Pre Prosthetic Surgery

Kuliah Bedah Mulut dan
Maksilofasial 1
Angkatan XI :
I Komang S.T.K.P.N, drg
Liska Barus, drg
Anindita Z. R., drg
PREPROSTHETIC SURGERY I
&
OPTEK Minor Preprosthetic Surgery
Angkatan XI
Presenter : Anindita Zahratur Rasyida, drg
Pembimbing : drg. Ahmad Hariadi, Sp.BM
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Contents
Introduction
Goal
Best denture support characteristic
Treatment planning
Basic armametarium needs
Basic pre prosthetic surgery
Hard tissue correction
Operative technique
Soft tissue correction

Operative technique
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INTRODUCTION
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DEFINITION
Preprosthetic Surgery is the Surgical
Improvement of the Denture bearing area
and Surrounding Tissues to Support the Best
possible Prosthetic replacement.
OBJECTIVE
Creation of proper supporting structures for
subsequent placement of prosthetic
appliances.
Petterson,et al. 2002. Contemporary Oral and Maxillofacial Surgery, 4ed. Missoury : Mo
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GOAL
to establish a functional biologic platform for supportive or
retentive mechanisms
maintain or support
prosthetic rehabilitation
without contributing to
further bone or tissue
loss.
This environment will allow for a prosthesis that restores

function, is stable and retentive, preserves the associated
structures, and satisfies esthetics
Peterson. 2004. Principles of oral and maxilofacial surgery 2nd ed. London : BC
Decker.
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Characteristics of the Best Denture Support

1. No evidence of Extra or Intra-Oral Pathologic conditions.
2. Proper Jaw Relationship.
3. Proper Configuration of the Alveolar Process (broad Ushaped ridge with Vertical components as Parallel as
possible).
4. No Bony or Soft tissue protuberances or undercuts.
5. Adequate attached Keratinized mucosa in the primary
denture-bearing area.
6. Adequate Vestibular Depth.
7. Adequate form and tissue coverage for possible Implant
placement
Petterson,et al. 2002. Contemporary Oral and Maxillofacial Surgery, 4ed. Missoury : Mosby
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PRINCIPLES OF PATIENT EVALUATION

AND TREATMENT PLANNING
Assesment and history
intraoral and extraoral examination
the existing tooth relationships if any remain
the amount and contour of remaining bone
the quality of soft tissue overlying the primary
denture-bearing area
the vestibular depth
the location of muscle attachments
the jaw relationships
and the presence of soft tissue or bony
pathologic conditions
Radiographic examination
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BASIC PREPROSTHETIC SURGERY
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Basic preprosthetic surgery

Hard tissue correction
Soft tissue correction
Those that may be

smoothed with
alveoloplasty immediately
after extraction of the
teeth (sharp spicules, bone
edges), or those detected
and recontoured in an
edentulous alveolar ridge.
Congenital abnormalities,
such as a hypertrophic
frenum, etc.
Congenital abnormalities,
such as torus
palatinus,torus
mandibularis, multiple
exostoses.
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Abnormalities created after

the use of dentures (e.g.,
fibrous hyperplasia of the
mucosa), and other
causes.
Fragiskos, 2007. Oral Surgery. Berlin: Springer.

9
BASIC ARMAMETARIUM NEEDS
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Armamaterium
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Diagnostic set
Local anasthesia armamaterium
Syringes
Handle Scalpel and blade
Rasparatorium
retractor
Bone file
Knable tang
Chissel and mallet
Bone burs
Rossen and cuttercross burs
Sutures and needle
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HARD TISSUE CORRECTION
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ALVEOLOPLASTY
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Definition
Alveoloplasty is the surgical procedure
performed to smooth or recontour the
alveolar bone, aiming to facilitate the
healing procedure as well as the
successful placement of a future
prosthetic restoration.

