PRE PROSTHETIC

SURGERY(Hard
tissue)

- Dr. Dona Bhattacharya

Contents
1.
2.
3.
4.
5.

Introduction
Objectives
Alveolar atrophy
Diagnosis & treatment planning
Ridge correction procedures

c)

Alveoloplasty
Mylohyoid reduction
Tuberosity reduction

d)

Genial tubercles reduction

e)

Removal of tori
Removal of exostoses
Removal of undercuts

a)
b)

f)
g)

6. Ridge augmentation
7. Conclusion
8. References

Introduction
Preprosthetic surgery refers to the surgical procedures that can

modify the oral anatomy to facilitate the retention of conventional

dentures.
According

to the Glossary of Prosthodontic Terms (7),

preprosthetic surgery is defined as surgical procedures
designed to facilitate fabrication or to improve the prognosis
of prosthodontic care.
According to Bruce 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.

Objectives

Elimination of disease
Conservation of oral structures

Provide residual tissue to withstand

masticatory forces

Maintain function

Esthetics

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
Pt factors (age, gender, skeletal morphology)
Endocrine & metabolic disorders (hyperparathyrodism,Ca
defeciency)
Dietary considerations
Mechanical factors (extractions,removable denture wearers,
combination syndrome)

Patterns of bone loss

The results of Talgren s studies indicate that changes under the

denture base more often occur in the mandible.(4:1)

The difference in resorption of the jaws increases within the first

year of denture wearing, which proves that the mandible cannot

resist the strong bite forces under the denture base.
According to Klemetti initially resorption starts on the alveolar

part of the mandible, and the rest of the mandible remains

unchanged.
Resorption is faster in the labial and buccal parts of the alveolar

ridge.
(Resorptive Changes of Maxillary and Mandibular Bone Structures; Dubravka Knezovi
et al, Acta Stomat Croat 2002; 261-265)

Alveolar Atrophy
Class

Characteristics

Treatment

Alveolar ridge (AR) adequate in height but Hydroxyapatite (HA) alone

inadequate in width, usually with lateral
deficiency or undercut areas

II

AR deficient in both height & width and HA alone

has a knife edge appearance

III

AR resorbed to level of the basilar bone, HA alone or mixed with

producing concave form on posterior areas autogenous
cancellous
of the mandible and sharp bony ridge form bone
with mobile soft tissue in the maxilla

IV

Resorption of the basilar bone, producing HA

mixed
with
pencil-thin, flat mandible or flat maxilla
autogenous
cancellous
bone

(Mercier,1995

Modifications:
Class II-no
wall
defect/buccal
wall/multiwall
defect
Class VImarginal
resection
/continuity
defect

Atrophy of the Residual Alveolar Ridge Following Tooth Loss in a Historical Population;
Reich, Karoline et al;"Oral Diseases 17, 1 (2010)

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

Ideal denture base has following characteristics:

a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)

Adequate bony support

Soft tissue coverage
No undercuts or protuberances
No sharp ridges
Adequate sulci
Absence of peripheral scar bands
no muscle fibres to mobilize prosthesis
No soft tissue folds/hypertrophies
No neoplastic lesions
Proper maxillomandibular arch relationships
Adequate palatal vault/tuberosity notching

Diagnosis &
Treatment Planning
1. History

Chief complaint
Medical history

2. Physical examination

Soft tissues
a)
b)
c)
d)
e)
f)

Presence of mass
Tenderness
Frena
Mucous membrane
Muscle movements
Relation of oral mucosa to gingiva

Hard tissues
a)
b)
c)
d)
e)
f)

3.

Undercuts
Bony prominences
Sharp ridges
Ridge form
Ridge parallelism
Tuberosity notching

Maxillo-mandibular relation
Dentition

Investigations
Radiographic
a) Gen condition of dentition
b) Bone resorption
c) Proximity to imp 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

Principles:
1.
2.
3.
4.
5.
6.
7.
8.

