Pre prosthetic surgery /certified fixed orthodontic courses by Indian dental academy

Pre Prosthetic Surgery
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Definition
―Surgery performed to prepare the remaining oral
tissues to best support a prosthesis‖


Objectives
• To provide a comfortable tissue foundation to

support the denture
• Proper jaw relationship in the anteroposterior,
transverse and vertical dimensions.

• Alveolar processes that are as large as possible and of
the proper configuration. (The ideal shape of the
alveolar process is a broad U-shaped ridge with the
vertical components as parallel as possible.

Objectives
• No bony or soft tissue protuberances or undercuts.
• Adequate attached keratinized mucosa in the
primary denture-bearing area.

• Adequate vestibular depth.
• Adequate form and tissue coverage for possible

implant placement

Patient evaluation & treatment planning
• History
• Physical examination –
Evaluation of supporting bony tissue

Evaluation of supporting soft tissue


Classification
• Corrective Procedures
• Ridge extension procedure
• Ridge augmentation


Corrective Procedures
Soft tissue
– Frenectomy
– Excision of flabby ridges
– Excision of denture induced granuloma
– Reduction of fibrous tuberosity
Hard tissue
– Alveoloplasty
– Removal of Tori
– Tuberosity reduction
– Myeloid hyoid ridge reduction
– Genial tubercle reduction

Bony Recontouring of the alveolar ridges

• Simple alveoloplasty
associated with multiple
removal of teeth

• Compression of the
lateral walls


Intraseptal alveoloplasty
Deans technique

• Involves removal of the intraseptal bone and
repositioning of the labial cortical bone
• Done immediately after tooth extraction or in the
initial post operative healing period
• Technique is best used when the ridges of regular
contour and adequate height but presents an
undercut to the depth of the labial vestibule

Advantages

• Labial prominence of the ridge can be reduced
without significantly reducing the height of the

ridge


Intraseptal alveoloplasty
• Periosteal attachment to the underlying bone,this
reduces the post operative bone resorption and
remodeling.
• Muscle attachment to the alveolar ridge can be left
undisturbed.


Maxillary tuberosity reduction
• Horizontal or vertical excess of the maxillary
tuberosity area can be due to
bone excess
soft tissue
both
Pre operative evaluation
• Clinical examination

• Radiographic examination
to locate the floor of the maxillary sinus

Objective

Procedure for hard tissue
• To provide adequate interarch space

• A firm mucosal base of consistent
thickness


Procedure
for

soft tissue


Mylohyoid ridge reduction


Genial tubercle
• Reduction or augmentation


Maxillary Tori
• Bony exostosis in the palate

• Origin is unclear
• Found twice as much in females than in males
• Single smooth elevation to multiloculated
pedunculated mass
• Speech problems,ulcers,interferes with prosthesis

• Usually present in the midline

Maxillary tori


Mandibular tori
• Present on the lingual aspect

• Usually premolar area
• Gradually increase in size
• May interfere with speech or tongue movement
• Rarely requires surgical intervention when
dentition is present


Mandibular tori


Unsupported hyper mobile tissue
• It is caused due to resorption of underlying bone or
ill fitting denture
• Treatment
augmentation of bone

soft tissue excision
• Complication
• obliteration of buccal vestibule due to
undermining

Inflammatory fibrous hyperplasia
• Epulis fisuratum

• Commonly caused by ill fitting denture
• Treatment
• initial stages– denture with a soft liner
• significant fibrosis – excision of the hyperplastic tissue
electro surgical

surgical excision

Inflammatory papillary hyperplasia of palate
• Mechanical irritation, poor hygiene, fungal
infection
• Appears as multinodular projections in the palatal
tissue
• Treatment
• initial stage – denture adjustment with tissue
conditioner
• Electro surgical excision
• Abrade with a rotating hand piece

Labial frenectomy
• It is a thin band of fibrous tissue covered with
mucosa extending from the lip and cheek to the
alveolar periosteum.

