Abhi Prostho

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    Presented by,Abhi AIV BDS (Part II)

    Annoor dental college

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    A significant number of prtients can neverbe made to use dentures effectivelybecause of bone atrophy,soft tissuehypertrophy or localized soft and hard

    tissue problems or all of them.various treatment methods to improvepatients denture foundation and ridgerelations are:


    Combination of both

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    Nonsurgical methods

    Rest for denture supporting tissues

    Occlusal correction of the old

    prosthesis Good nutrition

    Conditioning of the patientsmusculature

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    1. Adequate bone support.2. Adequate firm soft tissue coverage.3. No bony or soft tissue undercut or prominences.4. No sharp ridges.

    5. No high muscle or frenal attachments.6. No presence of peripheral fibrous tissue bands to

    prevent proper seating.7. No soft tissue hypertrophies on the ridges or in

    the sulci.

    8. No intraoral or extraoral pathology.9. Proper alveolar ridge relationship in all threeplanes.

    Characteristic of idealdenture bearing area

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    Preprosthetic surgery.

    Preprosthetic surgery is carriedout to reform/redesign soft /hard tissues by eliminating

    biological hinderness to receivecomfortable & stable prosthesis.

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    Aims of preprosthetic surgery

    1.To provide adequate bony tissue support forthe placement of rpd /cd.

    2. Provide adequate soft tissue support,optimum vestibular depth.

    3. Elimination of the pre-existing bonydeformities eg. Tori, promoinent mylohyoidridge,genial tubercle.

    4. Correction of mandibular and maxillary ridgerelationship.

    5. Elimination of preexisting deformities.eg.epulis,flabby ridges, hyperplastic tissues.6. Relocation of frenal or muscle attachments.7. Relocation of mental nerve.8. Establishment of correct vestibular depth.

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    Preprosthetic surgical procedures .

    Alveolar ridge correction

    Alveolar ridge extension

    Alveolar ridgeaugmentation.

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    Alveolar ridge correction

    Bony surgeries.

    Labial alveolectomy.

    Primary alveoplasty. Secondary alveoloplasty.

    Excision of tori.

    Reduction of genial tubercle.

    Reduction of mylohyoid ridges.

    Maxillary tuberosity reduction

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    Soft tissue surgeries:

    Removal of redundant crestal softtissue.

    Frenectomy labial & lingual.

    Excision of epulis fissuratum &

    palatal hyperplasia.

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    Surgical removal or trimming of thealveolar process.

    Trimming done with roungeur or round

    bur and smoothened with bone file.

    Use in the presence of sharp margins atinterseptal or labiobuccal alveolar ridge.

    Too much bone loss will result in poordenture base.

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    Single tooth alveolectomy

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    Simple Alveoloplasty

    Refers to surgical recontouring of thealveolar process.

    Primary alveoloplasty always done at the

    time of multiple extraction or singleextraction.

    Minimum amount of alveolar boneresorption occurs if after simple

    extraction ,digital compression of theaqlveolar cortices done immediately.

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    Intraseptal alveoloplastydeansalveloplasty with repositioning oflabial cortical bone. Used in maxilla. Used to reduce gross maxillary overjet. To reduce the volume of Cancellous bone ,

    maintaining stress bearing cortical bone intact. Not require for raising mucoperiosteal flap. Carried following extraction of anterior teeth

    immediately. Maintain periosteal attachment to the labial plate

    of bone. It will reduce buccal undercut or labial

    prominence without reducing the height ofresidual alveolar ridge. Best long time result. Indicated in cases , in which the adequate bone

    height exists.

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    Indications 1.Multiple extraction 2.Early initial post extraction period. Steps 1.removal of bone followed by

    2.repositioning of the labial corttical bone. Technique Teeth should be extracted avoiding trauma to the

    labial cortex. Interdental septal bone is cut from canine to

    canine region with the straight fissure bur attached

    to surgical handpiece or with rongeur. With the same bur ,vertical cuts are made only in

    the labial cortex at distal end of the canineextraction sockets bilaterally without perforation ofthe labial mucosa in the deans technique.

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    With periosteal elevator /osteotome placedin the base of the canine socketbilaterally, labial cortex is fractured.

    Digital pressure is used to compress the

    fractured labial cortex into the palataldirection.

    Labial and palatal plate will come intoapproximation with each other.

    Interrupted continous suturing is carried


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    Obwegessers modification for

    interseptal alveoloplasty

    Indication Gross max.overjet.( when compression of the

    labial cortex is not sufficient) After cutting the interseptal bone ,an inverted

    cone vulcanite bur is used to widen the socket. With small bur ,horizontal cuts are made at the

    base of the extraction socket in the labial andpalatal cortices.