Optimal ridge contour

Permit early construction of dentures
Preservation of alveolar bone
Broad alveolar ridges
Reduction of irregularities
Rounding off sharp ridges
Preserve cortical bone as much as possible
Defer surgery 4-6 weeks in case of severe
periodontitis

Alveoloplasty
Alveolar compression
Types

1) Alveolar
compression
Easiest & quickest method
Involves compression of cortical plates with fingers
Reduction in socket width

2) Simple
Alveoloplasty
Indications:

Reduction of buccal/labial plate

Extraction of single/multiple teeth

Technique:

Single tooth extraction

Multiple teeth extraction
Over erupted teeth

Cortical
Alveoloplasty

4) Deans Intraseptal
/Intercortical/Crush
Technique
Principles:
a)
b)
c)
d)
e)

Reduction of labial/alveolar prominences

Muscle attachments are undisturbed
Intact periosteum
Preserve cortical bone
Less post-op resorption

Indications:
immediate dentures
quadrant extraction

Technique:
Mac Kays modification(1964)

Technique
1966
Indication
-premaxillary protrusion
Technique
Advantages

Knife Edged Ridge

Reduction
Extreme resorption
results in sharp, pointed
ridge that cuts into
mucoperiosteum
on
pressure application.
Pain occurs on wearing
dentures.

Technique

Mylohyoid Ridge
Reduction
Gillies(1956):
Mylohyoid
ridge
should be reduced if found at
same or higher level than alveolar
process
Roberts(1977):
Reduction
of
mylohyoid ridge & extension of
posterior lingual denture flange
into retromylohyoid fossa
Howe(1964):
Mylohyoid
ridge
reduction is the most useful single
operation

Technique (Trauner)

Obwegesser
modification

Tuberosity
Reduction
Excess tissue in the region of the
maxillary tuberosity may become
so large that it:

Impinge upon the mandible

during mastication.

Interfere
with
denture
construction,
insertion
and
seating

Complication
of
tuberosity
reduction
-expanded tuberosity in proximity
to sinus

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.

Mandibular Tori
Removal
Torus

mandibular
is
an
exostosis found on the lingual
surface of the mandible
opposite the canine and
premolars 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

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

Technique
Complications

Palatal Tori
Removal
Torus palatinus present itself as an

outgrowth in the midline of the

palate.
Shapes
(single
dome
shaped,
spindle shaped, nodular, lobular or
multiple).
Present in approximately 25% of all
females
Etiology unknown
Composed of cortical bone; may
have a cancellous component

Indications for removal:

An extremely large torus filling the

palatal vault.
A torus that extend beyond the
posterior dam area.
Traumatized mucosa over the torus.
Deep bony undercuts interfering with
denture insertion and stability.
Interference with function (speech,
deglutition).
Psychological
considerations
(malignancy phobia).

Technique
Position: head tilted
backward

Complications:
Haemorrhage
Hematoma formation.
Nasal or antral perforation.
Sloughing and necrosis of palatal tissues.
Fracture of palatine bone.

Palatal Exostosis
Found in maxillary molar
region.
Preservation of vascular
supply: main concern
during surgery

Buccal Exostosis

Labial Undercuts
Caused by resorption in
apical areas.
Treatment:
Excision
Filling of undercut

Technique

Ridge
Augmentation

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

Ridge Augmentation

Materials used for

augmentation
Graft:
portion of a tissue or organ that after removal from its origin or
donor site is positioned or inserted at a different place with the
objective of reinforcing the existing tissues &/or correcting a
structural defect.

Classification
According to structure

Autogenous Grafts

Distant sites
Rib
Iliac crest
Calvarium
Fibula
Tibia

Local sites
Chin
Body and ramus
ZM buttress
Coronoid

Mandibular
Augmentation
AUGMENTATION OF SUPERIOR
BORDER OF MANDIBLE (Davis,
1970)
Indications:
Remaining bone < 10 mm
Ability of patient to tolerate
procedure
Donor considerations
Recipient site

Kerfing of rib graft

Mandibular
Augmentation
Augmentation of inferior
border of mandible
Indications:
Remaining bone < 10 mm
Risk of pathologic #
Management of malunion or non

union of #

Donor considerations
Recipient site

Mandibular
Augmentation
AUGMENTATION OF MANDIBLE BY PEDICLED FLAPS

Horizontal
osteotomy/sandwic
h technique

Vertical
osteotomy/visor
technique

Mandibular
Augmentation
Horizontal osteotomy (Danielson and
Nemarich)/sandwich technique
Indication
reasonable amt of bone above

mandibular canal
b/l dimension<12-15mm

Technique
Donor site
Recipient site
Lekkas modification

Mandibular
Augmentation
Vertical osteotomy
(Harle,1975)/visor osteotomy
Indications
little bone above mandibular

canal

Technique

Mandibular
Augmentation
Combined vertical and horizontal osteotomy (Koomen et al)
Advantages:
Less risk of #
Better sup & post repositioning of segment
Correction of mild-moderate AP discrepancies
Increase in amt of augmentation

Technique
Stoelinga modification

Maxillary
Augmentation
Bell & mc bride(1977)

Ridge
Augmentation
Augmentation with synthetic graft materials:
Hydroxyapatite is the prototype of the nonresorbable ceramic
bone substitutes. It is a calcium phosphate material having
physical and chemical characteristic nearly identical to dental
enamel and cortical bone.

