1. GOOD MORNING….

2. PREPROSTHETIC SURGERY
Presented by
Mala. M
Dept of oral and
maxillofacial surgery
Under the guidance of
Dr. Santosh A Nandimath

3. CONTENTS
 Introduction
 History
 Patterns of ridge resorption
 Aims and objectives
 Classification
Ridge correction procedures
Ridge extension procedures
Ridge augmentation procedures
 Conclusion
 References

4. INTRODUCTION
 Preprosthetic surgery encompasses the surgical
procedures with aim of redefining the soft or hard
tissues or both by the accomplishment of relieving the
biological interferences so that the individual can accept
a comfortable prosthesis.
 Preprosthetic surgery is defined as surgical procedures
designed to facilitate fabrication of a prosthesis or to
improve the prognosis of prosthodontic care. (GPT8)

5. History
 Preprosthetic oral surgery was born shortly after the
introduction of general anesthesia.
 Willard (1853) advocated the reduction of interdental
gingival papillae and alveolar margins after dental
extractions; this procedure permitted earlier construction
of dentures.
 For many years preprosthetic oral surgery consisted of
the removal of teeth and the reduction and trimming of
sharp edges.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

6.  Preprosthetic oral surgery emerged from a ridge-
trimming" service to a truly reconstructive service
when Kazanjian(1924) reported - prototype of
labiobuccal vestibuloplasty procedures.
 Kazanjian technique was modified by Godwin(1947),
Clark (1953), and others.
 Trauner (1952), Caldwell (1955), and Obwegeser (1963)
described techniques for extending the alveololingual
sulcus to provide additional denture-bearing surface for
increased denture stability.
 The use of skin grafts in vestibuloplasty was advocated
by Pichler (1931), Obwegeser (1963).
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

7.  Investigations by Hall and O'Steen (1970)and by.
Maloney et al. (1971) have advanced the art of
mucous membrane grafting vestibuloplasty.
 Smiler et al.(1977) have reported on experience with
dermal grafting in vestibuloplasty.
 The work of Davis(1970), Terry (1974), and others
have advanced the knowledge and scope of
reconstructive augmentation procedures in
preprosthetic surgery.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

8. Patterns of Bone Loss
 Tallgren, in 1972, has stated that most of the bone loss
occurs in the 1st year of denture wearing and it is 10
times greater than the loss seen in the following years
 Tallgren has estimated that the edentulous bone loss
(EBL) is up to 1 mm/year, with the greatest loss
occurring within 12–18 months after extractions.
 He also demonstrated 4 times more bone loss in the
mandible, than in the maxilla over the years.
Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition

9.  The usual resorption of the maxilla is on the buccal and inferior
portion of the alveolar ridge.
 The mandible resorbs downwards and outwards, causing rapid
flattening of the ridge.
Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition

13. CONSEQUENCES OF RRR
 Apparent loss of sulcus width and
depth
 Displacement of muscle close to the
crest of residual ridge.
 Loos of vertical dimension of
occlusion
 Relative prognathia
 Anterior rotation of mandible
 Changes in inferior alveolar ridge
relation ship.
 Morphological changes such as
sharp, spiny and uneven ridges.
 Location of mental foramina close to
the crest of the residual ridge.

14. AIMS AND OBJECTIVES
 Eliminating preexistent or recurrent pathology.
 Rehabilitating infected or inflamed tissue.
 Reestablishing maxillomandibular relationships in all spatial
dimensions.
 Preserving or restoring alveolar ridge dimensions (height,
width, shape, and consistency) conducive to prosthetic
restoration.
Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition

15.  Achieving keratinized tissue coverage over all loadbearing
areas.
 Relieving bony and soft tissue undercuts
 Establishing proper vestibular depth.
 Preventing or managing pathologic fracture of the atrophic
mandible.
Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition

16. Preprosthetic
Surgical
Procedures can
be Classified as

17. 1. RIDGE CORRECTION PROCEDURES
ALVEOLOPLASTY
Introduction
 Except for the removal of the natural tooth the most
commonly performed preprosthetic surgery is
alveoloplasty/alveolectomy.
 Alveolectomy is defined as the excision of portion of
alveolar process.
-Boucher(1974)
 In recent years the term alveoloplasty is used to signify
the recontouring of the alveolar process rather than its
removal.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

18. HISTORY OF ALVEOLOPLASTY
Beers (1976) Described his heroic treatment i.e. the radical
form of alveolectomy
Which became popular in 1920’s- dentists were
overenthusiastic towards alveolectomy
Devan (1930) stated that overenthusiastic
alveolectomies are the biggest blunder of his
professional life.
In 1923 Molt Recommended use of casts in
planning alveolectomy to avoid excessive removal.
Dean in 1936 introduces intraseptal alveolectomy which
was modified by Obwegesser in 1966.

