PRE PROSTHETIC SURGERY – I PROCEDURES TO

IMPROVE THE ALVEOLAR SOFT TISSUES

Dr. Rahul Tiwari

2nd Yr. Post Graduate,

Dept. of Oral & Maxillofacial Surgery,

SIBAR Institute of Dental Sciences.

CONTENTS

• INTRODUCTION

• SOFT TISSUE DEFORMITIES

1. Labial frenectomy.

2. Lingual frenectomy.

3. High frenal attachments.

4. Alveolar muco-periosteal hyperplasia.

5. Inflammatory fibrous hyperplasia.

6. Fibrous hyperplasia of maxillary tuberosity.

7. Fibromatous enlargement of retromolar area

8. Papillary palatal hyperplasia.

9. Gingival fibromatosis.

10. Double lip.

11. vestibuloplasty

12. Other Procedures

• CONCLUSION

• REFERENCES

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INTRODUCTION

• An understanding of the anatomy & physiology of the jaws & their

associated structures & especially of the denture bearing tissues

(basal seats) is essential to any detailed study of pre prosthetic

surgery.

• Hard tissues and soft tissues both are equally important in

maintaining form function and esthetics.

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INTRODUCTION

• It is aimed at providing a good healthy surface for the insertion of dentures.

• It also involves the surgical procedures aimed at making the best use of

residual tissues in terms of restoration of function and aesthetics.

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According to the Glossary of Prosthodontic Terms Preprosthetic surgery is defined as surgical procedures designed to facilitate fabrication or to improve the prognosis of prosthodontic care.

According to Brucc Donoff, Preprosthetic surgery is that part of the oral and maxillofacial surgery designed to establish the best hard and soft tissue bases for prosthetic appliances.

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HISTORY

• Pre prosthetic surgery was born around 18th century.

• Willard(1853) advocated the reduction of interdental

gingival papillae & alveolar margins after dental

extractions; the procedure permitted the earlier

construction of artificial dentures.

• Beers(1876)- excision of alveolus after extraction of

teeth.05/03/23 12:06 PMPRE PROSTHETIC SOFT TISSUE SURGERIES/RT/6/51 6

• For many years pre prosthetic surgery consisted of the removal of

teeth & the reduction of humps, bumps & sharp edges.

• Pre prosthetic surgery emerged from a “Ridge-trimming” service

to a truly reconstructive service when Kazanjian(1924,1935)

reported on the prototype of labiobuccal vestibuloplasty

procedures.

• His technique was modified by Godwin(1947),

clark(1953) & others.

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Some of the characteristics of this ideal form which provide for maximum support and stability and minimum interference with function are:

1. Adequate bone support for dentures.

2. Bone covered by adequate soft tissue.

3. No undercuts or overhanging protuberances.

4. No sharp ridges.

5. Adequate buccal and lingual sulcus.

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6. No scar bands to prevent normal seating of denture.

7. No muscle fibers or frenula to interfere with the periphery of the prostheses.

8. Satisfactory ridge relationship between the maxilla and the mandible.

9. No soft tissue folds or hypertrophies on the ridge or sulci.

10. A ridge free of neoplastic disease.

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The Dentition Function Curve

0

20

40

60

80

100

120

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80

Age

Func

tion

(%ag

e)

Dentate Partially dentate Edentulous

A model For Understanding Dental function over time

The Dentition Function Curve

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NON-SURGICAL METHODS

Non-surgical methods of edentulous mouth preparation

include:

1. Rest for denture supported tissues.

2. Occlusal and vertical dimension correction

of old prostheses.

3. Good nutrition.

4. Conditioning of the patient’s musculature 05/03/23 12:06 PMPRE PROSTHETIC SOFT TISSUE SURGERIES/RT/6/51 11

TYPES OF SURGERY

PROCEDURES TO IMPROVE THE ALVEOLAR SOFT TISSUES

PROCEDURES TO IMPROVE THE ALVEOLAR HARD TISSUES

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1. LABIAL FRENECTOMY

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2. LINGUAL FRENECTOMY

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3. FRENECTOMY FOR DIASTEMA/ HIGH FRENAL ATTACHMENT

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REPOSITIONING (DEPRESSOR SEPTI MUSCLE)

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4. ALVEOLAR MUCO-PERIOSTEAL HYPERPLASIA.

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5. INFLAMMATORY FIBROUS HYPERPLASIA

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6. FIBROUS HYPERPLASTIC MAXILLARY TUBEROSITY

7. FIBROMATOUS ENLARGEMENT OF RETROMOLAR AREA

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8. PAPILLARY PALATAL HYPERPLASIA

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SURGICAL REDUCTION OF BILATERAL FIBROMATOSIS OF PALATE

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9. GINGIVAL FIBROMATOSIS

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DOUBLE LIP

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PALATAL EXOSTOSIS

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MUCOSAL ADVANCEMENT (submucous) VESTIBULOPLASTY

• CLOSED SUBMUCOUS VESTIBULOPLASTY.

• OPEN VIEW SUBMUCOUS VESTIBULOPLASTY.

• SECONDARY EPITHELIZATION(RE-EPITHELIZATION) VESTIBULOPLASTY.

