PRE PROSTHETIC SURGERY

Objective of the preporosthetic surgery is that to

provide a better anatomic environment and to
create proper supporting structures for denture
construction

Preprosthetic surgery is carried out to

reform/redesign soft/hard tissues, by
eliminating biological hinderances to receive
comfortable and stable prosthesis. 2
Characteristics of Ideal Denture
Base Area.
The ideal edentulous ridges both maxillary and
mandibular should exhibit following features:

1. Adequate bone support - broad U-shaped alveolar

ridge with buccal and lingual/palatal cortices as
parallel to each as possible.
2. Adequate firm soft tissue
3. No bony or soft tissue undercuts or prominces.
4. No sharp ridges.

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5.no presence of peripheral fibrous tissue
bands(scars)to prevent proper seating of a
denture.
6. No high muscle or frenal attachments at the
crest of ridge to dislodge the denture.
7.No soft tissue redundancies or hypertrophies
on the ridges or in the sulci.
8. No intraoral or extraoral pathology.
9.Proper alveolar ridges relationship in all
three planes.

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Aims of Preprosthetic Surgery
1.Provide adequate bony tissue support for the
placement of RPD/CD(optimum ridge height
and width and contour).

2.Provide adequate soft tissue

support,Optimum vestibular depth.

3.Estimation of pre-existing bony

deformaties.e.g.tori,prominent mylohyoid
ridge,genial tubercle.

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Aims of Preprosthetic Surgery
4.Correction of maxillary and mandibular ridge
relationship.
5.Elimination of pre-existing soft tissue
deformities,e.g.epulis,flabby ridges,hyperplastic
tissues.
6.Relocation of frenal/muscle attachments.
7.Relocation of mental nerve.
8.Establishment of correct vestibular depth.

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Treatment Planning and Examination
Facial Esthetic Examination
1.Presence of unsupported upper lip
2.Poor vermilion show
3.Loss of nasolabial fold or decreased nasolabial
fold
4.Poor/obtuse nasolabial angle with poor
projection
5.Excessive lower lip show.

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Intraoral Examination
Systemic evaluation of the alveolar ridge and
supporting tissue should be done.
i. Ridge form and contour.
 Height and width of the ridge.
 Quality of the ridge-whether flabby,
mobile tissue is present over the ridge.
ii. Presence of any gross irregularities in the
ridge.

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iii. Presence of any exostosis, undercuts, prominences, tori,
sharp mylohyoid ridge with severe resorption of external
oblique ridge.

IV. Buccal and labial, as well as lingual vestibules

evaluation for depth and type of soft tissue.

v. Examination of palatal vault.

vi. Tuberosity area - undercuts, hyperplastic tissue, flabby

ridge, etc. Height, width, fibrous or excess bony
tuberosity can impair the arch space for fabrication of
full or partial denture.

vii. Interarch relationship.

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viii. Adequate post-tuberosity notching.
Supporting Soft Tissue examination

1.The amount of keratinized tissue& poorly keratinized or

freely movable tissue.
2. Inflammatory areas, scars, ulcers, hyperplastic tissues due
to ill-fitting dentures should be looked for.
3. Frenal attachments in relation to the alveolar crest.
4. Both buccal and lingual vestibular depth should be
checked.
5. On the lingual aspect, mylohyoid muscle attachmen and
genioglossus muscle attachment should be checked.
6. Tongue size and movement is also important for the
stability of the denture.

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RADIOLOGICAL EVALUATION
1.Orthopantograph or panoramic view
2.lateral cephalometric radiographs.
3.computed tomography - dental CT scan
4. 3-D CT can be used, if cost permits.

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DIAGNOSTIC MODELS
Mounted on articulator with proper vertical dimension
& studied.

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PREPROSTHETIC SURGICAL
PROCEDURES
classified as :
(i) basic procedures and
(ii) advanced surgery procedures.

The procedures can be carried out for the

following:
1. Alveolar ridge correction
2. Alveolar ridge extension
3. Alveolar ridge augmentation.