    Vertical cuts then made bilaterally in both thelabial and palatal cortices in the area distal to the

    canine socket. With digital pressure,both the labial and palatal

    cortices are compressed together and sutures aregiven.

    Immediate denture delivery is planned ,used as atemplate to check for any pressure points.

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    Alveoloplasty with post extractionhealing

    Crestal incision is taken not to tearthe mucoperiosteal flap, but thereflection

    Side ways separation with theperiosteal elevator will help thesmooth reflection.

    Sharp areas or large undercutsshould be trimmed with rongeur.And suturing done.

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    Elimination of unfavourableundercut

    Usually done in the mandibularlingual aspect (genial tubercle ,sharp mylohyoid ridge prominence.)

    Seen in patients wearing olddentures, due to resorption over theyears,the denture become unstable

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    Reduction /resection of the genialtubercle

    Are bony attachments of genioglossus muscle.

    Are seen on the crestal level on the lingualaspect.

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    Crestal incision is made from the lowercanine to canine region , after infilterationof the LA.

    No reflection of flap done on the labial

    side. Full thickness flap is reflected to expose

    the genial tubercle. Excision of tubercle is done by rotary

    instruments . Smoothening can be done by a bone file. Irrigation should be done before suturing.

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    Reduction of mylohyoid ridges

    Done with IFAN block. Crestal incision taken in the posterior ridge region. Mucoperiosteal flap reflected on the lingual side to

    expose the medial surface of the mandible at themylohyoid ridge region.

    Tissue from the floor of the mouth and lingualmucoperiostium are protected by inserting the flatblade of the tongue depressor .

    The reduction of the mylohyoid ridge is carried withosteotome or round bur ,after dissecting mylohyoidfibres away.

    Bone is smoothened with bone file. Soft tissue flap is returned back and the complete

    lingual vestibule checked with digital pressure for anysharp areas.

    After complete smoothening sutures are given.

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    Excision of tori

    Indications Large torus ,filling the palatal vault. Large torus extending beyond the

    postdam area. Ulceration or traumatisation or

    hyperkeratinisation of the overlyingmucosa.

    Deep bony undercut.

    Interference with function. Psychological consideration. Food lodgement.

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    Under LA ( bilateral grater palatine and incisivenerve block)

    A-P linear incision in the midline of the palate. Y shaped releasing incision at one or both the ends

    of the incision.

    Two mucoperiosteal flaps raised with periostealelevator from th midline sideways. Retraction sutures placed on both the flaps to

    minimize the exposure. Division of the torus into the multiple segments

    should be done with the bur.

    Small pieces removed with chisel and mallet. Conyinous over and under type suturing using fine

    absorbable suture material. Prefabricated acrylic stent or splint or iodoform pack

    can be given to prevent heamatoma.


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    Mandibular tori removal.


    IFAN block is given.

    Incision over alveolar ridge in lower

    premolar region. Mucoperiostral flap is raised

    Make a purchase point or groove with buron medial aspect of the tporus.

    Cleavage taken with a osteotome. Smoothen with roud bur or bone file.

    Irrigatre band suture.

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    Maxillary tuberosity reduction andexostosis removal


    Under infilteration or PSA nerve &GPN block.

    Crestal elliptical incisions fromtuberosity to premolar area.

    Periostium is reflected and tissue

    present b/w the crestal incisionremoved with chisel mallet or bur.

    Flap is sutured and stent is placed.

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    Soft tissue surgeries

    Removal of redundant crestal soft tissue - eg .enlarged tuberosity, enlarged retromolar pad.

    Denture granuloma or hyperplasia. To reduce this elliptical incision taken on either

    sides of the tissue . Excision of epulis fissuratum. Sharp excision Electrocauterisation Cryosurgery

    Laser excision Palatal papillary hyperplasia. Supraperiosteal excision.

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    High attachment of frenum.

    Ulceration at the frenal attachment a due to overuseof the denture


    Crosssdiamond excision.

    Base of the frenum at the alveolar crest is grasped with

    the hemostat and incision is taken below and above the

    hemostat.Surgical defect created by excision of fibrous bands.

    Z plasty procedure can be done.

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    Lingual frenectomy


    Tongue tie


    Bilateral lingual nerve blockSubmucosal dissection done oneither side .Dissection of genioglossus muscle

    and suture it.

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    Ridge extension procedure

    Vestibuloblasty or sulcoplastyIt is a deepening procedure of vestibule.

    Mandibular techniques

    done on labial side done on lingual side labial vestibular procedure

    transpositional flap vestibuloplasty orlip switch procedure

    IndicationsUsed when patient has a bone ht of 15mm

    or more in the ant region

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    kazanjian technique (1924) oldest technique

    use mucosal flap from the inner aspect of lowerlip.

    Carried out in premolar to premolar region.


    submucosal dissection is done anddirected inferiorly to remove muscle andconnective tissue attachments.

    Raised mucosal flap is adapted to thenew vestibule and

    Suture is done

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    Godwin s modification (1947)

    Mucosal incision in inner aspect of lip islonger than the proposed vestibular depth .

    Labial periosteal margin is sutured to theincised lip mucosa.

    Stent is placed.

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    Supraperiosteal flap on the inner aspect oflip leaves a raw surface on the bonecovering the inner lips surface .

    Incision started labial to the crest

    Supraperiosteal dissection is done along thelabial surface till the vestibular depth.

    Edge of the mobilized flap is pushed intothe new vestibular area and held in positionby sutures .

    Alveolar bone is covered by periosteallayer.

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    Similar to clarks method except the area ofalveolar bone with its periosteal attachment

    covered with split thickness graft. Advantages

    Covers the bone and ensures fast healing

    Less bone loss and scarring .

    Obwegessers modification

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    Lingual vestibuloplasty


    In case where mylohyoid and genioglossus closeto the alveolar ridge.

    Trauners technique

    Incision is done from 2nd molar to 2nd premolarregion

    Supraperiosteal dissection is done

    Instrument paseed below mylohyoid muscle andseparate it from bony attachment.

    Fixation of mylohyoid muscle to new desiredvestibular depth by sutures.

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    Here mylohyoid muscle superficaial fibreesof genioglossus muscle pushed inferiorly.

    Rubbertubing placed in the lingual vestibuleand flap is held in position by sutures

    Caldwells technique

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    Obwegessers technique

    Lingual vestibuloplasty + buccalvestibuloplasty

    Edges of buccal and lingual flaps areraised and sutured below the inferiorborder of the mandible.

    Skin graft is placed over the entirealveolar ridge.

    Acrylic stent or denture placed and fixedto mandible with circummandibularwiring.

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    Submucosal vestibuloplasty techniqueIndication Shallow vestibular depth with good

    underlying bone height and contour.Technique Vertical midline incision is made in the

    labial vestibule. Supraperiosteal tunnel from one premolar

    to other . Intervening submucosal tissue excised or

    repositioned superiorly.

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    Procedure involves surgical creating pockets in themax,mattress and pyriform aperture region helps inthe denture extension into the pockets.

    Intraoral incision is taken just above the attachedgingiva from one maxillary buttress to the other

    buttress. Supraperiosteal dissection is performed to create two

    pockets on either side of pyriform aperture. Dissection is extended superiorly to the level of

    attachment of the levator anguli oris. Also continued in the midline upto the base of the

    pyriform aperture. Impression is taken with the impression compound. Labial flanges of the dentures then covered with split

    thickness skin graft. Bilateral circumzygomatic wires and pyriform margin

    wires used to stabilize the denture.

    Max.pocket inlay vestibuloplasty (obwegesser)

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    Patients with severe mandibular atrophic ridges. Complain of pain after wearing denture because of

    superior position of the mental neurovascular bundle. Repositioning of the mental nerve should be done.

    A crestal incision is taken with buccal releasing incision inthe region of premolars. Mucoperiosteal flap is reflected inferiorly to locate the

    nerve. Dissection below the foramen till the inferior border of

    the mandible should be done and the nerve is freedlightly and held with hook upward.

    Bony groove is cut below the mental foramen,only in thebuccal cortex.

    Nerve is positioned inferiorly and secured in place withthe gelfoam and flaps is sutured.

    Mental nerve transposition

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    Ridge augmentation procedures

    Alveolar ridge resorption is soextreme that the alveolar bone iscompletely disappeared., in this

    case vestibuloplasty is not done.

    Two appointments are available

    Augmentation of alveolar bone.

    Place the implants.

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    Mandibular augmentation

    1. Superior border augmentation

    Bone grafts

    cartilage graft

    alloplastic grafts

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    2.inferior border augmentation

    bone grafts .cartilage grafts

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    3.interpositional or sand witch bonegrafts

    Bone grafts

    cartilage grafts

    hydroxyapatite blocks

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    4. visor osteotomy5.onlay grafting autogenous

    allogenous alloplasticB. maxillary augmentation. Onlay grafting Onlay grafting of alloplastic material Interpositional or sandwitch grafs Sinus lift procedure

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    Augmentation in combination withorthognathic surgery

    mandibular osteotomy procedure maxillary osteotomy procedure

    CombinationMaterials for augmentation of alveolar ridge autogenous grafts iliac crest rib graft

    allogenic bone freeze dried cadaver bone. Alloplastic material Hydroxyapatite

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    Mandibular augmentation

    Superior border grafting oraugmentation

    Use 15 cm rib graft . Fixed to mandibvle with trans osseous

    wiring of circum mandibular wiring.