19. Types
I. Alveolar compression
II. Simple alveoloplasty
III. Deans intraseptal alveoloplasty
IV.Obwegeser modification
V. Post extraction alveoloplasty
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

20. Alveolar compression
 Easiest and the quickest method
 Involves compression of cortical plates with fingers
following extraction of teeth.
 Reduction in socket width and eliminates the bony
undercuts.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

21. SIMPLE ALVEOLOPLASTY
a. Alveoloplasty After Extraction of
Single Tooth.
F. D. Fragiskos Textbook of oral surgery

22. F. D. Fragiskos Textbook of oral surgery

23. F. D. Fragiskos Textbook of oral surgery

24. b. Simple alveoloplasty Alveoloplasty After
multiple teeth extraction
F. D. Fragiskos Textbook of oral surgery

25. F. D. Fragiskos Textbook of oral surgery

26. F. D. Fragiskos Textbook of oral surgery

27. F. D. Fragiskos Textbook of oral surgery

28. Post extraction alveoloplasty
 Bony areas requiring recontouring
should be exposed using an envelop
type of flap.
 Incision along the crest of the ridge
with adequate A-P extension is given.
 Adequate visualization and access to
the alveolar ridge obtained.
 Vertical incisions given if necessary.
 Recontouring can be accomplished
with Rongeur Bone file Bone
bur in hand piece
F. D. Fragiskos Textbook of oral surgery

29. F. D. Fragiskos Textbook of oral surgery

30. F. D. Fragiskos Textbook of oral surgery
Bone irregularities of an edentulous alveolar ridge of
the mandible after multiple tooth extractions

31. F. D. Fragiskos Textbook of oral surgery

32. Deans interseptal alveoloplasty
Principles behind Deans technique
Dean's technique and its results are based on sound
biologic principles:
1. The prominence of the labial and buccal alveolar
margin is reduced to facilitate the reception of
dentures.
2. The-muscle attachments are undisturbed.
3. The periosteum remains intact.
4. The cortical plate is preserved as a viable onlay
bone graft with an intact blood supply.
5. Because the cortical bone is spared postoperative
resorption is minimized.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

33.  Used in maxilla only (mainly in the anterior region).
 Does not require raising a mucoperiosteal flap.
 Carried out immediately following extractions of
anterior teeth Indicated in cases, where adequate
bone height exists, but an undercut is present on the
buccal aspect of the maxillary ridge.
 Two steps—(1) removal of intraseptal bone followed
by (2) repositioning of the labial cortical bone
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

36. Obwegeser’s technique
 Repositioning of both labial and palatal cortices.
 It is used when the maxillary overjet is gross and
inward compression of only labial cortex is not
sufficient to reduce the overjet.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

39. Maxillary Tuberosity Reduction (Hard Tissue)
 Horizontal or vertical excess of the maxillary tuberosity
area may be a result of excess bone, an increase in the
thickness of soft tissue overlying the bone, or both.
 Recontouring of the maxillary tuberosity area may be
necessary to remove bony ridge irregularities or to create
adequate interarch space, which allows proper
construction of prosthetic appliances in the posterior
areas.
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition
 A preoperative radiograph or selective probing with a
local anesthetic needle are often useful to determine
the extent to which bone and soft tissue contribute to
this excess

40. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

41. REDUCTION OF THE KNIFE-EDGED OR SAW-TOOTH
RIDGE
Extreme alveolar atrophy of the mandibular ridge
often, and of the maxillary ridge occasionally, results
in a sharp residual alveolar crest that literally cuts into
the mucoperiosteum from the deep sur-face whenever
pressure is brought to bear on the area.
Denture wearing becomes extremely painful in this
situation.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

42. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

43. MYLOHYOID RIDGE REDUCTION(LINGUAL
BALCONY REDUCTION)
Alveolar Atrophy sometimes accentuates the mylohyoid
ridge, which can be palpated along the lingual surface of
the mandible in the second and 3rd molar region.
Indications for removal
 Pain when the lingual flange of the denture
compresses the intervening soft tissue against it.
 Affecting the stability of the denture
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

44. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

45. REDUCTION OF TORI AND EXOSTOSES
TORUS PLATINUS
 Tori, meaning ‘to stand out’ or ‘lump in Latin
 Torus palatinus, or palatal torus, is a benign, slowly
growing, bony-projection of the palatine processes of the
maxilla and occasionally of the horizontal plates of the
palatine bones.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

46.  It occurs bilaterally along the median suture on the oral surface of
the hard palate.
 Incidence- 20-25% of adult population, and 5% of newborn
 Females>males.
 Heredity, superficial trauma, malocclusion, and functional
response to mastication have been suggested as possible factors.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