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 ALVEOLAR RIDGE CORRECTION
BONY SURGERIES. SOFT TISSUE SURGERIES
i.Labial alveolectomy i.Removal of redundant
ii. Primary alveoloplasty crestal soft tissue
iii. Secondary ii. Frenectomy - labial and
alveoloplasty lingual
iv. Excision of Torri
iii. Excision of epulis
v. Reduction of genial
i.i.
fissurata and palatal
tubercle
papillary hyperplasia
vi. Reduction of
mylohyoid ridge
vii. Maxillary tuberosity
reduction and exostosis
removal

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ALVEOLECTOMY
Surgical removal or trimming of the alveolar process is
termed as alveolectomy

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ALVEOLOPLASTY
Alveoloplasty refers to surgical recontouring of the
alveolar process.

Primary and Secondary Alveoloplasty.

Primary alveoloplasty is always done

at the time of multiple extractions or single extraction.

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simple Conservative Alveoloplasty with
Multiple extractions

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Intraseptal Alveoloplasty-Dean's Alveoloplasty
with Repositioning of Labial Cortical Bone

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Obwegeser's Modification for Intraseptal
Alveoloplasty

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 Alveoloplasty after the Postextraction
Healing
Usually done in cases of multiple extractions
carried out at different times.

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Elimination Of Unfavourable
undercuts
reduction /Resecton of Genial tubercles

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Reduction of mylohyoid ridge

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Excision of Torri :

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Palatal torus excision

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Indications for excision of tori:
 An extremely large torus, filling the palatal vault.

 A large torus, that may extend beyond the post-dam

area.

 Ulceration/traumatization/hyperkeratinization of the
overlying mucosa.

 Deep bony undercuts.

 Interference with the function.

 Psychological consideration-malignancy/cancer phobia.
 Food lodgement under the folds and projection of the
tori
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Maxillary tuberosity reduction

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SOFT TISSUE SURGERIES
Removal of redundant crestal soft tissue

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Soft tissue surgeries:
1.Removal of redundant crestal soft tissue
2.Denture granuloma or hyperplasia
3.Excision of epulis fissurata
4.Palatal papillary hyperplasia
5.Frenectomy

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 FRENECTOMY Indications:

High attachments of labial frena or fibrous

bands attached near the alveolar crest in the
buccal regions, often displace the dentures
during function

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LABIAL FRENECTOMY

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Maxillary midline or labial frenectomy
procedure:
Whenever there is lot of tissue is available
then a cross-diamond excision is used.
The base of the frenum at the alveolar crest is
grasped with hemostat and incision is taken
below and above the hemostat.
The surgical defect is created by excision of
fibrous band.
The closure can be done by interrupted
sutures.
 The small defect at the alveolar crest can be
left to granulate.
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LINGUAL FRENECTOMY
Aim of surgery :
1.To correct speech
2.Prior to denture construction
3.To improve the tongue mobility

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Technique:
 LA-bilateral lingual nerve block with local infiltration.
 Tongue traction suture is taken to improve visibility and
control and stabilization of the tongue during procedure.
 One hemostat can be placed at the anterior attachment of
the frenum to the tongue and another hemostat be placed at
the inferior attachment to the ridge.
 A cross-diamond incision along the edge of both the
hemostats is made.
 Submucosal dissection on either sides to undermine lingual
and sublingual mucosa is carried out.
 Dissection of genioglossus muscle fibers is done, if
necessary.
 Care is taken to avoid damage to the submandibular
 duct orifice.
 Suturing done in vertical manner.

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Complications:
Intraoperative possible complications
Injury to superior lingual vessels Injury to Wharton's
duct/papilla.
Postoperative complications :
Hematoma in the floor of the mouth
Pain, restricted tongue movements
Partial dysphasia.

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RIDGE EXTENSION PROCEDURE
Whenever there is an inadequate vestibular depth
present, (due to mandibular atrophy and high muscle
and soft tissue attachments) to increase the retention
and stability of the denture, deepening of the vestibule
is considered.

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Vestibuloplasty:
Deepening of the vestibule without any addition of the
bone is termed as vestibuloplasty or sulcoplasty or sulcus
deepening procedure. Vestibuloplasty can be done in the
maxilla or in the mandible or in both the jaws.

