review article preprosthetic surgery: a review of literature · 2019-05-06 · of the alveolar...

Chronicles of Dental Research, June2019, Vol 8, Issue 1 Chronicles of

Dental Research

28 www.cdronline .org

Official Publication of Kothiwal Dental

College & Research centre

INTRODUCTION

Preprosthetic surgery is a surgical procedure designed

to facilitate fabrication of a prosthesis to improve the

prognosis of prosthodontic treatment. In 1967 the

principles of Preprosthetic reconstructive surgery were

first introduced by MacIntosh and Obwegeser.1,2

Every dental surgeon should have a thorough

knowledge of the conditions which favour success in

denture construction, for carefully planned and

executed surgery can prevent the occurrence of many

undesirable features and can eliminate others, either at

the time teeth are extracted or later.3,4

Patient Evaluation

Before any surgical or prosthetic treatment a thorough

evaluation outlining the problems to be solved and a

detailed treatment plan should be developed for each

patient.1

Initial preoperative examination:

Patient’s past medical history and current medical

status must be reviewed with particular attention to

allergies, drug idiosyncrasies, and medications.

Haemorrhages tendencies or systemic disorders which

would complicate anaesthetics procedures, increase

surgical risk etc.1

Secondary preoperative examination: patients

frequently have oral tissues which have been abused

and distorted by their existing malfitting prosthesis.1

Evaluation of supporting bony tissues: includes

visual inspection, palpation, radiographic examination

and cases evaluation of models. The remaining

mandibular ridge should be evaluated visually overall

ridge form and contour, gross ridge irregularities, tori

and buccal exostosis Cephalometric radiographics

may also be helpful in evaluating the cross sectional

configuration of the anterior mandibular ridge area and

ridge relationship.1

Surgical procedures for removable prosthesis:

A. Bony recontouring procedures

Simple Alveoloplasty Associated With Removal of

Multiple Teeth

Alveoplasty is contouring of the alveolar ridge to

remove any irregularities and undercuts. The goals

are to provide a stable base for the prosthesis and

REVIEW ARTICLE

Preprosthetic surgery: A review of literature

Prachi Madan Rohilla1, Manish Kumar2, Ulfat Majeed2, Akanksha Singh2

ABSTRACT

Following the loss of natural teeth after extraction, the bone begins to resorb. The results of this resorption are

accelerated by wearing dentures and tend to affect the mandible more severely than the maxilla. Preprosthetic

surgical treatment must begin with a thorough history and physical examination of the patient. One component that

can profoundly affect treatment success is the condition of the denture-bearing tissues. In preprosthetic surgery

every effort should be made to ensure that both the hard and soft tissues are developed in a form that will enhance

the patient’s ability to wear a denture.

Keywords: Alveoloplasty, Ridge augmentation, Osteopromotion, Vestibuloplasty, Sinus lift.

1. Senior lecturer.

2. Post Graduate Student. Department of

Prosthodontics and Crown & Bridge

*Correspondence Author:

Dr. Manish Kumar (P.G. Student) Kothiwal Dental

College and Research Centre, Mora Mustaqeem

Moradabad.

Email: [email protected]


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preserve as much alveolar bone as possible. Always

be conservative when removing the bone.1

Fig.1: Simple Alveoloplasty

Intraseptal Alveoloplasty- An alternative to the

removal of alveolar ridge irregularities by simple

alveoloplasty technique is the use of an intraseptal

alveoloplasty, or dean’s technique, involving

removal of intraseptal bone and the repositioning of

the labial cortical bone, rather than removal of

excessive or irregular areas of the labial cortex.2

Fig. 2: Intraseptal Alveoloplasty

Maxillary Tuberosity Reduction:

The maxillary tuberosities are found to be abnormally

large in a considerable number of edentulous patients

and in the vast majority of cases this enlargement is

due to an excess of white fibrous tissue.5

Fig 3: Maxillary Tuberosity Reduction

Buccal Exostosis and Excessive Undercuts:

Exostosis generally require removal, small undercut

areas are often best treated by being filled with either

autogenous or allogenic bone material. such situation

might occur in the anterior maxilla or mandible, where

removal of the bony buccal protuberance results in

narrow crest in the alveolar ridge area and a less

desirable area of support for the denture ,as well as an

area that may resorb more.