47.  A palatal torus - dense cortical surface and varying
amounts of a cancellous core.
 A torus grows slowly, attaining its maximum size in
the middle decades of the person's life.
 The size and shape are variable, more frequently
nodular than fusiform.
 The mucosa covering a torus is usually very thin.
 Because of the scarcity of submucosal connective
tissue, the vascular supply to the mucous
membrane is poor in comparison with other areas of
the jaws.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

48. Classification of tori
It was initially proposed by Kolas ,who classified them according
to number of nodes and their placement as bilateral single,
bilateral multiple, unilateral single, and unilateral multiple

49. Indications for removal
(1)They become so large as to interfere with
speech
(2)The mucosa becomes traumatized, ulcerates,
and fails to heal because of its poor
vascularity
(3)Interferes with the design and construction of
dental prosthesis.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

50. F. D. Fragiskos Textbook of oral surgery

51. F. D. Fragiskos Textbook of oral surgery

52. F. D. Fragiskos Textbook of oral surgery

53. F. D. Fragiskos Textbook of oral surgery

54. Complications
 Haemorrhage
 Hematoma
 Necrosis and slough of palatal mucosa
 Perforation of floor of the nose
 Fracture of palate
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

55. Torus mandibularis
 Torus Mandibularis or Mandibular
torus usually occurs bilaterally on the
medial surface of the body and
alveolar process of mandible.
 Incidence – 5%-10% of adult
population
 Male=female
 Composed of dense cortical bone
with minimal medullary bone.
 Indications for removal
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

56. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition.

57. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition.

58. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition.

59. EXOSTOSES –
It is a benign osseous hypertrophic formation with
more predilections to the maxilla
Multiple exostoses at the anterior region of the maxilla
F. D. Fragiskos Textbook of oral surgery

60. F. D. Fragiskos Textbook of oral surgery

61. Localized Mandibular Buccal
Exostosis
F. D. Fragiskos Textbook of oral surgery

62. F. D. Fragiskos Textbook of oral surgery

63. F. D. Fragiskos Textbook of oral surgery

65. Corrective soft tissue surgeries
 Labial frenectomy
 Lingual frenotomy
 Maxillary Tuberosity Reduction (Soft
Tissue)
 Unsupported hypermobile tissue
 Inflammatory Fibrous Hyperplasia
 Inflammatory papillary hyperplasia
of palate.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

66. Labial frenectomy
The labial frenum is a band of fibrous connective tissue,
covered with mucous membrane, that binds the lip to the
alveolar process.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

67.  When a frenum is attached at or near the crest of the
alveolar ridge, it may be subjected to repeated
irritation from a denture flange.
 The denture flange can be relieved to accommodate
the frenum, but this can produce an unsightly groove
in the labial flange and can weaken the denture and
predispose to fracture along the midline.
 To avoid such the attachment of the frenum has to be
raised of eliminated entirely.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

68. SURGICAL PROCEDURES
 Simple excision
 Z plasty
 V-Y plasty
 localized vestibuloplasty with secondary
epithelialization
 Laser assisted frenectomy
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

69. Simple excision
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

70. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

71. Z plasty
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

72. V-Y plasty

73. localized vestibuloplasty with
secondary epithelialization
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

74. Laser excision of frenum.
A, Broad-based frenum in
anterior maxilla.
B, Supraperiosteal
ablation of mucosal and
dense fibrous frenal
attachments. Healing
occurs by secondary
epithelialization.

75. Lingual Frenectomy
 An abnormal lingual frenal attachment usually consists of
mucosa, dense fibrous connective tissue, and occasionally,
superior fibers of the genioglossus muscle.
 This attachment binds the tip of the tongue to the posterior
surface of the mandibular alveolar ridge.
 Even when no prosthesis is required, such attachments can
affect speech.
 After loss of teeth, this frenal attachment interferes with
denture stability, because each time the tongue is moved,
the frenal attachment is tensed and the denture is dislodged
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

76. Lingual frenotomy
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

77. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

78. Maxillary Tuberosity Reduction (Soft Tissue)
The primary objectives
 Provide adequate interarch space for proper
denture construction in the posterior area.
 A firm mucosal base of consistent thickness over
the alveolar ridge denture bearing area.
 The amount of soft tissue available for reduction
can often be determined with a sharp probe after
local anesthesia is administered at the time of
surgery.
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

79. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

80. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

81. Unsupported Hypermobile Tissue
Excessive hypermobile tissue without inflammation on
the alveolar ridge is generally the result of resorption
of the underlying bone, ill-fitting dentures, or both
Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th edition

83. Inflammatory fibrous
hyperplasia of vestibule.
 Fibrous hyperplasia of the
mucosa (formerly known
as epulis fissuratum or
inflammatory hyperplasia)
is usually due to chronic
trauma of the mucosa of
the mucolabial or
mucobuccal fold, due to
ill-fitting complete or
partial dentures
 Treatment is surgical and
consists of excision of the
hyperplasia
F. D. Fragiskos Textbook of oral surgery