    Donor site morbidity Continued resorption of grafted sites.

    Soft tissue dehiscence or limitation.

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    Inferior border grafting It is indicated when the arch less than 5-

    8 mm in height.Procedure Supraclavicular incision followed by

    subplatysmal incision till the inferiorboredr of the mandible.

    Freeze dried alloogenic cadaver mandible

    is hollowed out and multiple perforationsmade into it and it is used as atray. It is then filled with autogenous

    cancellous graft particles fixed to theinferior border with 2-0 vicryl sutures by

    cicummandibular fixation

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    Interpositional bone grafting (sandwitch bone grafting)

    Horizontal osteotomy is performed

    Splitting is done and bone graft is graftedinto this gap

    In mandible , autogenic or allogenic boneor hydroxyapatite grafts can be used.

    Delivery of aplliance is delayed for 3-5months.

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    Onlay grafting

    Used in case of inadequate width but adequateheight for the maxilla or mandible

    Oldest technique

    Onlay augmentation with hydroxyapatite isadvocated by obwegessor via submucosalvetibuloplasty technique.

    After creating a tunnel via a midline a putty isformed of hydroxyapatite crystals is mixed withsaline or blood and is injected via syringe into the

    submucosal tunnel. Solid or porous blocks of hydroxyl apatite is used. Split thickness ribgraft or iliac crest can be used.

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    Technique High vestibular incision is taken , mucoperiosteal flap is

    reflected to expose the defect. Small perforations made in this external cortex by using

    small round bur.

    Grafting material is placed or mounted over the externalcortex.

    Visor osteotomy To increase the height of mandibular ridge for denture

    support. Consists of central splitting of the mandible in

    buccolingual dimension and the superior positioning of thelingual section of mandible wired in position

    Cancellous bone grafting material placed at the outercortex over the superior labial junction for improving thecontour.

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    Modified visor osteotomy Consists of splitting of the mandible

    buccolingually by vertical osteotomy only in theposterior region and a horizontal osteotomy inthe anterior region.

    Posterior lingual segments are then pushedsuperiorly on both sides. Anterior fragment is also pushed superiorly and

    fixed with wires. Corticocancellous bone graft particles with

    hydroxyapatite granules placed in the gap

    between the superior , inferior and anteriorsegments.

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    Sinus lift procedure or sinus grafting Sinus lining at the floor of the mouth is lifted up

    surgically and the bone graft is placed between thesinus lining and the inner aspect of the alveolarcrest or floor of the maxillary sinus in the posterior

    maxilla.Totum was the first surgeon who used this

    method.Materials used are autogenous bone allogenic bone. tricalcium phosphate hydroxyapatite. calcium phosphate. ceramics calcium deficient carbonate apatite from bovine


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    Technique Intraoral incision is taken on maxillary crest or

    slightly on the palatal aspect with vertical incisionfrom canine to tuberosity area

    Antrolateral wall of maxilla is exposed by reflecting

    the mucoperiosteal flap Bony windows made with trap door type osteotomy ,

    lateral and posterior to the caine fossa. 15 20 mm lomg inferior osteotomy cut placed

    3mm above the sinus floor Anterior vertical cut parallel to the lateral nasal wall

    and perpendicular to the horizontal osteotomy. Posterior vertical cut is at the maxillary tuberosity. Vertical cuts are joined superiorly by placing the

    small bur holes placed at small intervals withoutcompleting the superior cut.

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    Trap door type of bony window is lifted upsuperiorly o expose the schineiderianmembrane.

    Gap between lifted sinus membrane and

    the floor is filled with graft material. One stage implant Coticocancellous iliac crest bone block Otherwise 6-9 months before implant


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    Augmentation in combination withorthognathic surgery

    1.anterior maxillary osteotomy. 2.total lefort osteotomy used along with

    interpositioning of grafts. Limitation of augmentation technique 1.inadequate soft tissue coverage. 2.rejection of autografts.

    3.dehiscence of overlying mucosa. 4. migration of graft material. 5..resorption of graft.

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    Preprosthetic surgery offers a sigificant contributionin patients with bone atrophy,soft tissuehypertrophy or localized soft and hard tissueproblems or all of them.

    Pre existing stuctures like frenal

    attachments,exostosis,tori are insignificant whileteeth are present in the oral cavity. But these nonsignificant structures cause hindrences fordenture stability and resultant reducedmasticatory function after tooth loss.

    Preprosthetic surgery plays an important role in

    providing a better anatomic environment and tocreate proper supporting structures for dentureconstruction.