• Surgical techniques
simple excision
z plasty
localised vestibuloplasty

Augmentation procedures
Maxillary augmentation
• Onlay bone grafting
• Interpositional bone graft

• Maxillary hydroxyapetite augmentation
• Sinus lift

• Tuberocity augmentation

Mandibular augmentation
• Superior border augmentation
• Inferior border augmentation
• Pedicle or interpositional augmentation
• Hydroxyapetite augmentation


Superior border augmentation
Indications
• Inadequate height
• Irregular contour

• Potential risk of fracture
• Neurosensory disturbance


Advantages
• Adds strength to the mandible
• Increases height of the alveolus
• Increases the width and recontours
the mandible


Disadvantages
• Donor site morbidity
• Need for secondary soft tissue surgery
• Avoid denture for 6-8 months
• Resorption of the graft


Inferior border augmentation
Indications

• Improve the esthetic
• Prevent fracture of the mandible
Advantages
• Does not obliterate the vestibule
• Easier to do secondary vestibuloplasty

• Denture can be worn immediately

Inferior border augmentation

Disadvantages
• Extraoral scar
• May worsen the
facial appearance
Procedure


Pedicle & Interpositional bone graft
Horizontal osteotomy with interpositional
bone graft is an ideal procedure when there is
enough bone above the mandibular canal
Advantages
• Decreased bone resorption
• Maintain stable height &contour
• Avoids secondary vestibuloplasty
• Can wear denture in 3—5 months

Pedicle & Interpositional bone graft
Disadvantages
• Need hospitalisation & GA
• Donor site morbidity
Concept: bone attached to its own blood supply
will show less tendency to resorb and free
grafted bone placed between 2 layers left

undisturbed – permanent retention

Procedure


Visor or vertical osteotomy
• Modification of horizontal osteotomy

• Used when there is sufficient anterior bone to
form the pedicle graft, but there is hardly any

bone posteriorly above the mandibular canal
Limitations: width of mandible is reduced to half,

might damage the nerve

Augmentation with synthetic materials
Hydroxyapetite –
It is a dense biocompatible material that can be
produced synthetically or obtained from a biological
source such as coral
• Non resorbable ceramic bone substitute
• Calcium phosphate material
• Physical and chemical characteristic similar to enamel
and cortical bone
• Minimal foreign body reaction
• Histological examination has shown normal bone
healing around the material

Advantages
• Donor site surgery is eliminated

• Can be done in an out patient setting
• No post operative loss of graft

• Vascular in-growth around the H.A. provides an
adequate vascular bed for future soft tissue grafts


Disadvantages
• Not effective as bone grafts in preventing fracture in
a severely atrophic mandible
• Sometimes difficulty is encountered in containing
the material within the sub periosteal tunnel


Vestibuloplasty
• Definition:
‗Vestibuloplasty is defined as a procedure to
uncover the existing basal bone of the jaws
surgically by re-positioning the overlying
mucosa, muscle attachments to a lower
position in the mandible/superior position in
the maxilla.‘


Vestibuloplasty
• Classification:
– Maxilla
• Submucosal
• Secondary epithelization
• Tissue graft

– Mandible
• Submucosal
• Secondary epithelization
–
–
–
–

Clerk‘s technique
Kazanjian‘s technique
Lip switch
Lingual vestibulopasty

Secondary epithelization
• Procedure of choice for patients with extensive
scarring/epulis fissuratum
• Supra-periosteal dissection to raise a flap
• Superior/inferior (maxilla/mandible) repositioning by suturing the flap to the
periosteum
• Exposed periosteum will granulate secondarily
• Disadvantage: 50% relapse


Tissue graft vestibuloplasty
• Modification of previous procedure where in
tissue grafts are used to cover the exposed
periosteum and hold the repositioned muscles in
place
• Reduces wound contracture
• Palatal/buccal mucosa/skin/alloplastic materials


Expected Questions
I. Short Notes
a. Alveolectomy
b. Torus palatinus
c. Frenectomy

II. Classify pre-prosthetic surgical procedures & your
procedure to increase the depth of lingual sulcus
III. Define pre prosthetic surgery. Write your
technique for lingual sulcus extension

Thank you

Pre prosthetic surgery /certified fixed orthodontic courses by Indian dental academy

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Pre prosthetic surgery /certified fixed orthodontic courses by Indian dental academy