84. F. D. Fragiskos Textbook of oral surgery

85. F. D. Fragiskos Textbook of oral surgery

86. Replacement of old denture, immediately after the end of
the operation, retaining the depth of mucosa of the newly
created sulcus. The internal surface of the denture is lined
with tissue conditioner
F. D. Fragiskos Textbook of oral surgery

87. Inflammatory Papillary Hyperplasia of
the Palate
 Papillary hyperplasia is a rare pathologic
condition localized most often in the palate.
 It usually occurs in edentulous patients
who have been wearing dentures for a long
time
 Clinically, these are multifocal hyperplastic
nodules of the mucosa of the palate,
between which food may accumulate,
potentiating the inflammatory reaction.
 Treatment is surgical and consists of
removal of the lesion with a scalpel or
electrosurgical loop.
F. D. Fragiskos Textbook of oral surgery

88. F. D. Fragiskos Textbook of oral surgery
removal of the lesion with an electrosurgical loop

89. F. D. Fragiskos Textbook of oral surgery
the surgical field after removal of the lesion

90. RIDGE EXTENSTION PROCEDURES
VESTIBULOPLASTY
The reduction or obliteration of the sulcus is caused by:
 resorption of the alveolar process
 Abnormally high muscle attachment in mandible or
 low on the maxilla
 scar tissue resulting from trauma
 infection from the contiguous soft tissue
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

91. DEFINITION
“Vestibuloplasty” or “Sulcoplasty” or “Sulcus deepening
procedure” is a procedure to increase the depth of the
vestibule by uncovering the existing basal bone of the jaws
surgically and by repositioning the overlying mucosa, muscle
attachments to a lower position in the mandible/superior
position in the maxilla”

92. Indications
 Shallow buccal vestibule
 Presence of adequate bone
 Insufficient keratinized mucosa
 Shallow lingual vestibule with raised floor of the
mouth
Objectives
 To increase the size of denture bearing area
 To increase the height of the residual alveolar ridge
 To prepare the mouth for denture
 To improve its retention
 To maintain oral hygiene effectively

93. VESTIBULOPLASTY TECHNIOUES
The following broad categories of vestibuloplasty procedures:
1. Mucosal advancement (submucous)vestibuloplasty. The
mucous membrane of the vestibule is undermined and
advanced to line both sides of the extended vestibule.
2. Secondary epithelization (re-epithelization) vestibuloplasty.
The mucosa of the vestibule is used to line One Side of the
extended vestibule, and the other side heals by growing a
new epithelial surface.
3. Grafting vestibuloplasty. Skin, mucosa, and dermis can be
used as a free graft to line one or both sides of the
extended vestibule.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

94. Mucosal advancement (submucous)vestibuloplasty
A prime criterion for this type of procedure is the presence of
an adequate amount of bone and healthy mucosa.
Clinical test
A mouth mirror is inserted into the vestibule to the depth
required prosthetically. If the upper lip is not displaced upward
or drawn inward by the manoeuvre, it can be assumed that
there is sufficient mucosa for an advancement procedure.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

95. CLOSED SUBMUCOSAL VESTIBULOPLASTY
It was first described by Obwegeser in 1951
Indication- Clinically short alveolar ridge + enough bone but
mucosa and muscles of vestibular area attached too close
to the crest of ridge.
Objectives
 To extend the vestibule to provide additional ridge height.
 To excise or transfer the submucous connective tissue
and the adjacent muscles to a position farther from crest
of the ridge to prevent relapse.
This procedure is especially applicable in the maxillary
vestibule where better results are obtained compared to
mandibular vestibule.
Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition

96. Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition

97. Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition

98. Open-view submucosal vestibuloplasty
Described by Wallenius in 1963

99. SECONDARY EPITHELIZATION VESTIBULOPLASTY
Secondary epithelization vestibuloplasty is indicated when
sufficient bone is present but the mucosa is either insufficient
in quantity or of poor quality (e.g., inflammatory hyperplasia,
ulceration, or scar tissue is present).
There are two basic techniques of vestibuloplasty by
secondary epithelization, each with several variations.
1. Kazanjian(1935)technique
2. Clark(1953)technique

100. Kazanjian(1935)technique
 Uses mucosal flap from inner aspect of lower lip
 Raw area on the lip side heals by secondary intention
 Disadvantage- severe scarring of the lower lip.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

101. GODWIN’S TECHNIQUE
 Modification of Kazanjian’s technique
 Vestibule is deepened by subperiosteal dissection
 Disadvantage
 Scar on the labial side of sulcus
 Bone resorption

103. Lip switch vestibuloplasty- Howe(1965), Kethley and Gamble
(1978)
 The lip switch operation is a variation of Kazanjian's and Godwin's
mandibular vestibuloplasty.
 In this procedure the mucosal flap is developed in the same way as
suggested by Kazanjian, with the free margin in the lip and the base
attached to the crest of the residual alveolar ridge.

