PREPROSTHETIC

SURGERY(MANDIBLE)

CONTENTS
1. Introduction
2.Objectives
3. Alveolar atrophy
4.Diagnosis & treatment planning
5.Ridge correction procedures
Hard Tissue
tissue

Soft
Frenectomy

Vestibuloplasty
Alveoloplasty
Mylohyoid reduction
Genial tubercles reduction
Removal of tori
Removal of exostoses
Removal of undercuts
Ridge augmentation
6.Conclusion
7.References

INTRODUCTION
Preprosthetic surgery refers to the surgical procedures
that can modify the oral anatomy to facilitate the
retention of conventional dentures.
OBJECTIVES
1) to eliminate pre existent or recurrent pathology
(2) to rehabilitate infected or inflamed tissue
(3) To re establish maxillomandibular relationships in all
spatial dimensions
(4) To preserve or restore alveolar ridge
dimensions(height,width,shape,consistency)conducive to
prosthetic restoration
(5) To achieve keratinized tissue coverage over all loadbearing areas
6) to relieve bony and soft tissue undercuts
(7) to establish proper vestibular depth and repositioning
of attachments to allow for prosthetic flange extension if
necessary
(8) to establish proper notching of the posterior maxilla
and palatal vault proportions
(9) to prevent or manage pathologic fracture of the
atrophic mandible
(10) to prepare the alveolar ridge by onlay
grafting,cortico cancellous augmentation,sinus lift,or

distraction osteogenesis for subsequent implant

placement
(11) to satisfy facial esthetics,speech requirements,and
masticatory challenges.
The best denture support has the following
characteristics:
No evidence of intraoral or extraoral pathologic
conditions
Proper jaw relationship in anteroposterior, transverse
and vertical dimensions
Alveolar ridges that are as large as possible and of
the proper configuration
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

ALVEOLAR ATROPHY
The term alveolar atrophy refers to the regression of
the teeth-supporting, crescent-shaped osseous part
of the upper and lower jaw.

Causes:

Periodontal diseases

Trauma

Patient factors (age, gender, skeletal morphology)

Endocrine & metabolic disorders
(hyperparathyrodism,Ca defeciency)
Dietary considerations

Mechanical factors (extractions,removable denture

wearers,
combination syndrome.

Functional effects of edentulism

The maxillomandibular relationship is altered in all

spatial dimensions.

Progression toward decreased overall lower facial

height, leading to the typical overclosed appearance.

Progressive instability of conventional soft tissue.

Diagnosis & Treatment Planning

1. History
Chief complaint
Medical history
1. Physical examination
Soft tissues
a) Presence of mass
b)Tenderness
c) Frena
d)Mucous membrane
e) Muscle movements

f) Relation of oral mucosa to

gingiva
Hard tissues
a) Undercuts
b)Bony prominences
c) Sharp ridges
d)Ridge form
e) Ridge parallelism
f) Tuberosity notching
Maxillo-mandibular relation
Dentition
3. Investigations
Radiographic
a) General condition of dentition
b)Bone resorption
c) Proximity to important
structures
d)Maxillo-mandibular relation
Lab investigations
Patient selection
General physical status

 Age
Anatomic factors

ALVEOLOPLASTY
Defined as surgical recontouring of alveolar process
History:
Willard(1853) removal of interdental papilla ,permitting
edge to edge closure
Beers(1876): radical alveolectomy
De van(1930): trend towards conservatism had begun
Molt(1923):use of study casts in planning alveolectomy
Dean(1936):interseptal alveoloplasty
Obwegesser(1966):modification of deans technique
Michael & Barsoum(1976): study on post operative
resorption

ALVEOLAR COMPRESSION

Easiest & quickest method

Involves compression of cortical plates with fingers

Reduction in socket width

Alveoloplasty After Extraction of Single Tooth

After extraction of the tooth, a flap is created
and a rongeur is used to cut the jagged parts of
the tooth socket, until a clinically appropriate
interarch space is created. Afterwards, the bone
surface is smoothed using a bur and bone file , and
excess gingivae are trimmed with soft tissue
scissors. The area is irrigated with plenty of saline
solution and the wound is sutured with interrupted
sutures.
Afterwards, the bone is recontoured using a rongeur
and an acrylic-type bur, while the wound is then
sutured. When the presence of bone irregularity in
postextraction sockets is ascertained by palpation,
bone recontouring may be performed with a bone
file, alone or in combination with a rongeur .

a Periapical radiograph of the region of the canine

and first premolar of themandible. b Clinical
photograph.
Supraeruption of teeth and a high alveolar ridge are
noted

Removal of wedge-shaped portions of mucosa from

the alveolar ridge, from the area mesial and distal to
the sockets.