Fig 4: Removal of Buccal Exostosis

Lateral Palatal Exostosis:

The lateral aspect of the palatal vault may be

somewhat irregular because of the presence of lateral

palatal exostosis. This presents problems in denture


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construction because of the undercut created by the

Exostosis and the narrowing of the palatal vault.

Mylohyoid Ridge Reduction:

For most parts of the denture border, the limits of the

functional anatomy are determined by muscles in

activity; this activity may be favourable or

unfavourable depending on the direction of the muscle

fibres relative to the denture base.6

Genial tubercle reduction:

As the mandible begins to undergo resorption, the area

of attachment of the genioglossus muscle in the

anterior portion of the mandible may become

increasingly prominent. In some cases the tubercle

may actually function as shelf against which the

denture can be constructed, but it usually requires

reduction to construct the prosthesis properly. 1,2,3,4

Tori Removal:

After teeth are lost, tori may complicate or even

preclude denture fabrication. Large, lobulated tori

with undercuts must be treated, whereas the restoring

dentist may deem smaller, smooth, broad-based tori

insignificant.7

Fig 5; a, b : Surgical Process of Palatal Torus

removal

Fig 5; c : Surgical Process of Palatal Torus removal

B. Mandibular Augmentation

Superior Border Augmentation- Superior border

augmentation with a bone graft is occasionally

indicated when severe resorption of the mandible

results in inadequate height and contour potential risk

of fracture or when the treatment plan calls for

placement of implants in areas of insufficient bone

height or width.8,9( .

Fig.6: Superior Border Augmentation

Inferior Border Augmentation- Sanders and Cox

reported the first clinical use of an inferior border

technique for augmentation of the atrophic mandible.

This technique is rarely used for augmentation of

Mandibular bulk with inferior grafting using iliac crest

bone grafts and is secured with rigid fixation.10.

Fig 7: Inferior Border Augmentation


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Hydroxyapatite Augmentation of the Mandible:

Hydroxyapatite has revived interest in augmentation

of resorbed alveolar ridges. Because bony

augmentation of alveolar ridges often undergoes

resorption in a short period of time, nonresorbable

hydroxyapatite holds the promise of avoiding a

recurrence resorption. 10

Guided Bone Regeneration (Osteopromotion):

A membrane [nonresorbable or resorbable] is used to

cover an area where bone graft healing or bone

regeneration is desired. The concept of guided

regeneration is based on the ability to exclude

undesirable cell types, such as epithelial cells or

fibroblast from the area where bone healing is taking

place.11

Visor Osteotomy:

The goal of visor osteotomy is to increase the height

of Mandibular ridge for denture support. It 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

contour.

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.

Corticocancellous bone grafts particles with

hydroxyapatite granules are placed in the gap between

the superior and inferior anterior segments. Rest of the

graft material can be molded on the buccal aspect of

the posterior segments.12

Fig 8: Modified Visor Osteotomy

C. Maxillary Augmentation

In certain cases, a severe increase in interarch space,

loss of palatal vault, interference from the zygomatic

buttress area, and absence of posterior tuberosity

notching may prevent construction of proper denture.

Onlay Bone Grafting:

It is indicated primarily when severe resorption of the

maxillary alveolus is seen that results in the absence of

clinical alveolar ridge and loss of adequate palatal

vault form13.

Interpositional Bone Grafts:

Interpositional bone grafting in the maxilla is indicated

in the bone-deficient maxilla, where the palatal vault

is found to be adequately formed but ridge height is

insufficient.

Maxillary Hydroxyapatite Augmentation HA is

readily available, eliminates the need for donor-site

surgery and is easily placed in an outpatient setting.