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SIMPLE ALVEOLOPLASTY
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Introduction
If the alveolar ridge is suspected of
presenting abnormal morphology after the
extraction of one or more teeth, in order to
avoid such a possibility, alveoloplasty
must be performed at the same surgical
session
if not removed before placement of the
partial or complete denture, lead to injury
and stability or retention problems
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Indication
Alveoloplasty After Extraction of Single Tooth
Alveoloplasty After Extraction of MultipleTeeth
Intraseptal alveoloplasty

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ALVEOLOPLASTY AFTER EXTRACTION OF

SINGLE TOOTH
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1. Performing tooth extraction

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2. Creating flap
3. Cutting the jagged parts of the
tooth socket using a bone
rounger

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4. Smoothing of the alveolar ridge
with a bone file and/
or bur + PZ irrigation

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5.
6.
7.
8.
Trimming excess gingivae with soft tissue scissors

The bone is palpated to ensure smoothness
Irrigating with plenty of saline solution
wound is sutured with interrupted sutures

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ALVEOLOPLASTY AFTER EXTRACTION OF

MULTIPLE TEETH
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Alveoloplasty After Extraction of Multiple Teeth

1. Clinical and radiography
examination
2. Performing teeth extractions

Fragiskos,
2007. Oral
Surgery.
Berlin:
Springer.
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24

3. Incision is performed
along the alveolar ridge
to cut the interdental
papillae of the gingivae
4. Reflecting and elevating

of the mucoperiosteal
flap to expose thebone
area to be recontoured

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5. Removing of sharp bone edges with a rongeur

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with a bone file

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7. Trimming excess gingivae with
soft tissue scissors

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8. The bone is palpated to ensure smoothness
9. Irrigating with plenty of saline solution
10. Wound is sutured with continous sutures

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INTRASEPTAL ALVEOLOPLASTY
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Introduction
Intraseptal alveoloplasty, or Dean's technique,
involving the removal of intraseptal bone and the
repositioning of the labial cortical bone, rather than
removal of excessive or irregular areas of the labial
cortex
This technique is best used in an area where the
ridge is of relatively regular contour and adequate
height but presents an undercut to the depth of the
labial vestibule because of the configuration of the
alveolar ridge.
It can be accomplished at the time of tooth removal
or in the early initial postoper-ative healing period.
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Advantages
The labial prominence of the alveolar ridge can
be reduced without significantly reducing the
height of the ridge in this area.
The periosteal attachment to the underlying bone
can also be maintained, thereby reducing
postoperative bone resorption and remodeling.
The muscle attachments to the area of the
alveolar ridge can be left undisturbed in this type
of procedure.
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Disadvantage
Decrease in ridge thickness.
If the ridge form remaining
excessively thin, it may preclude
place-ment of implants in the
future
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operative technique
1. Teeth Extractions
2. Incision along the papil interdental
3. Reflection of mucoperiosteum flap
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operative technique
4. Removing intraseptal portion of the alveolar
bone
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operative technique
5. Small vertical cuts at either end of the labiocortical plate
(distal extraction area) was made using bur without
perforating of the labial mucosa
6. Fracturing the labiocortical plate of the alveolar ridge
inward using digital pressure to approximate the palatal
plate are more closely
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operative technique
7. Contouring irregular area using bone file/ bur
10. Reapproximated the alveolar mucosa with interrupted or
continous sutures
11. A splint or an immediate denture lined with a soft lining
material can then be inserted to maintain the bony
position until initial healing has taken place.
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RECONTOURING OF EDENTULOUS AREA

OF ALVEOLAR RIDGE
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Introduction
After tooth extractions and the wound has been
healed for a long time, the residual ridge may
present irregularities at a certain point or even
along the entire alveolar ridge.
This is usually the result of not taking the necessary
measures of bone recontouring after extracting
teeth so as to ensure optimal and speedy healing.
In such cases, the bone must be smoothed, to avoid
injury and avoid obstructing the proper support of
complete dentures.
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operative technique
1. asepsis
2. Local anasthesia admission
3. Incision along the alveolar ridge where the bone
irregularity is located

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operative technique
4. Reflecting the mucoperiosteal flap

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operative technique

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operative technique
6. Removing excess soft tissues with soft tissue scissors

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operative technique
9. Continuous suture along the alveolar ridge

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EXOSTOSIS REMOVAL
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Exostosis
Exostoses are generally bony protuberances, which
develop in various areas of the jaw. They are not
considered real neoplasms, but dysplastic
exophytic lesions.
Exostoses are classified into three types:
(1)torus palatinus
(2)torus mandibularis
(3)Multiple exostoses

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TORUS PALATINUS
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Introduction
localized at the center of the hard palate and the exact causes
remain unknown.
Clinical sign :
asymptomatic bone protuberances, covered by normal
mucosa
vary in size
the shape ranges from a single discrete exostosis, to
multiloculated, to irregular in shape.
They usually do not require any special therapy, except for
edentulous patients in need of prosthetic rehabilitation, and in
cases where the patient is greatly bothered by the exostoses.
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operative technique
1. asepsis
2. Nasopalatine nerve block and palatinus majus nerve block
3. An incision is made along the midline of the palate, which is
composed of two anterior and posterior oblique incisions