Technique

Advantages:
Simple

surgical technique suitable as an office

procedure.
No donor site is required to obtain autogenous bone
graft material unless a composite graft is being
accomplished.
HA is totally biocompatible and nonresorbable
Composite grafting can easily be accomplished as in
severe class III and IV cases.
Vestibular extension after alveolar augmentation is
possible after 3 months of primary healing.
Local augmentation is possible such as in bridge
pontic areas.
Metallic implant systems through HA augmented
ridges are possible.

Complications:
Dehiscence with extrusion of particles

Abrasion through the mucosa with extrusion of the HA implan

Infection
Abnormal color is noted under the mucosa
Mental nerve neuropathy

Augmentation using Ti
Mesh
The use of particulate bone with
membrane coverage allows for both
horizontal and vertical augmentation of
the mandible. The membrane is
designed to prevent infiltration of the
particulate graft with connective tissue
and allow bone to infiltrate into the
particulate graft mass rather than
connective tissue, with the formation of
sufficient bone.

Disadvantage:

premature exposure of
membrane through the mucosa.
infection

the

Used for ant maxillary combination

syndrome

Onlay graft
augmentation
Grafting bone on the superior surface of the residual alveolar cortical bone
is accomplished by first gaining access to the cortical bone, placing and
securing a bone graft to the region to be augmented, and closing the soft
tissue.
Indication: class V
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 longterm augmentation

for
Onlay Bone Graft
Augmentation:

Mandibular Tori as a Source for Onlay Bone Graft Augmentation:

A Surgical Procedure; Scott D. Ganz JPPA;2007

Vertical augmentation
with distraction
osteogenesis
After alveolar bone osteotomy,distractor device is placed in
transport segment, which remains vascularized via periosteum

Latency
period(5
-7 days)
Distraction
period(0.51mm/day
1-4 times
Consolidatio
n period(812 weeks)

Bony segment subjected to traction

Activation of tissue growth & regeneration

Formation of distraction callus, matures into bone

Indications:
Moderate-severe alveolar bone defects

Segmental deficiencies

Adjuvant to other grafts

Less b/l width of ridges

Simple, less resorption, include teeth,

implants in transport segment, less time

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.

References
1. Preprosthetic oral & maxillofacial surgery-Starshak
2.
3.
4.
5.
6.
7.
8.

& Sanders
Textbook of oral & maxillofacial surgery- Laskin vol
II
Principles of oral & maxillofacial surgery-Peterson
Textbook of oral & maxillofacial surgery- Fonseca
vol 7
Textbook of oral & maxillofacial surgery- Kruger
Textbook of oral & maxillofacial Surgery Archer
Textbook of oral & maxillofacial surgery- Killey And
Kay
Bone grafting in oral implantology: Alfaro

References
9.
10.
11.

12.

13.

14.

Alveolar bone grafting techniques for dental implant preparationOMFS,Aug 2010

Sugar,Hopkins et al:A sandwich mandibular osteotomy, BJOMS,
1982, 20:168
Interpositional
Osteotomy
for
Posterior
Mandible
Ridge
Augmentation
Michael
S.
Block,
DMD,*
Christopher
J.
Haggerty.JOMS 67:31-39, 2009, Suppl 3
Distraction implants: a new operative technique for alveolar ridge
augmentation
Alexander
Gaggl,
Gfinter
Schultes,
Hans
K~ircherJournal of Cranio-Maxilloj'acial Surge , (1999) 27, 214-221
Reconstruction of the severely atrophic mandible with iliac crest
grafts and endosteal implants: a report of two cases; OConnell
J.E. ,Galvin M, Journal of the Irish Dental Association 2009; 55 (5):
237-241.
Mandibular Tori as a Source for Onlay Bone Graft Augmentation:A
Surgical Procedure Scott D. Ganz,JPPAD

Thank You