Reflection of the mucoperiosteum and removal of

bone margins of the wound with a rongeur

Smoothing of the bone surface with a bone bur.

Operation site after placement of sutures.

Postoperative clinical photograph 1month after the
surgical procedure

Mylohyoid Ridge Reduction

 Anesthesia is achieved with buccal,inferior

alveolar,and lingual nerveblocks.
A crestal incision over the height of contour is
made,erring toward the buccal aspect to protect
the lingualnerve.
Subperiosteal dissection along themedial aspect
ofthe mandible reveals theattachment ofthe
mylohyoid muscle tothe adjacent ridge.

 This can be sharply separated with

electrocautery to minimize muscle bleeding.
Once the overlying muscle is relieved,a
reciprocating rasp or bone file can be used to
smooth the remaining ridge.
Copious irrigation and closure with particular
attention to hemostasis is completed.
Placement of a stent or existing denture may
also aid inhemostasis as well as inferiorly
repositioning the attachment

GENIAL TUBERCLE REDUCTION

3 techniques:
Removal of tubercle followed by allowing
genial muscle to reattach on its own.
Removal of tubercle followed by
repositioning of muscle with sutures
fastened to chin.
Removal of tubercle followed by
transposition of muscle to inferior border.

 Bilateral lingual nerve blocks in thefloor

ofthe mouth are necessary to achieve
adequate anesthesia in this area.
A crestal lincision from the midbody ofthe
mandibleto the midline(canine to canine
region) bilaterally is necessary forproper
exposure.
A subperiosteal dissection exposes the
tubercle and its adjacent muscle
attachment.
Sharp excision ofthe muscle from its bony
attachment may be performed with
electrocautery,with careful attention to
hemostasis.
A subsequent hematoma in the floor ofthe
mouth may lead to airway embarrassment
and life threatening consequences if left
unchecked.

 Once the muscle is detached,the

bony tubercle may then be relieved using
rotary instrumentation or a rongeur.
Smoothening can be done with a bone file.
Copious irrigation of the area prior to
suturing is needed.
Closure isperformed using a resorbable
suture in a running fashion.
The genioglossus muscleis left to reattach
independently.

MANDIBULAR TORI REMOVAL

 Torus mandibular is an exostosis found on the

lingual surface of the mandible opposite the
canine and premolar region.
Present in 8% of the population, with equal
frequency in males and females
Usually bilateral, (80% of affected patients), may
be single, multiple or lobulated.
Etiology: unknown, functional reaction to
masticatory forces.
Indications for removal:
Tori causing lingual undercuts and interfering with
lingual flange extension of the planned prosthesis.
When the mucosal covering is ulcerated.
Large tori interfering with speech and deglutition
PROCEDURE
LA-pterygomandibular block with local infiltration.
An incision is made at the crest of the alveolar ridge
for the surgical removal of exostoses,and after
extensive reflection of the flap lingually.

 the lesion is removed using a chisel, bone file, or bur.

The wound is then irrigated with plenty of saline
solution and is suturedwith interrupted sutures.
LocalizedMandibular Buccal Exostosis

The surgical technique applied depends on

its size and the area of lesion localization.
If the premolar area is involved in the
exostosis
the procedure used is as follows.
After local anesthesia, a trapezoidal flap is
created,
with particular care taken to avoid injuring
the mental
neurovascular bundle.
Therefore, the vertical incisions must be
made at a distance from the mental
foramen.

 After being exposed, the lesion is cleaved at

its base, in a direction parallel to that of the
alveolar ridge .
The bone is then smoothed with a bone bur
and the wound is cared for and sutured.

Lingual frenectomy
Technique Using Hemostat.
After local anesthesia, the tongue is retracted
upwards and posteriorly with a traction suture that is
passed through the tip of the tongue.
The frenum is then grasped approximately at
themiddle of the vertical length with a straight
hemostat, which is parallel to the floor of the mouth.
Using a scalpel the clasped portion of tissue is
excised, first above the hemostat and then below.
The wound margins are then undermined with
scissors and interrupted sutures are placed.

Technique Without the Aid of Hemostat.

The lingual frenum may be removed with a scalpel
without the aid of a hemostat.

 More specifically, after upward retraction of the

tongue, the frenum is incised with converging
incisions, first on the area of lingual attachment and
then on the other side.
After the frenum is loosened and the tongue is
released, the tongue is retracted even further
superiorly and posteriorly, to
facilitate the removal of the rest of the frenum,
whichis still inplace.
After removal of the frenum, the wound margins are
undermined and suturing follows, as outlined in the
previous case. Because
the frenum is attached close to the deep lingual vein
and the submandibular duct, careful attentionmust
be given so that injury is avoided during the surgical
procedure.
VESTIBULOPLASTY
Deepening of the vestibule without any addition of
bone is termed as vestibuloplasty or sulculoplasty or
sulcus deepening procedure.
Labial vestibular procedures
Transpositional flap vestibuloplasty or lip switch
procedure
Soft tissues from the inner aspect of the lip is shifted
to a favourable zone on the alveolar bone,so that the
increase in the denture bearing area is achieved.
Bone ht of ant region should be 15mm or more.

 Mucosa must be healthy and exhibit no

fibrosis,scarring or hyperplasia.

KAZANJIAN TECHNIQUE
Oldest technique
Use mucosal flap from the inner aspect of lower lip to
increase the depth of the ant mand labial vestibule
Premolar to premolar region only
Drawback-severe scarring of the lip mucosa.

A submucosal dissection is done from the inner

aspect of the lower lip to the mucogingival
junction,near the alveolar crest on the labial side.

 A supra periosteal dissection is directed inferiorly to

remove muscle and connective tissue attachments to
the desired vestibular depth.
The raised mucosal flap is adapted to the depth of
new vestibule and fixed with the sutures or a stent.
The raw area on the lip is left alone.
Transpositional flap or lip switch procedure
After elevation of the mucosal flap,the
periosteum is incised at the crest ofthe
alveolar ridge and a subperiosteal dissection is
completed onthe anterior aspect ofthe mandible.
The periosteum is then sutured to the anterior
aspect ofthe labial vestibule,and the mucosal
flap is sutured to thevestibular depth at the area
ofthe periosteal attachment.
A stent can be used. Post operatively,extra oral
dressing can help the adaptation of the tissue
intra orally.

TRAUNERS TECHNIQUE
Used for increasing the depth of the floor of the
mouth in the mylohyoid region.

 Incision is given over lingual side of the alveolar

ridge bilaterally,in the posterior region or from
second molar to second molar region.
Supraperiosteal dissection is done to identify
mylohyoid muscle and muscle seperated from the
bony attachment.
Care is taken to avoid lingual nerve damage.
Fixation of incisal edge of the mylohyoid muscle to a
new desired vestibular depth of lingual side by:
Sutures passed extra orally over the skin at the
inferior border of the mandible
Placement of the skin graft and preformed denture or
stent.
Obwegeser's Technique(Combination of Buccal and
Lingual Vestibuloplasty)
Incision is given on the alveolar ridge.
Mucosal flap raised buccally and lingually.
Mylohyoid muscle attachment and only superficial
fibres of genioglossus muscle are seperated on the
lingual side.
Edges of buccal and lingual flaps attached/sutured to
each other,below inferior border of the mandible
Skin graft is placed over entire alveolar ridge.
Preformed acrylic stent /denture placed and fixed to
the mandible,with circummandibular wiring.