104. Clark's technique
Clark’s extension procedure (1953) can be considered as the
reverse of Kazanjian’s technique
Clark based his operation on Four principles of plastic surgery:
1. Raw surfaces on connective tissue Contract, whereas the
same surfaces undergo minimal contraction when covered
with the epithelium.
2. Raw surfaces overlying bone cannot contract.
3. Epithelial flaps must be undermined sufficiently to permit
repositioning and fixation without tension
4. Soft tissues undergoing plastic revision have a tendency to
return to their former position so, overcorrection and firm
fixation are necessary.

106. Clark’s Technique of Vestibuloplasty - A Case Report by Dr. Benju Shrestha et.. al J
Nepal Soc Perio Oral Implantol. 2020;4(8):93-5

107. Clark’s Technique of Vestibuloplasty - A Case Report by Dr. Benju Shrestha et.. al J
Nepal Soc Perio Oral Implantol. 2020;4(8):93-5

108. Amniotic Membrane as a Biological Scaffold After
Vestibuloplasty by R. Keerthi et.al. J. Maxillofac. Oral Surg

109. RESULTS- Three weeks after the procedure the graft
area could be noticed but the amnion had completely
degenerated and disappeared. The patient complained
of very little discomfort and mild pain with no burning
sensation. No complications such as infection or graft
rejection was observed.
Amniotic Membrane as a Biological Scaffold After
Vestibuloplasty by R. Keerthi et.al. J. Maxillofac. Oral Surg

110. Obwegeser’s modification
 Similar to Clark’s method, except the area of the
alveolar bone with its 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
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

111. Following conclusions can be drawn regarding secondary
vestibuloplasty:
1. The Clark procedure, which leaves epithelization a raw
periosteal surface, is preferred to the Kazanjian
procedure, which leaves a raw lip wound that undergoes
considerable contracture.
2. The mucosal flap must be free of tension and must be fixed
for a sufficient period to prevent relapse-perhaps 14 days or
longer.
3. Relapse can be minimized further if the periosteum is
incised al the base of the vestibule.
4. All Connective tissue and muscle should be removed from
the periosteum.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

112. 5. The denture flange should not irritate the healing
periosteal surface.
6. Corticosteroids can be injected into the vestibule to
reduce the scar contracture.
7. A new prosthesis may be made after 4 to 5 weeks.
8. Overcorrection should be attempted whenever possible to
prevent relapse.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

113. Lingual Vestibuloplasty
 Also called floor-of-the-mouth-plasty
 Extension of the lingual sulci or lowering of the floor of
the mouth
 It extends the denture bearing surface and improve
stability and retention of the mandibular denture
 Eliminates the muscle attachments that dislodge the
prosthesis.
 Used in the mandible, when the mylohyoid and
genioglossus attachments are close to the alveolar ridge.

115. ANTERIOR LINGUAL SULCOPLASTY
 Cooley 1952
 Often combined with
reduction of genial
tubercles
 Crestal incision given to expose
the upper genial tubercle and to
detach the genioglossus muscle
(only lateral and superior fibers
to prevent post operative
complaints of difficult
swallowing and speech)

116.  Genial tubercles removed if too large
 Heavy nylon sutures attached to the muscles and
pulled through the skin under the chin and
repositioned inferiorly using buttons. As the suture is
tightened the muscle is pulled downwards .

117. POSTERIOR LINGUAL SULCOPLASTY
CALDWELL PROCEDURE
 It is a subperiosteal procedure
 Suggested method when mylohyoid ridge reduction
is recommended along with the sulcoplasty
COMPLICATIONS
 Hematoma and edema of the sublingual tissues
 Difficulty in swallowing and speech for few days

118.  Crestal incision given(molar to molar) and subperiosteal
dissection done to reflect a full thickness periosteal flap
 Mylohyoid muscle stripped away to expose the prominent ridge
which is reduced with a chisel or rounger
 Flap is sutured back
 Denture or splint with an elongated flange is used to hold the lingual
tissues down to the required depth and held in place with
circummandibular wiring.

