularis
It is an exostosis that usually occurs bilaterally on the
median surface of the body and the alveolar process of
the mandible
Generally located in the canine-premolar region
Etiology- unkown
Equally occur in both the sexes
Technique
Area is anaethetised with inferior alveolar and lingual
nerve blocks
Incision is made on the crest of the alveolar process
from molar to incisor region. If bilateral tori are to be
removed in the same appointment the mucosa in the
incisor region should not be reflected
Moucperiosteal flap reflected.
Mandibular tori can be easily removed with chisel and
mallet. A bur can also be used.
A stent is usually not required post op in mandibular
tori removal
Removal of Torus
mandibularis
A. Pre op
Incision made over
the crest of the
alveolar ridge from
molar to central
incisor. Chisel is
used to remove the
torus
C. Bone bur is used
to smoothen the
stump
D. suturing
Corrective soft tissue surgery

Labial Frenectomy
The labial frenum is a band of fibrous connective
tissue, covered with mucous membrane that binds the
lip to the alveolar process.
The upper labial frenum is usually more prominent
and fibrous than the lower.
When a frenum is attached at or near the crest of the
alveolar ridge, it maybe subjected to repeated
irritation from a denture flange
Technique
The lip is elevated, everted and tensed so that the
frenum becomes prominent.
The purpose of the frenectomy is to eliminate the
fibrous part of the frenum and the mucosa should be
repositioned to cover the surgical defect.
A narrow V shaped incison is made in the mucous
membrane around the frenum and is carried to the
bone.
The apex of the V should correspond to the inferior
extent of the frenum.
When the frenum is detached from the bone with
periosteal elevator, most of the connective tissue fibres
retract into the upper lip.
The small tag of labial mucosa and any surplus
connective tissue can beremoved easily with scissors.
The margins of the resultant diamond shaped defect
can be undermined and closed with sutures
Labial Frenectomy
A. Lip is everted and
the frenum is tensed
B. Narrow V shaped
incision is made
around the frenum
through the mucosa
and the periosteum
C. Fibres of the frenum
are stripped away from
the bone
D. Small tag of labial
mucosa and redundant
tissue can be removed
with scissors
E. Margins of the
diamond shaped defect
undermined
F. Suturing
Lingual Frenotomy
Ankyloglossia/ tongue tie is usually present in children
and is corrected in the childhood itself. Occasionally
an adult patient maybe foung to have an untreated
hypertrophied lingual frenum
Test of lingual Function: Patient is asked to to touch
the upper lip with the tip of his tongue. When the
patient is unable to do frenectomy is indicated.
Technique
Bilateral lingual nerve blocks are performed.
A traction suture is placed on the tip of the tongue so
that the tongue may be elevated and the frenum
tensed.
A transverse incision was made in the mucous
membrene of the frenum midway between the ventral
surface of the tongue and sublingual caruncles with
sharp scissors.
Deeper dissection is performed in the midway to avoid
ducts of the submandibular salivary glands.
The dissection is continued till the tip of the tongue
can be retracted sufficiently to touch the maxillary
incisor teeth or alveolar process while the mouth is
open.
The mucosal flaps are undermined with scissors and
closed as a longitudinal linear incision.

Lingual Frenotomy
A. Pre op.
B. Suture is placed
through the tip of
the tongue to retract
the tongue and tense
the frenum.
Transverse incision
made
C. Deeper dissection
is done
D. Margins of the
diamond shaped
defect undermined
Suturing
INFLAMMATORY PAPILLARY
HYPERPLASIA OF THE PALATE
Inflamatory papillary hyperplasia is a painless
irreversible disease of the oral mucous membrane
It commonly occurs in the hard palate in patients who
wear complete maxillary denture
Younger patients affected more than older patients
Etiology is obscure

Number of contributing factors include
1. Poorly fitting denture
2. Wearing a denture 24 hours a day
3. Poor oral hygiene
4. Patients wearing dentures with palatal relief
Treatment includes early stages non-surgical
treatment such as proper denture adjustments
combined with tissue conditioner
If removal is required a mucousal excision superficial
to periosteum is recommended
Another technique to use is electrosurgical loops
After excision patients denture or a specially prepared
surgical stent can be lined with an analgesic paste and
used to cover and protect the surgical site
Granulation and reepithelization take 3 - 6 weeks after
which new denture can be made