Mandibular techniques are further divided into two

categories:
1.Those done on the labial side
2.Those done on the lingual side

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Labial vestibular procedures:

1. Kazanjian Technique(1924)

2. Godwin's Modification (1947 )
3.Clark's Technique
4.Obwegeser's Modification (1959)

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Lingual Vestibuloplasty
Floor of the mouth extension or floor of the mouth
lowering can be done by following methods:
1.Trauner's Technique
2. Caldwell's Technique

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Vestibuloplasty :
Obwegeser's technique (Combination of
Buccal and Lingual Vestibuloplasty)

Submucosal VestibuloplastyTechnique
Maxillary’pocket inlay’vestibuloplasty
(obwegeser)

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Kazanjian Technique (1924):
Oldest Technique
 Uses mucosal flap from the inner aspect of the
lower lip to increase the depth of the anterior
mandibular labial vestibule.
 Carried out in premolar to premolar region only.
 Raw area is left on the lip side to heal by
secondary intention.
 Periosteum on the bone is left intact.

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Procedure
A submucosal dissection is done from the inner
aspect of the lower lip to the mucogingival
junction, near the alveolar crest on the labial side.
A supraperiosteal dissection is directed inferiorly
to remove muscle and connective tissue
attachments to the desired vestibular depth. The
raised mucosal flap is adapted to the depth of the
new vestibule and fixed with the sutures or a stent.
The raw area on the lip is left alone.

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Fig. 34.12: Kazanjian labial vestibuloplasty

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 Drawback
Severe scarring of the lip mucosa, may decrease
the flexibility of the lower lip (Poor long-term
results).

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Godwin's Modification (1947)
Mucosal incision on the inner aspect of the lip is
designed longer than the proposed vestibular depth to
be achieved.

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Clark's Technique
 Supraperiosteal flap based on the inner aspect of the lip.
 Leaves raw surface on the bone, covering the inner lip
surface, thereby reducing bleeding, postoperative pain
and scarring.
 An incision is started slightly labial to the crest along the
alveolar ridge.
 Mucosal flap based on the inner aspect of the lip is
undermined, till vermilion border, to ensure adequate
mobility and overcorrection.
 Supraperiosteal dissection is done, along the labial
surface of the alveolar bone till the desired vestibular
depth.

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Clark's Technique
Edge of the mobilized flap is pushed into the
new vestibular depth area and held in
position by sutures passed through the chin
area extraorally and tied around cotton roll or
rubber catheter placed below the chin.
As the alveolar bone is covered by periosteal
layer, it heals quickly by granulation.
Success rate is better than Kazanjian
method.

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Clark's Technique

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Obwegeser's Modification (1959)
Similar to Clark's method, except the area of the
alveolar bone with it's periosteal attachment is
covered with a split thickness skin graft and held
in position by sutures or stent constructed
preoperatively. Instead of skin, mucosal graft has
also been tried.
 Covers the bone and ensures faster healing .
 Reduces chances of postoperative infection
 Less bone loss and scarring

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Lingual Vestibuloplasty
Submucosal VestibuloplastyTechnique

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 Trauner's Technique
 Used for increasing the depth of the floor of the mouth in
the mylohyoid region
 Incision given over lingual side of the alveolar ridge
bilaterally, in the posterior region or from second molar to
second molar region
 Supraperiosteal dissection is done to identify mylo­hyoid
muscle
 Instrument is passed below mylohyoid muscle and muscle
separated from the bony attachment
 Care is taken to avoid lingual nerve damage.
 Fixation of incisal edge of the mylohyoid muscle to a new
desired vestibular depth on lingual side by:
a. Sutures passed extra orally over the skin at the inferior
border of the mandible
b. Placement of the skin graft and preformed denture / stent.

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Caldwell's Technique
 Entire lingual mucoperiosteal flap is reflected from
molar to molar region.
 Mylohyoid ridge is reduced/removed along with the
reduction of genial tubercle.
 Mylohyoid muscle and superficial fibres of genio­glossus
muscles are pushed inferiorly.
 Rubber tubing placed in the lingual vestibule and the
flap is held in position at the vestibular depth, by sutures
passed through the skin extraorally, at the inferior
border of the mandible.