1. KAZANJIAN’S TECHNIQUE.

2. GODWIN’S TECHNIQUE.

3. LIPSWITCH VESTIBULOPLASTY.

4. CLARK’S TECHNIQUE.

5. OBWEGESER’S SECONDARY EPITHELIZATION PROCEDURE.

6. PERIOSTEAL FENESTRATION.

7. LABIAL-PALATAL ADVANCEMENT VESTIBULOPLASTY.

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MAXILLARY MUCOSAL ADVANCEMENT (closed submucous) VESTIBULOPLASTY. OBWEGESER 1959

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MANDIBULAR MUCOSAL ADVANCEMENT (closed submucous) VESTIBULOPLASTY

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SECONDARY EPITHELIZATION VESTIBULOPLASTY (kazanjian’s technique) 1935

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LABIAL PEDICAL FLAP

OTHER MODIFICATIONS

• GODWIN 1947- STRIPPED PERIOSTEUM

• COLLETT 1954- NO SUTURES

DISADVANTAGE- All had scar contractures on the labial side.

• CLARK 1953- PEDICLED FLAP FROM LIP NOT FROM ALVEOLAR PROCESS.

• HOWE 1966 & KETHLEY GAMBLE 1978- LIP SWITCH PROCEDURE.

• OBWEGESER 1959- SUBMUCOSAL DISSECTION

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CLARK 1953- PEDICLED FLAP FROM LIP NOT FROM ALVEOLAR PROCESS.

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HOWE 1966 & KETHLEY GAMBLE 1978- LIP SWITCH PROCEDURE/MOD. KAZANJIAN.

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DEEPENING THE MANDIBULAR SULCUS

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EXCISION OF MENTALIS MUSCLE & DEEPENING OF ANTERIOR MANDIBULAR SULCUS

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MAXILLARY SECONDARY EPITHELIZATION VESTIBULOPLASTY

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MAXILLARY SECONDARY EPITHELIZATION VESTIBULOPLASTY WITH EXCISION OF FLABBY GINGIVAL

CREST

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MANDIBULAR SEC. EPI. VESTIBULOPLASTY

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MAXILLARY LABIAL-PALATAL ADVANCEMENT VESTIBULOPLASTY (double flap technique)

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GRAFTING VESTIBULOPLASTY

• SKIN GRAFT VESTIBULOPLASTY- MOSCOWIZ & ESSER 1917

1. MAX. SKIN GRAFT VESTIBULOPLASTY.

2. MAN. SKIN GRAFT VESTIBULOPLASTY.

• DERMAL GRAFTING- SMILER ET AL 1977

• MUCOSA GRAFT VESTIBULOPLASTY – BONDREAU STARSHAK 1975

1. PALATAL MUCOSA GRAFT VESTIBULOPLASTY- HALL & O STEEN 1970

2. BUCCAL MUCOSA GRAFT VESTIBULOPLASTY- EVASKUS, HEZOG 1980

3. IMMEDIATE VESTIBULOPLASTY WITH FREE MUCOSAL GRAFT AFTER DENTAL EXTRACTIONS

• VESIBULOPLASTY WITH XENOGRAFTS.

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TRAUNER,SCHUDARTZ, OBWEGESER 1953

MAX. VESTIBULOPLASTY WITH MUCOSA OR SKIN GRAFTING

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MAN. VESTIBULOPLASTY WITH MUCOSA OR SKIN GRAFTING

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MAN. VESTIBULOPLASTY WITH PALATAL MUCOSA GRAFT

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MUCOSAL GRAFT SUTURED IN PLACE ON SUPRAPERIOSTEAL DISSECTION

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REPOSITIONING OF THE GENIOGLOSSUS MUSCLE TO DEEPEN THE ANT. LINGUAL SULCUS

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MYLOHYOID MUSCLE ATTACHMENT LEVEL

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LINGUAL SULCOPLASTY(Caldwell’s Technique 1955)

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LINGUAL SULCOPLASTY AND LOWERING OF FLOOR OF THE MOUTH (Trauner’s Technique 1955)

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TECHNIQUE OF CIRCUMMANDIBULAR SUTURINGCLARK & OBWEGESER 1963

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COMBINED VESTIBULOPLASTY & LINGUAL SULCOPLASTY WITH SKIN GRAFTING (Obwegeser’s Technique)

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REPOSITIONING OF MENTAL NERVEMATHIS & COOLEY 1952

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CONCLUSION

A thorough examination of the mouth prior to construction of complete dentures is necessary to identify potential problem areas.

To determine whether surgery is necessary or not is an essential part of examination and plays an important role in successful patient management.

Many conditions should be corrected prior to denture construction to improve the treatment prognosis and reduce the number of post-insertion adjustments.

In general, bony abnormalities should be managed first. Associated soft tissue corrections can be delayed if required.

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REFERENCES

• Preprosthetic oral & maxillofacial surgery by Thomas J. Starshak.

• Oral & maxillofacial surgery by Daniel M Laskin.

• Oral & maxillofacial surgery by Archer.

• Oral & maxillofacial surgery by Fragiskos and Fragiskos.

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• 1. Tallgren A: The continuing reduction of residual alveolar ridges in

complete denture wearers: mixed longitudinal study covering 25 years, J

Prosthet Dent 27:120-132, 1972.

• 2. Weintraub JA, Burt BA: Oral health status in the United States: tooth loss

and edentulism, J Dent Educ 49:368-378, 1985.

• 3. Bays RA: The pathophysiology and anatomy of edentulous bone loss. In

Fonseca R, Davis W, editors: Reconstructive pre- prosthetic oral and

maxillofacial surgery, Philadelphia, 1985, WB Saunders.

• 4. Starshak TJ: Oral anatomy and physiology. In Starshak TJ, Sanders B,

editors: Preprosthetic oral and maxillofacial surgery, St Louis, 1980, Mosby.

• 5. Starshak TJ: Corrective soft tissue surgery. In Starshak TJ, Sanders B,

editors: Preprosthetic oral and maxillofacial surgery, St Louis, 1980, Mosby

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THANK YOU

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