Fibrous Hyperplasia of maxillary
tuberosity

Surgical reduction of hyperplastic submucosa of
maxillary tuberosity can be performed under local
anaesthesia
Elleptical Incisions are made around the gingival
masses and are carried to the bone so that full
thickness block of tissue can be removed with rongeur
forceps
Buccal and palatal flaps should be thinned uniformly
The incision is then closed with dissolvable sutures

Fibrous
hyperplasia of
maxillary
tuberosity
Vestibuloplasty
Vestibuloplasty is a surgical procedure whereby the
oral vestibule is deepened by changing the soft tissue
attachments
This procedure increases the size of the denture
bearing area and height of the residual alveolar ridge

Vestibuloplasty procedure can be divided into
following categories
1. Mucosal advancement(Submucous) Vestibuloplasty
- The mucous membrane of vestibule is undermined
and advanced to line both the sides of the extended
vestibule
2. Secondary epithelization
(Reepithelization)Vestibuloplasty The mucosa of the
vestibule is used to line one side of the extended
vestibule and the other side heals by growing new
epithelial surface
3. Grafting Vestibularplasty Skin mucosa and dermis
can be used as a free graft to line one or both the sides
of the extended vestibule

Mucosal Advancement
(Submucosal) Vestibuloplasty

Primary criterion for this type of procedure is presence
of adequate amount of bone and healthy mucosa
A test can be performed to determine whether
sufficient mucosa is available
With lips in a relaxed position mouth mirror is
inserted into the vestibule to the depth required
prosthetically if the upper lip is not displaced upward
or drawn inward it can be assumed that there is
sufficient mucosa for the advancement procedure
Closed submucous vestibuloplasty
Objectives
1. To extend the vestibule to provide the adequate ridge
height and
2. To excise or transfer the submucous connective tissue
to a position farther from the crest of the ridge to
prevent relapse
Given by Obwegeser (1959)
Technique Vertical incision is made in the midline of
the vestibule through the mucosa only extending from
the muco gingival junction into the lip
With the lip everted in the horizontal plane a scissior
is introduced into the incision and blunt dissection is
performed on both the sides
A tunnel is formed mucosa and submucosa extending
from the mucogingival junction into the lip
The tunnel is carried posteriorly to zygomatic
buttresses of the maxilla or to mental foramen area of
the mandible

When the submucous tunnels have been completed
the vertical incision is deepened to periosteum at the
midline
Super periosteal dissection extended as far as the
proposed vestibular extention required
The freely mobile mucosa then is adopted to the
deepened sulcus with fingure pressure
Vertical incision is sutured
Closed submucous
vestibuloplasty
A. Median incision
made
B. Mucous
membrane
undermined with
blunt dissection as
dar as
zygomaticomaxillry
ridge
C. Tunnels created
on either side with
suopraperiosteal
dissection
D. Connective tissue
septum excised
E. Suturing
Open view submucous
vestibuloplasty
Given by Wallenius(1963)
Similar to Obwegeser technique but used an open view
procedure
Horizontal incision is made along mucogingival
junction through mucosa only
The mucosa is dissected from submucosa into the lip
Supraperiosteal dissection is then performed to the
extent desired for proposed vestibular extention
Stay sutures placed in the flap to fix into the
periosteum deep in the vestibule
Free margin of the flap then is returned to its original
position and sutured

Secondary
epithelialization(reepithelialization)
vestibuloplasty
It is indicated when sufficient bone is present but the
mucosa is either insufficient or of poor quality
There are two basic techniques each with several
variations
Given by Kazanjian(1935) and another by Clark(1953)
Kazanjian Technique
Incision is made in the mucosa of the lip and a large flap of
labial and vestibular mucosa is reflected
The vestibule is deepened by supraperiosteal dissection
The flap of mucosa is turned downward from its
attachment on the alveolar ridge and is placed directly
against the periosteum to which it is sutured
Rubber catheter stent is placed into the deepened sulcus
and fixed with percutaneous sutures
Catheters removed after 7 days
The labial donor sight is left to granulate and heal by
secondary epethelization
Kazanjians technique

Lipswitch Vestibuloplasty
Variation of Kazanijian Technique
The mucosal flap is developed in the same way as given by
Kazanjian with the free margin in the lip and the base
attached to the crest of the residual alveolar ridge. But
instead of being excised the periosteum is incised and high
on the alveolar ridge just below the crest and reflected from
the bone
The flap consisting of periosteum connective tissue, and
muscle, is tranposed outwardly and sutured to the margin
of the raw wound in the lip
Thus the vestibule is lined on the osseous side with
mucosa and on the labial side with periosteum
Clarks technique
Incision is made on the alveolar ridge and dissection is
carried out to the depth desired
Mucosa of the lip is undermined to the vermillion
border
Sutures are placed in the free margin of the mucosal
flap and are tied to the skin over a cotton roll
Soft tissue of the vestibule is thus covered with
mucosa, whereas, on the osseous side, the raw
periosteal surface is left to granulate and epithelialize
Clarks Technique

Lingual Sulcoplasty
Used in patients with grrossly resorbed mandible
Extention of the lingual sulci or the floor of the mouth
is lowered to increase the denture bearing area.