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Obwegeser's Technique (Combination of
Buccal and Lingual Vestibuloplasty)
 Incision is given on the alveolar ridge
 Mucosal flap raised buccally and lingually
 Mylohyoid muscle attachment and only
superficial fibres of genioglossus muscle are
separated on the lingual side

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Obwegeser's Technique (Combination of
Buccal and Lingual Vestibuloplasty
 Edges of buccal and lingual flaps attached/
sutured to each other, below inferior border of
the mandible
 Skin graft is placed over entire alveolar ridge
 Preformed acrylic stent/ denture placed and
fixed to the mandible, with circummandibular
wiring.

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RIDGE AUGMENTATION PROCEDURES
,AIMS
 Restoration of optimum/near optimum ridge
height and width, ridge form, vestibular depth
and optimum denture bearing area
 Protection of neurovascular bundle
 Establishment of proper interarch relationship
 Improvement of retention and stability of
denture
 Improve the patient comfort for wearing the
denture.

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Ridge augmentation procedures
A.Mandibular augmentation
1.Superior border augmentation
a. Bone grafts
b.Cartilage grafts
c. Alloplastic grafts.
2.Inferior border augmentation
a. Bone grafts (autogenous or allogenic freeze dried cadaveric
mandible)
b. Cartilage grafts.
3.Interpositional or Sand witch bone grafts
a. Bone grafts
b.Cartilage grafts
c. Hydroxyapatite blocks.

4.Visor osteotomy.

5. Onlay grafting-autogenous, alloplastic, allogenic material.

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Ridge augmentation procedures
B.Maxillary augmentation
1.Onlay bone grafting - autogenous I allogenic
grafts.
2.Onlay grafting of alloplastic material.
3.Interpositional or Sandwich grafts.
4.Sinus lift procedure.
C.Augmentation in combination with
orthognathic surgery
1.Mandibular osteotomy procedure.
2.Maxillary osteotomy procedure.
3.Combination procedure.

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Materials used for augmentation of alveolar
ridge
 Autogeneous bone graft-iliac crest, rib grafts.
 Allogenic bone grafts-freeze dried cadaver bone.
 Alloplastic material-hydroxyapatite.
 Metal mesh with autogenous cancellous bone.
 Metal mesh with hydroxyapatite.

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Materials used for augmentation of alveolar
ridge
 Autogeneous bone graft-iliac crest, rib grafts.
 Allogenic bone grafts-freeze dried cadaver bone.
 Alloplastic material-hydroxyapatite.
 Metal mesh with autogenous cancellous bone.
 Metal mesh with hydroxyapatite.

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MandibularAugmenmtion
Superior border grafting/augmentation

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Inferior border grafting
by Marx and Saunders (1986)
Modified by Quinn (1991)

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Interpositional Bone Grafts (Sandwich
Grafting)

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Advantages
 Less resorption rate than onlay grafting.
 More predictable long-term results.
 Decreased incidence of nerve paraesthesia than the.
visor osteotomy.
 Can be used in conjunction with osseointegrated
implants

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Visor Osteotomy
The Visor osteotomy consists of central splitting
of the mandible in buccolingual dimension and
the superior positioning of the lingual section of
the mandible,which is wired in position.
Cancellous bone graft material is placed at the
outer cortex over the superior labial junction for
improving the contour.

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Modified Visor Osteotomy
Consists of splitting of mandible
buccolingually by vertical osteotomy only in
the posterior regions and a horizontal
osteotomy in the anterior region

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Advantage Eighty per cent of the height
is maintained at the end of 3-5 years.
Disadvantages
Nerve paraesthesia and dysaesthesia.
Need for hospitalization.
Donor site morbidity.
Inability to wear the dentures for 3 to 5 months
following surgery.

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Augmentation in Combination with
Orthognathic Surgeries
Many osteotomies have been performed for
reconstruction of edentulous atrophied
maxilla/mandible.
i. Anterior maxillary osteotomy.
ii. Total LeFort I osteotomy, can be used
along with interpositioning of the grafts.
Total maxillary osteotomy with palatal vault
osteotomy also can be used for deepening the
palatal vault.

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