TECHNIQUES AND TECHNOLOGIES Fabrication of a Sur ical Stent for Bilateral Tuberosity and Man ibular Alveolar Reduction

!(

JefV C. Markt, DDS

A technique for constructing a single surgical stent to direct bilateral preprosthetic maxillary tuberosity reductions and mandibular alveolectomies is presented. The stent is fabricated using unaltered articulated definitive casts. The stent allows the oral surgeon to replicate the desired vertical dimension of occlusion for a thorough assessment of the sufficiency of the surgical revisions. The situation illustrated is unique, in that preoperatively, the patient's maxillary tuberosities were situated inferior and medial to their ipsilateral retromolar pads. J Prosthod 1999;8:264-267. Copyright@ 1999 by TheAmerican College o f Prosthodontists.
INDEX WORDS: preprosthetic surgery, orthognathic surgery, complete dentures, reduced interarch distance, surgical guide

COMPLETE denture prosthodontics, several dilemmas may cornpromise the optimal vertical distance between the maxillary tuberosity and the mandibular retromolar pad area. These include the phenomenon known as the combination syndrome,' anomalous craniofacial development, maxillofacial trauma, and others. Simple methods to determine the interarch distance have been described in the literature. The passage of a mouth mirror head' or thrcc stacked tongue blades" through the interarch distance while the paticnt is positioned at an appropriate vertical dimension of occlusion are both means of assuring adequate prosthetic space. The latter technique ensures at least 6 mm of interarch distance. Irrespective of the evaluative methodology, however, the minimal polymethylmethacrylate denture base thickness must be 1 mm to provide optimal strength of the For situations involving vertical dimension of occlusion restrictions, a 3-mm interarch distance has been suggested to allow a 1-mm clcarance between opposing denture bases." In addition, the incorporation of cast alloy shims in polymethylmethacrylate bases has been described as an alternative for situations in which there is insufri-

IK

cient space to oppose denture bases consisting of polymethylmethacrylate alone .4,6,7 Although surgical procedures designed to increase the posterior interarch distance in edentulous patients are often empirically performed, thc use of surgical stents as a means of ensuring an appropriate reduction of interfering anatomy has bccn deThcsc surgical stents are fabricated on duplicates of articulated diagnostic casts that have been modified to simulate thc desired postoperative anatomic topography. Although these methods of stent fabrication involve a thorough evaluation of the vertical dimension of occlusion by means of the preoperative articulation of diagnostic casts, the resulting stcnts do not offer the surgeon a definitive chairside assessment of the predetermined vertical dimension of occlusion. This article presents an alternative procedure for fabricating a surgical stent to lend guidance to the surgeon for thc preprosthctic reduction of hard and soft tissues in posterior edentulous arches, at the appropriate vertical dimension of occlusion.

Technique
A 48-year-old white woman reported receiving a
mandibular orthognathic surgical procedure approximately 20 years previously as a partially edentulous patient. The presence of residual fixation wires on a panoramic radiograph confirmed the reported hislory of mandibular fixation. A preliminan evaluation of the maxillornandibular relationship at the estimated vertical dimension of occlusion revealed the

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Figure 1. Right anterolateral vie\+ of drfinitive casts mounted at the vertical dimension of cxclusiori (VDO) in centric relation (CR).
position of the crests of the maxillary tuberosities to be infcrior and medial to the posterior crests of thr mandibular alveolus bilaterally. Conscquently, plans were made for bilatcral tuberosity reductions and mandibular alveolectomies, and a surgical stent was Gbricated. The sequence by which such a stent is made is as follow~s : Primary irreversible hydrocolloid impressions are made of each arch. Modeling plastic impression compound is used to border mold custom impression trays berore obtaining final impressions of each arch. Posteriorly shortened maxillary and mandibular baseplates are fabricated to support wax occlusion rims. Face-bow transfcr and centric relation records at the appropriate vertical dimension of occlusion are obtained so that definitive casts can be

Figure 3. Right anterolateral view of the stents wax pattern.

mounted on a scmiadjustable articulator (Figs 1 and 2). 5. A baseplate wax pattern is fashioned to cover the maxillary mucosal surfaces, and two bilateral wax pillars are extended from the anterior aspect of the pattern to engage the mucosal surface or the mandibular alveolus (Figs 3 and 4). (In the situation illustrated here, onc pillar also covered one of two rctaincd anterior root tips that were to be extracted subsequcntly.) 6. Those portions of the wax pattern covering areas of the tuberosities to be reduced are removed from the maxillary cast, leaving two windows in the

Figure 2. Left anterolateral view or definitive casts mounted at the W O in CR.