HA can be used to contour and eliminate minor ridge

irregularities and undercut areas in the maxilla.14

D. Alveolar distraction osteogenesis

This process is based on the concept of bone

distraction along a vector that is transverse to the long

axis of the bone, which results in bone formation. A

primary advantage of distraction osteogenesis is that

there is no need for additional surgery at the donor site.

Another benefit is the coordinated lengthening of the

bone and associated soft tissues.13,14

E. Correction of Abnormal Ridge Relationship

In totally edentulous patients, the interarch space and

the anteroposterior and transverse relationships of the

maxilla and mandible must be evaluated with the

patient‘s jaw at proper occlusal vertical dimension. In

the diagnostic phase may require the construction of

bite rims with proper lip support.4

Soft tissue abnormalities and their surgical

management:

a. Soft tissue surgery for ridge extension of the

mandible

As alveolar ridge resorption takes place, the

attachment of mucosa near the denture –bearing area

exerts a greater influence on the retention and stability

of dentures. Soft tissue surgery performed to improve

denture stability may be carried out alone or may be

done after bony augmentation.15,16,


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1. Transpositional flap vestibuloplasty [lip

switch]:

A lingually based flap vestibuloplasty was first

described by Kazanjian. These techniques provide

adequate results in many cases and generally do

not require hospitalization.

2. Vestibule and floor of mouth extension

procedure:

This combination procedure effectively

eliminates the dislodging forces of the mucosa

and muscle attachments and provides a broad base

of fixed keratinized tissue on the primary denture

–bearing area.

b. Soft Tissue Surgery for Maxillary Ridge

Extension

The Submucosal vestibuloplasty as described by

Obwegeser may be the procedure of choice for

correction of soft tissue attachment on or near the crest

of the alveolar ridge on the maxilla. This technique is

particularly useful when maxillary alveolar ridge

resorption has occurred but the residual bony maxilla

is adequate for proper denture support.

Maxillary Vestibuloplasty with Tissue Grafting:

When sufficient labiovestibular mucosa exists and lip

shortening would result from the submucosal

vestibuloplasty technique, other vestibular extension

techniques must be used a modification of Clark‘s

vestibuloplasty technique using mucosa pedicled from

the upper lip and sutured at the depth of the maxillary

vestibule after a supraperiosteal dissection can be

used.17,18

Surgical procedure in fixed denture prosthesis

1. Gingivectomy and Gingivoplasty

Gingivectomy means excision of the gingiva.

Gingivoplasty is a reshaping of the gingiva to create

physiologic gingival contours with the sole purpose of

recontouring the gingiva in the absence of pockets.19

Techniques to increase attached gingiva:

To simplify and better understand the techniques, the

following classifications are presented:

A. Gingival Augmentation Apical to

Recession

Root resection:

A procedure where one or two roots of a

multirooted tooth are amputated, leaving the

crown to be supported by the remaining root

or roots.

Hemisection:

The most common root resection involves

the distobuccal root of the maxillary first

molar.

B. Gingival Augmentation Coronal to

Recession (Root Coverage) :

Understanding the different stages and

condition of gingival recession is necessary

for predictable root coverage.19

Immediate Ridge Augmentation:

Performed at the time of tooth extraction

Onlay graft- It is of value and predictable in small

areas.

Pouch technique- Garber and Rosenberg (1981) -

Used for soft tissue ridge augmentation .Usually for

Class I type of defects.

Roll technique:

Used for soft tissue ridge augmentation, Class I

defects.

Ridge augmentation: improved technique.

Techniques to remove frenum Frenectomy:

Frenectomy is complete removal of the frenum,

including its attachment to underlying bone, and may

be required in the correction of an abnormal diastema

between maxillary central incisors. Frenotomy is

incision of the frenum.19

1. Conventional technique

A narrow elliptical incision around the frenal area

down to the periosteum is completed. The fibrous

frenum is then sharply dissected from the underlying

periosteum and soft tissue, and the margins of the

wound are gently undermined and reapproximated


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2. Z-plasty:

After excision of the fibrous tissue, two oblique

incisions are made in a z fashion, one at each end of

the previous area of excision. The two pointed flaps

are then gently undermined and rotated to close the

initial vertical incision horizontally. The two small

oblique extensions also require closure.