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operative technique
4. Reflecting the flaps and retracting with the aid of sutures

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Operative technique
5. After complete exposure of the lesion, it is sectioned with a fissure
bur and the segments are individually removed using a monobevel
chisel + irrigation with PZ steril

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Operative technique
6. After complete exposure of the lesion, it is sectioned with a fissure
bur and the segments are individually removed using a monobevel
chisel

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Operative technique
7. Smoothing the bone surface using bur + PZ irrigation

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Operative technique
9. Trimming excess soft tissues
10.Irrigation with saline solution
11.Repositioning the flaps and sutured with interrupted sutures

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TORUS MANDIBULARIS
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Introduction
Torus mandibularis is an exostosis of unknown etiology. It is localized

in the lingual aspect of the body of the mandible, either on one side
or more commonly on both sides, and as a rule in the canine and
premolar region.
Clinically :
an asymptomatic bony protuberance covered by normal mucosa
Radiographically :
it presents as a circumscribed radiopacity in the area of localization.
Torusmandibularis is completely innocent in nature and does not
require any therapy whatsoever, except in cases where complete
Fragiskos, 2007. Oral Surgery. Berlin:
dentures are to be constructed.
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Springer.
56
Operative technique
1. asepsis
2. Local anasthesia admission
3. Incision along the alveolar ridge (without vertical releasing
incisions)

Springer.
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Operative technique
4. Reflecting mucoperiosteal flap

Springer.
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Operative technique
5. Removing exostoses with a bone bur + PZ irrigation
6. Smoothing of the bone surface with a bone file

Springer.
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59
Operative technique
8. Trimming excess soft tissues
9. Irrigation with saline solution
10.Repositioning the flaps and sutured with interrupted
sutures

Springer.
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MULTIPLE EXOSTOSIS REMOVAL
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Introduction
These are rare asymptomatic bony excrescences, usually

localized at the buccal surface of the maxilla and mandible.
The causes are unknown, although some people suggest that
they may be due to bruxism as well as chronic irritation of the
periodontal tissues.
No therapy is usually required, except for those cases where,
due to the large size of the exostoses, severe esthetic and
functional problems are created. Fragiskos, 2007. Oral Surgery. Berlin:
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Springer.
62
Operative technique
1.
2.
3.
4.
5.
Asepsis
Local anasthesia admission
Incision along to create mucoperiosteal flap with trapezium
design
Retracting flap carefully
Removal the lesion with a bone bur + PZ irigation

Springer.
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63
6.
7.
8.
9.
Smoothing of the bone surface

Trimming excess soft tissues
Irrigation with saline solution
Repositioning the flaps and sutured with interrupted sutures

Springer.
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SOFT TISSUE CORRECTION
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LABIAL FRENECTOMY
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Labial Frenulums problems

Labial frenal attachments consist of thin bands of
fibrous tissue covered with mucosa, extending
from the lip to the alveolar periosteum.
hypertrophic frenulum maxilla
orthodontic problem central diastema
complete denture problem discomfort and
ulceration and may interfere with the
peripheral seal and dislodge the denture.
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MAXILLARY LABIAL FRENECTOMY
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SIMPLE EXCISION TECHNIQUE
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Operative technique
1. Asepsis
2. Local anesthesia admisssion
3. lip is pulled upwards

Springer.
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Operative technique
4. Frenulum is grasped using two curved hemostats, which
are positioned at the superior and inferior margins
5. The lip is then further retracted

Springer.
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Operative technique
7. A thin scalpel blade incises the tissue found behind the
hemostat, first behind the lower hemostat and then behind
the upper hemostat

Springer.
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Springer.
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8. Removal of hypertrophic tissue found between and behind

the central incisors

Springer.
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9. Undermining of mucosa of wound margins from underlying

tissues

Springer.
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10. The first suture is placed at the middle of the wound

(maximal depth of the vestibule and should include both
edges of mucosa and underlying periosteum at the height
of the vestibule beneath the anterior nasal spine ) to
facilitate subsequent suturing

Springer.
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11. Performing interrupted suturing

12. Place the periodontal pack on the defect of ridge and/
palatum after removing hyperthropic tissue. Keep this
packing in position for 5 days