Anterior lingual sulcoplasty:
Suggested by Cooley(1952)
Consists of lingual frenotomy and transplantation of
the lingual fibres of the genioglossus muscle.
It is often combined with reduction of the genial
tubercles
Posterior lingual sulcoplasty:
The floor of the mouth frequently becomes elevated
above the level of the residual alveolar ridge during
normal functional movements especially the posterior
fibres of the residual alveolar ridge.
Mylohyoid ridge should be palpated.
If the mylohyoid ridge reduction is to be performed ,
the periosteum should be reflected as described by
Caldwell (1955), If not then , incision of the mylohyoid
muscle fibres and supraperiosteal dissection will
permit the extention of the lingual sulcus as described
by Trauner (1963)

Augmentation
A. Mandibular augmentation
1. Superior bone augmentation- Bone grafts, cartilage
grafts or alloplastic grafts
2. Inferior border augmentation- bone grafts or
cartilage grafts
3. Interpositional or sandwich grafts- bone, cartilage or
hydroxyapatite blocks
4. Visor osteotomy
5. Onlay grafting- autogenoue, alloplastic or allogenic
material
B. Maxillary augmentation procedures
1. Onlay bone grafting: autogenous/allogenic materials
2. Onlay grafting of alloplastic materials
3. Interpositional or sandwich grafts
4. Sinus lift procedure
Augmentation in combination with orthognathic
surgery
1. Mandibular osteotomy procedures
2. Maxillary osteotomy procedures
3. Combination procedures
Mandibular augmentation
Superior border grafting:
Describe by davis(1970)
Used 15cm autogenous rib grafts
Rib is scored at the cortex and adapted to the shape of
the mandible and fixed with transosseous or
circummandibular wiring
The other rib graft is made into corticocancellous
particles and moulded around the first rib graft

Inferior border grafting:
Indicated when the alveolar ridge is less than 5 to 8
mm in height and is at risk of pathological fractures
First described by Marx and Sanders and modified by
Quinn
Bilateral supraclavicular incision made and dissection
in subplatysmal plane done upt inferior border of the
mandibke
A freeze dried cadaveric mandible is hollowed out and
multiple perforations made into it to allow it for
revascularization and is used as a tray
The cadaveric bone is then filled with cancellous bone
graft harvested from iliac crest and is fixed to the
mandible using circummandibular wiring
Interpositional grafts/sandwich
grafting
A horizontal osteotomy is performed in residual
maxilla or mandible
Allogenic bone/ hydroxyapatite grafts can be used to
augment the jaw.
Secondary vestibuloplasty procedurs maybe necessary

Onlay grafting
Used when adequate height is present but width of the
jaw is inadequate
Oldest technique of onlay grafting advocated by
Obwegeser using allograft(hydroxyapatite) through
submucosal vestibuloplasty.
After creating a submucosal tunnel in the midline
hydroxapatite crystals mixed with saline/blood is
injected via a syringe into the tunnel.
Visor osteotomy
Goal of this procedure is to increase the height of the
mandibular ridge for denture support.
Consists of central splitting of the mandible in the
buccolingual dimension and the superior postioning
of the lingual section of the mandible which is wired
into position
Cancellous bone is placed at the outer cortex over the
superior labial junction for improving the contour
Modified Visor osteotomy
Consists of splitting the mandible buccolingually using
a vertical osteotomy only in the posterior region and a
horizontal osteotomy in the anterior region
Sinus lift procedures or sinus grafts
Used to assist placements of osseointegrated implants
in the posterior maxilla.
In older patients the sinus floor is lowered almost to
the level of the alveolar crest due to pneumatization
Thus to improve support the sinus floor is lifted up
surgically and a bone graft is placed between sinus
lining and the inner aspect of the alveolar crest
Augmentation in combination with
orthognathic procedures
Anterior maxillary osteotomies
Total lefort I osteotomy with interpostional grafts
Le fort I osteotomy