119. TRAUNERS PROCEDURE
 Trauner in 1952
 Supra-periosteal procedure
Indications
 If mucosa of floor of mouth rises as high as the
mandibular ridge
 When the tongue is elevated
 Mylohyoid muscle is attached at the level of the
residual alveolar ridge

120.  Long crestal incision given , supraperiosteal dissection
done.
 Heavy nylon sutures placed and mylohyoid muscle pulled
down to desired depth
 Held in place with buttons
 Stent placed with split thickness graft to enhance healing

121. OBWEGESERS PROCEDURE
 Macintosh and obwegeser in
1967
 Method of combining skin graft
vestibuloplasty along with
lowering of the floor of the
mouth
 Lingual sulcus deepening
followed by buccal/labial
vestibuloplasty.

122. GRAFTING VESTIBULOPLASTY
INDICATIONS
• Inadequate amount of bone to compensate for relapse
after vestibuloplasty
• Large surgical defect
ADVANTAGES
 Less relapse
 Early covering of surgical
defect
 Rapid healing
DISADVANTAGES
 Donor site morbidity.
 Skin grafts may not take
up well on exposed bone.
 Hair growth if graft is thick.
 Reduced secretory capacity,
color and surface
consistency.
PART II

123. PRINCIPLES OF GRAFTING
1. Skin grafts to be removed from a relatively hairless
area.(upper thigh, inner surface of arm).
2. Thin split thickness grafts are less likely to have hair
follicles in the dermis.
3. Split thickness graft will give better results than full
thickness, but a full thickness graft contracts less.
4. Recipient site should be free of infection and have good
blood supply
5. Graft should cover the entire raw area.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

124. 6. Hemostasis should be obtained in the recipient
site before graft placement
7. Graft should be placed over periosteum and not
cortical bone
8. Graft should be immobilized until healing has
occurred (7 to10 days) by either by stent or
suturing
9. If palatal mucosa used, it should be defatted to
make it as thin as possible
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

125. Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

126. SKIN GRAFT VESTIBULOPLASTY
STAGE I - DONOR SITE SURGERY
 Patients thigh is prepared with a
surgical soap and Skin lubricated with
mineral oil.
 Graft width depends on the height
of body of mandible(5 to 6 cms)
and thickness being about
 0.012 inch(0.3mm)
 Dermatome used to prepare skin graft
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

127.  The skin graft is kept moist and
rolled in gauze
 Donor site is covered with fiber mesh gauze
and pressure dressing.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

128. STAGE II - RECIPIENT SITE SURGERY
 Mucosa infiltrated with local anesthesia and crestal incision
given from lateral margin of one retromolar pad to the other
 Mandibular labio-buccal, submucosal and supra-
periosteal dissections done, mucosal flap reflected and
sutured to the desired vestibular depth
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

129. STAGE III – GRAFT SECURED TO THE
RECIPIENT SITE
1. STENT – dermatome cement is used to attach the graft to the
stent such that the raw side is in contact with the periosteum
2. SUTURES
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

130. DERMAL GRAFTING
 Introduced by smiler et. al
Advantages
 Readily available in sufficient quantity
 Easily re-vascularized
 Viable and immuno-compatible transplants
 Inhibit wound margin contracture
 Ability to take on the characteristics of
surrounding mucosa
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

131.  Thin split thickness graft (0.012 –
0.014 inch), is raised with a
dermatome, but the skin is not
removed and left pedicled at one end.
 Dermatome is again used to get a
slightly narrower strip of only
dermis (0.015 – 0.022 inch) thick
(below the skin pedicle)
 The pedicled skin flap is returned
to its bed and sutured in place
SURGICAL PROCEDURE
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

132. PALATAL MUCOSAL GRAFT (sanders and starshak 1975)
 Supraperiosteal dissection
done in vestibule and desired
height is achieved
 2 spilt thickness strips of
mucosa taken from right and
left side of palate
 The 2 grafts are then placed on
the recipient site and sutured,
followed by stent placement.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

133. RIDGE AUGMENTATION
 When the alveolar ridge resorption is so extreme, that in
maxilla, the height has been reduced to the point that a nearly
flat surface exists between the vestibule and palate and the
piriform aperture lies just beneath the gingiva.
 Mandible, the basal bone has shown considerable amount of
resorption with the mental nerve positioned almost at the crest
and very thin mandibular alveolar ridge exists, which can end
up in fracture easily.
 Vestibuloplasty is out of consideration in such cases, until the
replacement of necessary supportive bone is done
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

134. 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 inter-arch relationship.
 Improvement of retention and stability of denture
 Improve the patient comfort for wearing the denture.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

135. Limitations
 Physical condition of the patient
 Metabolism of the patient (healing capacity)
 Nutritional deficiencies
 Availability of adequate soft tissue coverage
 Compliance of the patient for major surgery
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