SUBMUCOSAL VESTIBULOPLASTY TECHNIQUE

Was first described by MacIntosh and Obwegeser in
1967.
Indicated ,when the dentures are unstable,due to
shallow vestibular depth and/or high muscle
attachments,but with good underlying bone height
and contour available.
The mouth mirror test is used to determine the
adequacy of mucosa available.
A mouth mirror is placed in the vestibule and
elevated against the bone to the desired vestibular
depth.
If mobile tissue is present and no abnormal
shortening of the lip occurs,then adequate mucosa
exists to perform the submucosal vestibuloplasty.
A vertical midline incision is made in the labial
vestibule.
A supraperiosteal tunnel is made from premolar to
premolar area.
The intervening submucosal tissue is then excised or
repositioned superiorly.
The new depth is maintained by placement of
preformed dentures/stents,which can be fixed to the
mandible with circummandibular wiring.

RIDGE AUGMENTATION
Indications for Ridge Augmentation
Progressive loss of denture stability
and retention.
Loss of alveolar ridge height, width
and decreased vestibular depth
and denture bearing area.
Considerable basal bone resorption
in the mandible, resulting in
neurosensory disturbances.
Increased susceptibility to fracture
of the atrophic jaws.
Replacement of necessary
supportive bone.
Altered interarch relationship

MANDIBULAR AUGMENTATION
Superior border augmentation (Iliac crest, rib graft,
hydroxyapatite)
Inferior border augmentation (Autogenous or
allogenic freeze dried cadaveric mandible)
Interpositional / sandwich bone grafts
Visor osteotomy
Onlay grafting: Autogenous, allogenic

AUGMENTATION OF SUPERIOR BORDER OF

MANDIBLE (Davis, 1970)

Indications:
Remaining bone < 10 mm
Ability of patient to tolerate procedure.
Use two 15 cm autogeneous rib grafts
One is scored athe cortex-contoured in the shape of
mandible
Fixed with transosseous or circummandibular wiring.
Other is made into cortico cancellous particles and
moulded around the first rib graft
Surgical flap is then closed.

Augmentation of inferior border of

mandible(Marx and Saunders)

Modified by Quinn.
Indications:
Remaining bone < 5-8mm
Supraclavicular,subplatysmalincisions and
incision through the periosteum is
completed from angle to angle.
Perforated freeze dried allogenic cadaveric
mandible-tray
Cancellous bone graft is harvested from the
iliac crest.
The cadaver mandible filled with
autogenous cancellous graft particles and
fixed to the inferior border with 2-0 vicryl
sutures along with circummandibular
fixation.
The neck flap is closed in tension free
manner.

 Osseo integrated implants can be placed

approximately 4-6 months following surgery.
Horizontal osteotomy (Danielson and
Nemarich)/sandwich technique
Indication
reasonable amountt of bone above
mandibular canal
b/l dimension<12-15mm
Vertical osteotomy (Harle,1975)/visor
osteotomy
Indications
little bone above mandibular canal
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 the contour.

ONLAY BONE GRAFTING

Advantage:
1. Avoidance of direct damage to the IAN
2. Ease of placement of the graft

3. Immediate postoperative vertical augmentation.

Disadvantage:
incision breakdown over the graft can result in a
reduction of the long-term augmentation .

METHOD
Hydroxy apatite is advocated by
Obwegesser via submucosal vestibuloplasty
technique
After cfreating a tunnel via midline,a putty is
formed of hydroxy apatite crystals,mixed
with saline and blood ,and is injected via
syringe into the submucosal tunnel.
Solid or porous blocks of hydroxy apatite
have been used as onlay or interpositional
grafts to improve the bony defect.
The hydroxy apatite powder can be used in
conjunction with onlay bone grafting
procedure

CONCLUSION
Accurate diagnosis of the problem areas during
denture construction and determination of the
necessity of surgery is accomplished by careful
evaluation of the information systematically
obtained from the patient.
As conservation is the philosophy of surgical patient
management, therefore every attempt should be
made to preserve as much as oral structures as
possible.
Proper knowledge of the available surgical
procedures helps in achieving the best results.

BIBILIOGRAPHY
Peterson-Principle of oral and maxillo facial
surgery
Fragiskos-Oral surgery
Text book of oral and maxillofacial surgeryNeelima Anil Malik