Fig 9 : Z-plasty technique

Sinus lift and bone augmentation procedures for

implant placement, 20, 21, 22

Subantral Option 1: Conventional implant

placement sufficient bone available for implant

placement:

In case of abundant bone (Division A) use implant of

Height > 12 mm and 4 mm diameter. In Division B

bone, osteoplasty or augmentation is done to increase

the width to Division A. Augmentation for width is

accomplished by bone spreading and autogenous

Onlay.

Subantral Option 2: Sinus lift and simultaneous

implant placement:

Vertical bone present is 10 – 12 mm. Antral floor is

elevated by 0-2 mm

Subantral Option 3: Sinus graft with delayed

endosteal implant placement -Atleast 5 mm of

vertical bone is present between antral floor and crest

of residual ridge.

Subantral Option 4: Sinus graft and extended delay

of endosteal implant placement

Height of bone is < 5 mm between residual crest and

sinus floor.

CONCLUSION

Preprosthetic surgical approach, however, calls for the

utmost of surgical and prosthetic preplanning and

cooperation, as well as meticulous attention to detail

in all phases of treatment. When the principles of case

selection and treatment outlined previously are

followed, excellent results and patient satisfaction can

be expected

REFERENCES

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Contemporary oral and maxillofacial surgery. 4TH

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2. Koerner KR Manual of Minor Oral Surgery for

the General Dentist. Victoria 3053, Australia

Blackwell Publishing, 2006 :81-97

3. Ephros H, Klein R, Sallustio .A Preprosthetic

Surgery. Oral Maxillofacial Surg 2015;27: 459–

472

4. Malik NM. Textbook of Oral and Maxillofacial

Surgery.3rd ed.New Delhi: Jaypee Brothers

Medical Publishers; 2008.

5. Crabtree DG, Bell DH, Alexander JM.Surgical

template as a guide for reduction of maxillary

tuberosities. J Prosthet Dent.1986; 55(1):137-39

6. Roberts BJ. Mylohyoid ridge reductions as an aid

to success in complete lower denture. J Prosthet.

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7. K.Smitha, Smitha GP. Alveolar exostosis

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72

8. MaselLa R, Mercier P. Surgical and

prosthodontics reconstruction of the severely


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handicapped edentulous patient. J Prosthet Dent..

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R Simple Bone Augmentation for Alveolar Ridge

Defects. Oral and Maxillofacial Surgery Clinics

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11. Stoelinga PJ, koomen, HA,Tideman H,Hujibers

TJ.Repraissal of the interposed bone graft

augmentation of atropic mandible. J

Maxillofac.Surg.1983;11(3):107-112

12. Sugar W, Thielens P, Stafford G. D, Willins M.

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open vestibuloplasty. Br J Oral and Maxillofac

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14. Mahdy FA,Belasy A. Mandibular Anterior Ridge

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Vestibuloplasty Technique.J Oral Maxillofac

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15. Burton DJ, Holton SH. A simplified two-stage

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Surgery, Oral

Medicine,OralPathology.1981;51(4):335-341

16. Riley C., Surgical stents for vestibuloplasty and

alveolar ridge skin grafts. J Prosthet Dent.1971;

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17. Carranza, Newman, Henry .Clinical

Periodontology 9th ed, Saunders. Noida, India.

18. Felix F. An evaluation of the drugs used for

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769-776

19. Misch CE. Dental Implant Prosthetics. Elsevier

Mosby; 2005.

20. Misch CE. Contemporary Implant Dentistry, 3rd

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21. Babbush CA. Dental Implants The Art and

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MedicalAssociation.2015;78(22):85-88

review article preprosthetic surgery: a review of literature · 2019-05-06 · of the alveolar...

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