136. RIDGE AUGMENTATION PROCEDURES

138. MATERIALS USED FOR AUGMENTATION OF
ALVEOLAR RIDGE
1. AUTOGENOUS BONE GRAFT
Iliac crest, Rib Graft
2. ALLOGENIC BONE GRAFT
Freeze dried bone
3. ALLOPLASTIC MATERIAL
Silastic, Carbon-impregnated Teflon Foam(Proplast)
Ceramic materials
Hydroxyapatite (Calcitite)
Tricalcium phosphate
4. Metal Mesh with
a. autogenous cancellous bone
b. hydroxyapatite

139. 1. .SUPERIOR BORDER AUGMENTATION BY RIB GRAFT
● Davis in 1970, described this technique for ridge augmentation.
● Preoperative considerations
 Remaining height of the body of edentulous mandible is less
then 10mm
 patient’s ability to tolerate the procedure psychologically &
physically.
● Donor consideration
○ 2 Rib segments about 16 cm are taken anywhere from the
5th to 9th ribs may be used.
MANDIBULAR RIDGE VAUGMENTATION
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

141. KERFING:
the vertical removal of the
Bone on the internal surface
is carried out through the
superior and inferior
Edges.
2nd Rib is cut into small pieces about 2 X 3 mm to facilitate placement
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

142. TECHNIQUE
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

143. Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

144. INFERIOR BORDER AUGMENTATION
● First described by Marx & Saunders in 1986.
● Modified by Quinn in 1991.
● INDICATIONS
 Augmentation of the severely atrophic mandible
 prevention of pathologic fracture
 management of nonunion and malunion
• Advantages
• Disadvantages
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

145. TECHNIQUE

146. Interpositional Bone Grafts (Sandwich
Grafting)
 Danielson and Nemarich advocated this
technique.
 During this procedure, a horizontal osteotomy is
performed, splitting of the residual maxilla or
mandible and bone is grafted into this osteotomy
gap.

147.  In mandible, sandwich technique is mainly used for
augmentation of the anterior mandible, between the
mental foramina.
 The autogenous or allogenic bone or hydroxyapatite
grafts can be used successfully.
 Delivery of the prosthetic appliance is delayed 3–5
months for allowing the remodeling of the bone.
 Secondary vestibuloplasty procedures may be
necessary.
 For the posterior region, reasonable amount of bone
should be present above mandibular canal.

148. Advantages
 Less resorption rate than onlay grafting.
 More predictable long-term results.
 Decreased incidence of nerve paresthesia than
the visor osteotomy
 Implant success rate is reported as high as
98% with low resorption rate

149. Visor Osteotomy–Vertical Osteotomy
Harle, in 1975, proposed this technique.
The goal of visor osteotomy is to increase the height of the
mandibular ridge for denture support.

150. MODIFIED VISOR OSTEOTOMY
 Peterson and Slade in 1977
 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.
 It is a combination of vertical and horizontal
osteotomies.

152. Advantage:
 Less risk of fracture.
 Better repositioning of superior and posterior
segments.
 Correction of mild to moderate A-P
descripancies.
 Also allows increase in the amount of
augmentation in more stable fashion. 80% of
the height is maintained at the end of 3–5
years.

153. Disadvantages
 Nerve paresthesia
 Need for hospitalization
 Donor site morbidity
 Inability to wear the dentures for 3–5 months
following surgery

154. Pedicled Augmentation–Horizontal Pedicled
Osteotomy
 This is a recently developed technique.
 Schettler and Holteman et al., in 1977, reported a resorption
pattern after this method of 0–2 mm.
 After 6–18 months, horizontal osteotomy is carried out
pedicled on lingual tissues/ muscles, for postoperative blood
supply.
Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce Sanders”.

155.  Sandwich grafting is done between superior and inferior
segments.
 Bone healing with pedicled flaps occurs primarily and
does not depend on replacement of nonvital bone.
 The attachment of genioglossus and suprahyoid muscles
helps.

156. Augmentation in Combination with Orthognathic
Surgeries
 Many osteotomies have been performed for
reconstruction of edentulous atrophied maxilla/mandible.
 Anterior maxillary osteotomy 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.

157. Posterior segmental osteotomy to achieve interocclusal
clearance
 Whenever tooth is lost/removed and not rehabilitated
prosthetically for a long period of time, it will lead to
supraeruption of the opposing tooth, thereby decreasing
interocclusal clearance.
 Conventionally to achieve interocclusal clearance, the most
commonly used technique was extraction of the offending
supraerupted tooth or teeth.
 Over a period time, various options have been proposed, i.e.
performing an intentional root canal therapy for the supraerupted
tooth and crown shortening, orthodontic intrusion of teeth using
implants, or by performing posterior maxillary segmental
osteotomy (PMSO).

158.  Posterior segmental osteotomy is considered
versatile and useful treatment.
 It is alternative for variety of dentofacial conditions,
especially in case of bilateral distal extension RPD
construction.
 Bell and Levy described that the vertical osteotomy
cut should be 5 mm above the apices of the posterior
teeth and they considered this distance to be safe
with regards to the neurovascular regeneration of the
pulp of the teeth involved.

159. Procedure:
 Vestibular incision placed extending from first premolar
to second molar and full thickness mucoperiosteal flap
is raised.
 Osteotomy cuts are placed 5 mm above the apices of
teeth and at interdental bone with the help of fine
surgical burs, care is taken not to damage the roots of
the teeth.
 Transantrally with the help of osteotomies, palatal cuts
are completed.

160.  Anterior cut is made interdentally and posterior cut is
limited to the socket of the third molar tooth.
 The segment is down fractured and sufficient amount of
bone is removed superiorly and the segment is
repositioned as planned preoperatively.
 The posterior maxillary segment is secured across the
osteotomy site with the help of miniplates and screws.
 The case is evaluated clinically and radiographically at the
end of 6 months.

161. Use of Distraction Osteogenesis for Preprosthetic
Purpose
 Distraction osteogenesis is a surgical procedure that utilizes
the body’s own reparative mechanisms for hard and soft
tissue reconstructions.
 This approach has numerous clinical applications in the
maxillofacial complex and has been used successfully to
vertical and horizontal augmentation of the alveolar ridges.

162.  It offers a useful and acceptable alternative to
conventional bone graft technique, in a selected group
of patients.
 Optimal results can be obtained with accurate planning
of the osteotomies and accurate positioning of
distraction device using 3D models.
 Block et al. and Chin and Toth, in 1996, first used this
method as more successful and stable alternative for
augmentation of the ridges prior to implant placement.
Success rate was 90.4%

163.  Distraction osteogenesis is a biological process of new
bone formation along with its soft tissue, in which slow
and controlled distraction of bony segments with
preservation of periosteal and medullary blood supply,
results in elongation of bone.
 The tension/traction stimulates the new bone formation,
parallel to the vector of distraction.
 Development of miniaturized distraction device has made
distraction osteogenesis of small segments feasible.

164. Distraction Osteogenesis
1. Vertical distraction: To generate vertical dimension of
the alveolar process prior to prosthetic rehabilitation.
2. Horizontal distraction: To correct interarch relationship
of the atrophic ridges.

165. Indications The process is applied for atrophic
alveolar process, resulting from periodontal disease,
trauma, congenital deformity, marginal bone
resection of a jaw tumor, extraction and traumatic
avulsion of teeth.
Contraindications In patients with severe
osteoporosis, patients with space limitation for
distraction device placement, extremely advanced
age.

166. Increasing the Volume/Vertical Height of Atrophic Alveolar
Ridge by Vertical Distraction Osteogenesis Procedure

167. Piezosurgical Rigde Expansion for Immediate
Implant Placement-Ridge Splitting Technique
 The use of a piezosurgical device for performing a
piezoelectric alveolar ridge expansion procedure
permits a precise and tactile controlled osteotomy
facilitating implant placement in anatomic situations
previously impossible in a single stage procedure.
 The technique is also characterized by a valid
vascular supply and a rich osteoinductive cellularity,
which comes from the diversion of the medulla.
 Also the morbidity associated with the use of second
surgical site for harvesting autogenous bone grafts or
micromovements of implants formed by a particulate
graft is avoided.

169. Conclusion
 The art of designing the soft- and hard-tissue framework for the
smooth placement of the prosthesis is a challenging task. This
task is achieved by the meticulous planning and execution of the
planned presurgical procedures in a systematic manner.
 The intimidating impressive trends of implantology might have
downsized the charm of preprosthetic surgery, yet in certain
avenues the preprosthetic surgical manoeuvres become
inevitable.
 So it is not possible to completely thwart or baffle the procedures
belonging to the preprosthetic surgery as an obsolete one

170. REFERENCES
1. Preprosthetic oral and maxillofacial surgery by Thomas J Starshak and Bruce
Sanders”.
2. Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition
3. Contemporary oral and Maxillofacial surgery by J.R. Hupp, Edward Ellis, Tucker 7th
edition.
4. Reconstructive preprosthetic oral and maxillofacial surgery-Fonseca and davis, 2nd
edition
5. Atlas of preprosthetic oral surgery by Russel Hopkins
6. F. D. Fragiskos Textbook of oral surgery
7. Amniotic Membrane as a Biological Scaffold After Vestibuloplasty by R. Keerthi et.al.
J. Maxillofac. Oral Surg
8. Preprosthetic Surgery And Its Current Trends : A Review by Dr. Balakrishnan et. al.
Journal of Positive School Psychology 2022, Vol. 6, No. 3, 3752 –3755
9. Clark’s Technique of Vestibuloplasty - A Case Report by Dr. Benju Shrestha et.. al J
Nepal Soc Perio Oral Implantol. 2020;4(8):93-5