Figure 4. I,&
patlrm.

anterolateral view of the stents wax

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Tuberosip and Alceolar Reduction Stent

Markt

Figure 7. Occlusal view of the invested wax stent. Figure 5. View of the inferior aspect of the wax pattern
with windows.

maxillary base of the wax pattern (Fig 5). The edges of the windows represent the desired inferior limitation of the maxillary tissues after surgery. 7. Thc wax pattern is invested (Figs 6 and 7) and processed with a clear, heat-activated polymcthylmethacrylate. It is then polished and disinfected in preparation for surgery (Fig 8).

achieve the desired vertical dimension of occlusion. The presence of the tuberosit) inferior to the stents windows indicates the need for further surgical reduction. Positioning the patient in centric relation at the appropriate vcrtical dimension olocclusion using the stent allows the surgeun to assess the extent of any required mandibular alveolectomy.

Summary
The fabrication of a stent intended to ensure an appropriatc preprosthetic reduction of maxillary tuberosity and mandibular alveolar tissues was described. The technique offers several advantages over previously published methods of stent In addition to providing the surgeon an intraoperative assessment of the maxillomandibular relationship at a predetermined vertical dimension of occlusion, the described stent requircs no modification or

Discussion
Intraoperativc positioning of a stent fabricated as described can provide the surgeon with information as to whether enough tissue has been rcmoved to

Figure 6. View ofthe invested rnaxillaq cast.

Figure 8. Finished stent.

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duplication of diagnostic or definitive casts. Also, a single stent fabricated in this fashion facilitates the ability to predictably provide sufficient maxillary and mandibular soft tissue and alveolar bone reduction to allow the placement of opposing complete denture prostheses without more complicated, invasive, and expensive preprosthetic orthognathic surgical procedurcs. The time required for fabricating a disposable stent and the associated laboratory expense constitute the method's greatest drawbacks. In addition, laboratory technicians may be unfamiliar with thc pcculiarities associated with forming and investing the wax pattern necessary for the stent's fabrication. Similarly, the stent's intended use must be thoroughly communicated to surgeons inexperienced in its use arid purpose. Despite these rcservations, howcvcr, preparation of a stcnt using the described technique offers a practical means for prescribing preprosthetic surgical rcvisions for patients cxhibit-

ing unusual or extrcmc maxillomandibular relationship variations.

References
1. Kelly E: Changes caused by a rriandibular removable partial dcnlurr opposing a maxillary complete denture. J Prosthet Dent 1972;27:140-1.50 2. Hernandez 4: MLaxillarytuberosity ridge reduction. Dent Sew 1978;54:43-44 3. Choy E: Prosthetics and the maxillar). tuberosity. Gen Dent 1977;25:46-47 4. Johnson DL, Stratton RJ: Fundamentals of Removable Prosthdontics. Chicago, IL, Quintessence Publishing, 1980, p 314 5. Mitchener RW Vertical space for denture bases-Without surgery..J Prusthet Dent 1982;47:354-355 6. Badr SE, U n g e r p , Stone CK: Some treatment alternatives for dealing with the enlarged maxillary tuberosity. Quintessence Int 1987;18:465-168 7. Bell lL4, Kichardson A: Prusthudontic treatment of pendulous maxillar?; tuberosities.J h i Dent &soc 1981;103:894-895 8. Barrett GD: A simplified surgical guide stent technique for the reduction of the impinging maxillary tuberosity. Conipend Contin FXiic Dent 1988;9:196-202