Archer. 1961. Oral Surgery. Philadelphoa: WB. Saunders
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Z PLASTY TECHNIQUE
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Z-plasty is a plastic surgery technique used to

improve the functional and cosmetic appearance
of scars.
This technique virtually increases vestibular
depth and should be used when alveolar height is
in question
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Operative technique
1. Asepsis
2. Local anesthesia admisssion
3. lip is pulled upwards

Springer.
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80
Operative technique
4. Frenulum is grasped using two curved hemostats, which
are positioned at the superior and inferior margins
5. The lip is then further retracted

Springer.
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81
Operative technique
7. A thin scalpel blade incises the tissue found behind the
hemostat, first behind the lower hemostat and then behind
the upper hemostat

Springer.
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Springer.
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8. 2 oblique incisions are made in a Z shape, one at each end

of the previous area of excision (an angle of 45 degree).
Equal size and equal shape.
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9. The two pointed flaps are then gently under-mined and

rotated to close the initial vertical incision horizontally.
B
A
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Performing Interrupted suturing
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LINGUAL FRENECTOMY
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Lingual Frenulums problems

the lingual frenulum thats too short
causing partial or complete ankyloglossia
limits movement of the tongue speech
difficulties
Denture problems
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Springer.
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USING HEMOSTAT
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Operative Technique
1. Asepsis
2. MA block to block lingual nerve
3. The tongue is retracted upwards and posteriorly with a
traction suture that is passed through the tip of the
tongue.
4. The frenulum is then grasped approximately at the middle
of the vertical length with a straight hemostat, which is
parallel to the floor of the mouth
5.

Springer.
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5. 1st incision, the scalpel is always in close contact with the

upper surface of the hemostat
6. 2nd incision, involving the portion beneath the hemostat
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Springer.
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Springer.
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7. Undermining the mucosa at wound margins from

underlying tissues
8. Interrupted suturing
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Springer.
93
WITHOUT HEMOSTAT
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Operative Technique
1. Asepsis
2. MA block to block lingual nerve
3. The tongue is retracted upwards and posteriorly with a
traction suture that is passed through the tip of the
tongue.

Springer.
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Operative Technique
4. Excision of the frenum with converging incisions towards
the base of the tongue
5. Undermining the wound margins with scissors

Springer.
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Operative Technique
6. Interrupted suturing

Springer.
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TERIMA KASIH
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Pre Prosthetic Surgery

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Kuliah Bedah Mulut dan

Soft tissue correction

This environment will allow for a prosthesis that restores

Characteristics of the Best Denture Support

PRINCIPLES OF PATIENT EVALUATION

BASIC PREPROSTHETIC SURGERY

Basic preprosthetic surgery

Soft tissue correction

Those that may be

Abnormalities created after

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

BASIC ARMAMETARIUM NEEDS

HARD TISSUE CORRECTION

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

ALVEOLOPLASTY AFTER EXTRACTION OF

Alveoloplasty After Extraction of Single Tooth

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Alveoloplasty After Extraction of Single Tooth

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Alveoloplasty After Extraction of Single Tooth

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Alveoloplasty After Extraction of Single Tooth

Trimming excess gingivae with soft tissue scissors

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

ALVEOLOPLASTY AFTER EXTRACTION OF

Alveoloplasty After Extraction of Multiple Teeth

2. Performing teeth extractions

Alveoloplasty After Extraction of Multiple Teeth

4. Reflecting and elevating

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Alveoloplasty After Extraction of Multiple Teeth

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Alveoloplasty After Extraction of Multiple Teeth

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Alveoloplasty After Extraction of Multiple Teeth

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Alveoloplasty After Extraction of Multiple Teeth

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

RECONTOURING OF EDENTULOUS AREA

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Fragiskos, 2007. Oral Surgery. Berlin: Springer.

Torus mandibularis is an exostosis of unknown etiology. It is localized

Fragiskos, 2007. Oral Surgery. Berlin:

Fragiskos, 2007. Oral Surgery. Berlin:

Fragiskos, 2007. Oral Surgery. Berlin:

Fragiskos, 2007. Oral Surgery. Berlin:

MULTIPLE EXOSTOSIS REMOVAL

These are rare asymptomatic bony excrescences, usually

Fragiskos, 2007. Oral Surgery. Berlin:

Smoothing of the bone surface

Fragiskos, 2007. Oral Surgery. Berlin: