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Pre prosthetic surgery

1. The document discusses pre-prosthetic surgery procedures performed before denture construction and placement. It covers topics like patient evaluation, classification of ridge resorption, characteristics of an ideal denture ridge, and various basic and advanced surgical techniques. 2. Basic techniques include soft tissue operations to address issues like fibrous hyperplasia and frenum attachments. Bony operations recontour ridges and remove exostoses. Advanced techniques augment ridges with grafts and extend them with vestibuloplasties. 3. Ridge augmentation aims to restore ridge height and width through grafts to bone. Mandibular augmentation techniques include superior border grafts to add strength and contour.

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PRE PROSTHETIC SURGERY Dr. Saleh Bakry Assistant Professor of Oral and Maxillofacial Surgery
Definition Corrective operations performed before denture construction and placement.
Objectives (goals - Aims) of preprosthetic surgery • Improvement of masticatory function. • Reconstruction of acceptable facial and dental esthetics. • Creation of broad ridge form for denture and implant. • Adequate fixed soft tissue over denture bearing area. • Adequate vestibular depth. • Proper inter arch relationship. • Protection of neurovascular bundle.
PATIENT EVALUATION BEFORE CORRECTIVE SURGERY 1. History: • Pt. chief complaint. • Pt. expectations of surgical and preprosthetic treatment. • Esthetic and functional goal of the pt. • Psychological factors and adaptability of the pt. to function with P.D or C.D. dentures. • Systemic diseases that may affect bone or soft tissue healing.
2. Intra oral and extra oral clinical examination: A. Evaluation of supporting hard bony tissue • This occur by visual inspection, palpation, radiographic examination and evaluation of models. I. Evaluation of denture bearing area of maxilla • No bony undercuts or gross bony protuberance. • Adequate post-tuberosity notching for denture stability and seal.
II- Evaluation of mandibular ridge • Gross ridge irregularities, tori and buccal exostosis. • Moderate to severe resorption of alveolar bone. • Muscular and mucosal attachments near the crest of ridge. • The location of mental nerve.
B-Evaluation of supporting soft tissue to detect • Quality of tissue in denture bearing area. • Degree of keratinization. • Degree of tissue mobility. • Presence of inflammation. • Presence of irregularities at depth of vestibule. • Inspection of lingual aspect of mandible by mirror to determine level of mylohyoid and Geniohyoid. • Depth of lingual vestibule through different tongue position.
C. Evaluation of interarch relationship: • This includes antro-posterior and vertical relationship and skeletal asymmetries that may exist between maxilla, and mandible. • Proper radiographs like panoramic views and cephalometric radiograph are important for initial diagnosis and treatment plan
3. Lab. Investigations: • Serum (calcium level - phosphate level) • Alkaline phosphatase enzyme. 4. Radiographic examination: • Panoramic radiograph provides information about: (Pathological lesions — impacted teeth — remaining roots)
CLASSIFICATION OF RIDGE ACCORDING TO RESORPTION BEHAVIOR (LEVEL) • Class I: adequate height but inadequate width. • Class II: inadequate height and width. • Class III: at the level of basal bone. • Class IV: resorption of basal bone.
Factors affect ridge resorpation General factors: • Systemic bone diseases. • Osteoporosis • Endocrine dysfunction. Local factors: • Alveoloplasty. • Surgical removal of teeth.
Characteristics (criteria) of an ideal denture support ridge 1. Adequate bony support: • No irregularities. • No sharp edge. • No undercuts. • No exostosis. 2. Bone covered by adequate attached keratinized mucosa: • Not flabby. • Adequate vestibular depth. • No hypertrophy. • No ulceration. 3. Freedom from pathologic or neoplastic disease. 4. Satisfactory relationship of the maxillary and mandibular alveolar ridge.
TREATMENT PLANNING OF THE PREPROSTHETIC SURGERY
1. Basic (Traditional) Operations: • Soft tissue operations. • Bony operations. 2. Advanced (contemporary) operations: • Ridge augmentation. • Ridge extension (vestibuloplasty). • Ridge relationships.
I. BASIC PREPROSTHETIC SURGICAL TECHNIQUES
A. SOFT TISSUE OPERATIONS: • Labial frenectomy. • Lingual frenectomy. • Denture fissuratum. • Flabby ridge. • Maxillary tuberosity soft tissue reduction. • Inflammatory papillary hyperplasia of the palate
B. BONY OPERATIONS: I. Alveolar ridges recontouring (Alveoloplasty) • Alveolar compression. • Simple Alveoloplasty. • Intra septal Alveoloplasty.  Dean’s alveoloplasty.  Obwegeser’s modification. II. Tori removal: • Maxillary tori. • Mandibular tori.
B. Bony operations: III. Maxillary tuberosity reduction: IV. Buccal exostosis V. Mylohyoid palatal reduction
II. ADVANCED OR CONTEMPORARY PREPROSTHETIC PROCEDURE
A. RIDGE AUGMENTATION I. MANDIBULAR AUGMENTATION: • Superior border augmentation. • Inferior border augmentation. • Pedicle or interpositional bone graft (visor osteotomy augmentation). • Hydroxyapatite (HA) augmentation.
A. RIDGE AUGMENTATION II. MAXILLARY AUGMENTATION: • Onlay bone grating. • Interpositional bone grafting. • Hydroxyapatite (HA) augmentation. • Tuberoplasty.
B. RIDGE EXTENSION (VESTIBULOPLASTY) I. MANDIBULAR VESTIBULOPLASTY: • Lingually based flap vestibuloplasty (Kazanjian). • Transpositional flap vestibuloplasty (Lip switch).
B. RIDGE EXTENSION (VESTIBULOPLASTY) II. MAXILLARY VESTIBULOPLASTY: • Submucosal vestibuloplasty. III. Grafted vestibuloplasty. • Full thickness skin. • Split thickness skin. • Palatal mucosa. • Cheek mucosa.
I. BASIC PREPROSTHETIC SURGERY (SOFT TISSUE OPERATIONS)
A. SOFT TISSUE OPERATIONS: • Labial frenectomy. • Lingual frenectomy. • Denture fissuratum. • Flabby ridge. • Maxillary tuberosity soft tissue reduction. • Inflammatory papillary hyperplasia of the palate
1. LABIAL FRENECTOMY Indication for removal: • A highly attached frenum interfering with the peripheral seals of the denture and dislodge the denture.
1. LABIAL FRENECTOMY
2. LINGUAL FRENOTOMY • It is a congenital condition. The patient is unable to protrude the tongue. Indications for removal • Speech difficulty. • Prevents seating and retention of the mandibular denture during speech or mastication.
2. LINGUAL FRENECTOMY
Intraoperative possible complications • Injury to superior lingual vessels. • Injury to Wharton’s duct/papilla.
3. DENTURE FISSURATUM (DENTURE GRANULOMATA) Etiology • Ill-fitting denture. Treatment 1. Early stages • The lesion may shrink and even disappear if the offending denture is either not worn for a period. • New denture should then be constructed. 2. Late stages • The lesion should be excised before new dentures are constructed. • Challenge: Great care and skill are required to preserve the shallow sulcus that remains after their excision.
4. FLABBY RIDGE (UNSUPPORTED HYPER MOBILE TISSUE) By definition it is a pendulous gingival ridge with lack of bony support. Etiology • Excessive occlusal trauma due to lack of posterior support, which causes bone resorption.
5. MAXILLARY TUBEROSITY REDUCTION (SOFT TISSUE EXCESS) It is a fibrous tissue accumulates in the maxillary tuberosity region. Causes • Periodontal disease around natural maxillary molars. • Overgrowth of the soft tissues distal to an over erupted unopposed maxillary molar.
FIBROUS HYPERPLASTIC MAXILLARY TUBEROSITY
6. INFLAMMATORY PAPILLARY HYPERPLASIA OF THE PALATE Causes: • Chronic irritation by a denture. • Poor oral hygiene • Fungal infection. Clinically: • This condition usually appears as multiple nodular projections in the palatal tissue.
6. PAPILLARY PALATAL HYPERPLASIA
II. Basic preprosthctic surgery (Bony operations)
B. BONY OPERATIONS: I. Alveolar ridges recontouring (Alveoloplasty) • Alveolar compression. • Simple Alveoloplasty. • Intra septal Alveoloplasty.  Dean’s alveoloplasty.  Obwegeser’s modification. II. Tori removal: • Maxillary tori. • Mandibular tori.
B. Bony operations: III. Maxillary tuberosity reduction: IV. Buccal exostosis V. Mylohyoid palatal reduction
1. Alveoloplasty TYPES Alveolar compression Simple alveoloplasty Dean’s intraseptal Obwegesser’s technique
1. ALVEOLAR COMPRESSION • Easiest & quickest method • Involves compression of cortical plates with fingers • Reduction in socket width
2. SIMPLE ALVEOLOPLASTY • It is simply reshaping the alveolar process by removal of all sharp and rough bony projections. Indications: • Facilitate removal of teeth. • Correct irregularities of the residual alveolar ridge following removal of teeth. • Removal of undercuts for denture reconstruction. • Removal of excessive ridge height to ↓ inter- maxillary space.
Types: • Alveoloplasty after Extraction of Single Tooth. • Alveoloplasty after Extraction of Two or Three Teeth or multiple extractions. • Recontouring of Edentulous Alveolar Ridge.
A. Alveoloplasty after Extraction of Single Tooth
Slide Title B. Alveoloplasty after Extraction of Two or Three Teeth or multiple extractions.
C. Recontouring of Edentulous Alveolar Ridge.
3. DEAN’S INTERSEPTAL ALVEOLOPLASTY • Only done in maxillary anterior region to reduce gross maxillary overjet. • Mostly done immediately after extraction of anterior teeth.
4. OBWEGESER’S MODIFICATION OF DEAN’S ALVEOLOPLASTY • In this both the labial and palatal cortices are repositioned. • This is done when the anterior overjet is too gross that cannot be reduced by labial plate repositioning. Procedure: • Procedure is same as dean’s alveoloplasty but the only addition is that, here palatal plate is fractured too at its base and repositioned with labial plate in palatal direction.
Slide Title • Make Effective Presentations • Using Awesome Backgrounds • Engage your Audience • Capture Audience Attention
• Alveoloplasty: means Bone contouring of the alveolar ridge. • Alveolectomy: means Removal of projecting interseptal bone. • Alveolotomy: means cutting through the alveolar process as in surgical removal of R.R or impacted tooth.
2. TORI REMOVAL
A. MAXILLARY TORI (TORUS PALATINUS) • It is a congenital exostosis usually situated in the midline of the palate. Indication for removal: • An extremely large torus, filling the palatal vault. • Ulceration/traumatization/hyperkeratinization of the overlying mucosa. • Deep bony undercuts. • Interference with the function—speech-deglutition. • Psychological consideration—malignancy/cancer phobia. • Food lodgment under the folds and projection of the tori.
Complications of maxillary tori removal: Intra-operative complication • Fracture of the palatal process and nasal floor • Injury to the greater palatine nerve. • Oronasal/ oroantral bleeding. Post-operative complication • Necrosis of the palatal mucosa. • Hematoma formation. • Oronasal/ oroantral fistula.
B. MANDIBULAR TORI (TORUS MANDIBULARIS) • It is a congenital exostosis situated on the lingual surface of the mandible in the canine - premolars area, and is usually bilateral. Indication for removal: • If they cause pain, ulceration or difficulty to denture wearers.
Possible complication 1. Intra-operative complication: • Injury to the submandibular salivary gland duct. • Excessive bleeding. • Laceration of the mylohyoid ridge. • Tearing of the flap complication. 2. post-operative complication: • Life threatening hemorrhage in the floor of the mouth. • Infection. • airway obstruction.
3. MAXILLARY TUBEROSITY REDUCTION (BONE EXCESS) Horizontal and/or vertical excess of the maxillary tuberosity area may be the result of excess bone, excess thickness of the soft tissue overlying bone or both.
Slide Title • Make Effective Presentations • Using Awesome Backgrounds • Engage your Audience • Capture Audience Attention
Complications: Perforation in the floor of the sinus: • No specific treatment is required. • Tension free water tight seal closure over the area for 10- 14 days. • Postoperative antibiotics and decongestants should be given for 7 - 10 days postoperatively. • Ask pt. to avoid creation of excessive sinus pressure such as nose blowing for 10 - 14 days.
4. BUCCAL EXOSTOSIS • Buccal exostoses are more common in maxilla than in mandible. • Buccal exostosis presents problems in denture construction because of the undercut created by exostosis.
5. MYLOHYOID RIDGE REDUCTION (LINGUAL BALCONY REDUCTION) • It is a prominent internal oblique ridge and it is also called lingual balcony. • These bilateral ridges result from advanced resorption of the alveolar process. Indications for removal • pain when the lingual flange of the denture compresses the intervening soft tissue against it. • Affecting the stability of the denture.
II. ADVANCED PREPROSTHETIC SURGERY
A. RIDGE AUGMENTATION I. MANDIBULAR AUGMENTATION: • Superior border augmentation. • Inferior border augmentation. • Pedicle or interpositional bone graft (visor osteotomy augmentation). • Hydroxyapatite (HA) augmentation.
A. RIDGE AUGMENTATION II. MAXILLARY AUGMENTATION: • Onlay bone grating. • Interpositional bone grafting. • Hydroxyapatite (HA) augmentation. • Tuberoplasty.
1. RIDGE AUGMENTATION
INDICATIONS OF RIDGE AUGMENTATION • When there is extreme resorption of the alveolar ridge i.e. when there is less than 2 cm of bone height. AIM OF RIDGE AUGMENTATION • Restoration of ridge height and width, ridge form, vestibular depth and denture bearing area. • Protection of neurovascular bundle. • Establishment of proper interarch relationship. • Improvement of retention and stability of denture.
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 Cortical Cancellous Cortico- cancellous According to source Autograft Allograft Xenograft Alloplast According to embryologic origin Membranous Endochondral
Autogenous Grafts Distant sites •Rib •Iliac crest •Calvarium •Fibula •Tibia Local sites •Chin •Body and ramus •ZM buttress •Coronoid
A. MANDIBULAR AUGMENTATION
1. SUPERIOR BORDER GRAFT:
1. SUPERIOR BORDER GRAFT: • Source of graft material: ribs / iliac crest / freeze dried bone. • Fixation: Circumferential wiring or Tranosseous wiring or Screws or Implants. Advantages • Adds strength / contour / height / preserve mental nerve at the location of mental foramen / decrease inters arch distance.
Disadvantages • The morbidity associated with removal of ribs. • Significant postoperative resorption of graft.
2. INFERIOR BORDER GRAFTS
2. INFERIOR BORDER GRAFTS Indication and advantage: • Management of Severely atrophic alveolar ridge in addition to prevention and management of atrophic mand. • This occurs by using a rib for augmentation of inferior border of mand. Disadvantage: • This procedure can't solve the problems of: • Wide interarch space • Irregularities of superior border. • Exposed position of mental nerve at superior border.
3. MANDIBULAR AUGMENTATION; PEDICLE GRAFT (VISOROSTEOTOMY) • The mandible is split sagitally in the buccolingual dimension and the lingual cortex is moved vertically to gain height.
4. MANDIBULAR AUGMENTATION INTERPOSITIONAL BONE GRAFT • This technique involves a horizontal osteotomy separating the residual ridge of the maxilla or the mandible and bone is grafted into this osteotomy. • The bone graft can be autogenous or allogenic bone.
4. MANDIBULAR AUGMENTATION INTERPOSITIONAL BONE GRAFT
5. HA AUGMENTATION OF THE MANDIBLE: • HA augmentation is done by subperiosteal tunnel technique.
6. ALVEOLAR SPLIT GRAFT (RIDGE SPLIT OSTEOTOMY) • Used to gain width for the alveolar ridge→ expanding the knife edge ridge in a B-L direction. • It is easier in the maxilla. • Requires a minimum of 4 mm wide alveolar crest.
6. ALVEOLAR SPLIT GRAFT (RIDGE SPLIT OSTEOTOMY)
7. ALVEOLAR DISTRACTION OSTEOGENESIS: • Distraction osteogenesis (DO) is a biologic process of new bone formation between surfaces of bone segments which are gradually separated by traction forces.
7. ALVEOLAR DISTRACTION OSTEOGENESIS:
B. MAXILLARY AUGMENTATION
1. ONLAY BONE GRAFTING: • We use 2 ribs or iliac crest bone graft fixed with screws to the atrophic maxillary arch.
2. INTER POSITIONAL BONE GRAFT (LE FORT I OSTEOTOMY). • We use iliac crest bone graft. • Augmentation is completed by down fracturing maxilla (le fort I osteotomy) and placing interpositional graft using autogenous iliac crest bone graft.
3. MAXILLARY HA AUGMENTATION: • Subperiosteal tunnel technique is used.
4. TUBEROPLASTY • Tuberoplasty is designedto deepen the hamular notch by fracturing the pterygoid plate and hamulus and positioning them in a post. direction to deepen the notch and to improve denture retention. Indication: • Adequate ridge and palatal vault but inadequate notching in tuberosity hamular area, so no peripheral seal of Max denture. Disadvantage: • Risk of hemorrhage. • Unpredicted deptli.of nothcing after healing.
2. Ridge Extension (Vestibuloplasty)
• By definition, it is surgical deepening of the vestibule without any addition of bone. Idea • It is the repositioning the overlying mucosa, or muscle attachments, to a lower position in the mandible or to a superior position in the maxilla leading to larger denture flange. Requirements • Adequate alveolar bone with sufficient height remaining. i.e. 15 to 20 mm or greater of the denture bearing area is present. • If the bone is less than 15 mm ridge augmentation is the treatment of choice.
A. MANDIBULAR RIDGE EXTENSION (MANDIBULAR VESTIBULOPLASTY)
1. Lingually based flap vestibuloplasty (Kazanjian) (secondary epithelialization vestibuloplasty).
1. Lingually based flap vestibuloplasty (Kazanjian) (secondary epithelialization vestibuloplasty). Indication: • Adequate mandibular ridge height. (15 mm at least). • Inadequate vestibular depth in buccal side due to high mucosal and muscle attachment. • Adequate vestibular depth from lingual side.
2. Trans positional flap vestibuloplasty (lip switch):
2. Trans positional flap vestibuloplasty (lip switch):
2. Trans positional flap vestibuloplasty (lip switch): • It is a modified kazanjian procedure. • Incising periosteum at crest of the alveolar ridge and suturing free periosteal edge of this periosteal flap to exposed labial tissue. • Then mucosal flap is sutured over the exposed bone to the periosteal junction at depth of the vestibule.
Advantages • Do not require hospitalization. • There is no donor site surgery. • Does not require prolonged periods without a surgery. Disadvantages • Unpredictability of the amount of relapse of the vestibular depth. • Scarring at the depth of the vestibule. • Problems with the adaptation of the peripheral flange area.
3. SUB MUCOSAL VESTIBULOPLASTY
B) MAXILLARY EXTENSION (MAXILLARY VESTIBULOPLASTY)
1. SUB MUCOSAL VESTIBULOPLASTY Indications • Adequate underlying bone is present, but the clinically apparent ridge is shallow. Examination • A useful test is to push a mirror superiorly into the labial sulcus; if the lip is not inverted or drawn by the mirror leading to sufficient mucosa for this type of surgery.
1. SUB MUCOSAL VESTIBULOPLASTY
C. GRAFTING VESTIBULOPLASTY– MUCOSAL VS. SKIN
• Donor sites of mucosal grafts are varied. Such as the inside of the cheek (obtained by the mucotome), a full thickness mucosa could be removed from the palatal mucosa. Types of grafts: • Skin graft • Palatal graft. • Mucosal graft (cheek). • Allogenic dermal grafts.
Skin graft vestibuloplsaty Advantages: • For cases which require more covering than mucosal graft. • Skin resists mechanical insult such as pressure better than mucosa. Requirements • The graft should be obtained from a hairless area (e.g.) the inner thigh, the medial side of the forearm. • A thin graft is preferable to a thick one. • The recipient area should have a good blood supply and be free from infection. • The graft should cover all the raw area and should be immobilized with great care under moderate pressure.
THANK YOU

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In this document
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Introduction to preprosthetic surgery, defining it as corrective operations before denture procedures.

Objectives include improving function and aesthetics, creating suitable ridge forms, and ensuring tissue health.

Comprehensive evaluation including history, clinical exams, and necessary lab investigations before surgery.

Ridge resorption levels classified as Class I to IV, with factors affecting resorption discussed.

Criteria for an ideal support ridge, emphasizing adequate bony support, mucosal health, and absence of disease.

Overview of traditional and advanced surgical operations needed for effective preprosthetic treatments.

Basic soft tissue operations for preprosthetic surgery including frenectomies and treatment of hyperplastic areas.

Advanced procedures like ridge augmentation and extension, detailing methods and techniques for each.

Detailed discussion on various soft tissue operations and their indications, including complications.

Various bony operations like alveoloplasty and tori removal, with techniques and indications outlined.

Discussion on types of alveoloplasty techniques used for ridge contouring post-extraction.

Procedures and indications for removal of maxillary and mandibular tori, including complications.

Techniques and potential complications for reducing excess tissue in the maxillary tuberosity.

Complications and techniques related to buccal exostosis and reducing the mylohyoid ridge.

Details on several augmentation procedures like superior and inferior border grafting and their indications.

Various techniques for maxillary augmentation including onlay grafting and HA augmentation.

Details on techniques for mandibular and maxillary vestibuloplasty, including grafting types.

Closing remarks and acknowledgment of the audience.

Pre prosthetic surgery

  • 1.
    PRE PROSTHETIC SURGERY Dr. SalehBakry Assistant Professor of Oral and Maxillofacial Surgery
  • 2.
    Definition Corrective operations performed beforedenture construction and placement.
  • 3.
    Objectives (goals -Aims) of preprosthetic surgery • Improvement of masticatory function. • Reconstruction of acceptable facial and dental esthetics. • Creation of broad ridge form for denture and implant. • Adequate fixed soft tissue over denture bearing area. • Adequate vestibular depth. • Proper inter arch relationship. • Protection of neurovascular bundle.
  • 4.
    PATIENT EVALUATION BEFORE CORRECTIVESURGERY 1. History: • Pt. chief complaint. • Pt. expectations of surgical and preprosthetic treatment. • Esthetic and functional goal of the pt. • Psychological factors and adaptability of the pt. to function with P.D or C.D. dentures. • Systemic diseases that may affect bone or soft tissue healing.
  • 5.
    2. Intra oraland extra oral clinical examination: A. Evaluation of supporting hard bony tissue • This occur by visual inspection, palpation, radiographic examination and evaluation of models. I. Evaluation of denture bearing area of maxilla • No bony undercuts or gross bony protuberance. • Adequate post-tuberosity notching for denture stability and seal.
  • 6.
    II- Evaluation ofmandibular ridge • Gross ridge irregularities, tori and buccal exostosis. • Moderate to severe resorption of alveolar bone. • Muscular and mucosal attachments near the crest of ridge. • The location of mental nerve.
  • 7.
    B-Evaluation of supportingsoft tissue to detect • Quality of tissue in denture bearing area. • Degree of keratinization. • Degree of tissue mobility. • Presence of inflammation. • Presence of irregularities at depth of vestibule. • Inspection of lingual aspect of mandible by mirror to determine level of mylohyoid and Geniohyoid. • Depth of lingual vestibule through different tongue position.
  • 8.
    C. Evaluation ofinterarch relationship: • This includes antro-posterior and vertical relationship and skeletal asymmetries that may exist between maxilla, and mandible. • Proper radiographs like panoramic views and cephalometric radiograph are important for initial diagnosis and treatment plan
  • 9.
    3. Lab. Investigations: •Serum (calcium level - phosphate level) • Alkaline phosphatase enzyme. 4. Radiographic examination: • Panoramic radiograph provides information about: (Pathological lesions — impacted teeth — remaining roots)
  • 10.
    CLASSIFICATION OF RIDGE ACCORDINGTO RESORPTION BEHAVIOR (LEVEL) • Class I: adequate height but inadequate width. • Class II: inadequate height and width. • Class III: at the level of basal bone. • Class IV: resorption of basal bone.
  • 11.
    Factors affect ridgeresorpation General factors: • Systemic bone diseases. • Osteoporosis • Endocrine dysfunction. Local factors: • Alveoloplasty. • Surgical removal of teeth.
  • 12.
    Characteristics (criteria) ofan ideal denture support ridge 1. Adequate bony support: • No irregularities. • No sharp edge. • No undercuts. • No exostosis. 2. Bone covered by adequate attached keratinized mucosa: • Not flabby. • Adequate vestibular depth. • No hypertrophy. • No ulceration. 3. Freedom from pathologic or neoplastic disease. 4. Satisfactory relationship of the maxillary and mandibular alveolar ridge.
  • 13.
  • 14.
    1. Basic (Traditional) Operations: •Soft tissue operations. • Bony operations. 2. Advanced (contemporary) operations: • Ridge augmentation. • Ridge extension (vestibuloplasty). • Ridge relationships.
  • 15.
  • 16.
    A. SOFT TISSUEOPERATIONS: • Labial frenectomy. • Lingual frenectomy. • Denture fissuratum. • Flabby ridge. • Maxillary tuberosity soft tissue reduction. • Inflammatory papillary hyperplasia of the palate
  • 17.
    B. BONY OPERATIONS: I.Alveolar ridges recontouring (Alveoloplasty) • Alveolar compression. • Simple Alveoloplasty. • Intra septal Alveoloplasty.  Dean’s alveoloplasty.  Obwegeser’s modification. II. Tori removal: • Maxillary tori. • Mandibular tori.
  • 18.
    B. Bony operations: III.Maxillary tuberosity reduction: IV. Buccal exostosis V. Mylohyoid palatal reduction
  • 19.
  • 20.
    A. RIDGE AUGMENTATION I.MANDIBULAR AUGMENTATION: • Superior border augmentation. • Inferior border augmentation. • Pedicle or interpositional bone graft (visor osteotomy augmentation). • Hydroxyapatite (HA) augmentation.
  • 21.
    A. RIDGE AUGMENTATION II.MAXILLARY AUGMENTATION: • Onlay bone grating. • Interpositional bone grafting. • Hydroxyapatite (HA) augmentation. • Tuberoplasty.
  • 22.
    B. RIDGE EXTENSION(VESTIBULOPLASTY) I. MANDIBULAR VESTIBULOPLASTY: • Lingually based flap vestibuloplasty (Kazanjian). • Transpositional flap vestibuloplasty (Lip switch).
  • 23.
    B. RIDGE EXTENSION(VESTIBULOPLASTY) II. MAXILLARY VESTIBULOPLASTY: • Submucosal vestibuloplasty. III. Grafted vestibuloplasty. • Full thickness skin. • Split thickness skin. • Palatal mucosa. • Cheek mucosa.
  • 24.
  • 25.
    A. SOFT TISSUEOPERATIONS: • Labial frenectomy. • Lingual frenectomy. • Denture fissuratum. • Flabby ridge. • Maxillary tuberosity soft tissue reduction. • Inflammatory papillary hyperplasia of the palate
  • 26.
    1. LABIAL FRENECTOMY Indicationfor removal: • A highly attached frenum interfering with the peripheral seals of the denture and dislodge the denture.
  • 27.
  • 28.
    2. LINGUAL FRENOTOMY •It is a congenital condition. The patient is unable to protrude the tongue. Indications for removal • Speech difficulty. • Prevents seating and retention of the mandibular denture during speech or mastication.
  • 29.
  • 30.
    Intraoperative possible complications •Injury to superior lingual vessels. • Injury to Wharton’s duct/papilla.
  • 31.
    3. DENTURE FISSURATUM(DENTURE GRANULOMATA) Etiology • Ill-fitting denture. Treatment 1. Early stages • The lesion may shrink and even disappear if the offending denture is either not worn for a period. • New denture should then be constructed. 2. Late stages • The lesion should be excised before new dentures are constructed. • Challenge: Great care and skill are required to preserve the shallow sulcus that remains after their excision.
  • 33.
    4. FLABBY RIDGE(UNSUPPORTED HYPER MOBILE TISSUE) By definition it is a pendulous gingival ridge with lack of bony support. Etiology • Excessive occlusal trauma due to lack of posterior support, which causes bone resorption.
  • 35.
    5. MAXILLARY TUBEROSITYREDUCTION (SOFT TISSUE EXCESS) It is a fibrous tissue accumulates in the maxillary tuberosity region. Causes • Periodontal disease around natural maxillary molars. • Overgrowth of the soft tissues distal to an over erupted unopposed maxillary molar.
  • 36.
  • 37.
    6. INFLAMMATORY PAPILLARY HYPERPLASIAOF THE PALATE Causes: • Chronic irritation by a denture. • Poor oral hygiene • Fungal infection. Clinically: • This condition usually appears as multiple nodular projections in the palatal tissue.
  • 38.
  • 39.
  • 40.
    B. BONY OPERATIONS: I.Alveolar ridges recontouring (Alveoloplasty) • Alveolar compression. • Simple Alveoloplasty. • Intra septal Alveoloplasty.  Dean’s alveoloplasty.  Obwegeser’s modification. II. Tori removal: • Maxillary tori. • Mandibular tori.
  • 41.
    B. Bony operations: III.Maxillary tuberosity reduction: IV. Buccal exostosis V. Mylohyoid palatal reduction
  • 42.
  • 43.
    1. ALVEOLAR COMPRESSION •Easiest & quickest method • Involves compression of cortical plates with fingers • Reduction in socket width
  • 44.
    2. SIMPLE ALVEOLOPLASTY •It is simply reshaping the alveolar process by removal of all sharp and rough bony projections. Indications: • Facilitate removal of teeth. • Correct irregularities of the residual alveolar ridge following removal of teeth. • Removal of undercuts for denture reconstruction. • Removal of excessive ridge height to ↓ inter- maxillary space.
  • 45.
    Types: • Alveoloplasty afterExtraction of Single Tooth. • Alveoloplasty after Extraction of Two or Three Teeth or multiple extractions. • Recontouring of Edentulous Alveolar Ridge.
  • 46.
  • 48.
    Slide Title B. Alveoloplastyafter Extraction of Two or Three Teeth or multiple extractions.
  • 50.
  • 52.
    3. DEAN’S INTERSEPTALALVEOLOPLASTY • Only done in maxillary anterior region to reduce gross maxillary overjet. • Mostly done immediately after extraction of anterior teeth.
  • 55.
    4. OBWEGESER’S MODIFICATIONOF DEAN’S ALVEOLOPLASTY • In this both the labial and palatal cortices are repositioned. • This is done when the anterior overjet is too gross that cannot be reduced by labial plate repositioning. Procedure: • Procedure is same as dean’s alveoloplasty but the only addition is that, here palatal plate is fractured too at its base and repositioned with labial plate in palatal direction.
  • 56.
    Slide Title • MakeEffective Presentations • Using Awesome Backgrounds • Engage your Audience • Capture Audience Attention
  • 57.
    • Alveoloplasty: meansBone contouring of the alveolar ridge. • Alveolectomy: means Removal of projecting interseptal bone. • Alveolotomy: means cutting through the alveolar process as in surgical removal of R.R or impacted tooth.
  • 58.
  • 59.
    A. MAXILLARY TORI(TORUS PALATINUS) • It is a congenital exostosis usually situated in the midline of the palate. Indication for removal: • An extremely large torus, filling the palatal vault. • Ulceration/traumatization/hyperkeratinization of the overlying mucosa. • Deep bony undercuts. • Interference with the function—speech-deglutition. • Psychological consideration—malignancy/cancer phobia. • Food lodgment under the folds and projection of the tori.
  • 62.
    Complications of maxillarytori removal: Intra-operative complication • Fracture of the palatal process and nasal floor • Injury to the greater palatine nerve. • Oronasal/ oroantral bleeding. Post-operative complication • Necrosis of the palatal mucosa. • Hematoma formation. • Oronasal/ oroantral fistula.
  • 63.
    B. MANDIBULAR TORI(TORUS MANDIBULARIS) • It is a congenital exostosis situated on the lingual surface of the mandible in the canine - premolars area, and is usually bilateral. Indication for removal: • If they cause pain, ulceration or difficulty to denture wearers.
  • 65.
    Possible complication 1. Intra-operativecomplication: • Injury to the submandibular salivary gland duct. • Excessive bleeding. • Laceration of the mylohyoid ridge. • Tearing of the flap complication. 2. post-operative complication: • Life threatening hemorrhage in the floor of the mouth. • Infection. • airway obstruction.
  • 66.
    3. MAXILLARY TUBEROSITYREDUCTION (BONE EXCESS) Horizontal and/or vertical excess of the maxillary tuberosity area may be the result of excess bone, excess thickness of the soft tissue overlying bone or both.
  • 67.
    Slide Title • MakeEffective Presentations • Using Awesome Backgrounds • Engage your Audience • Capture Audience Attention
  • 68.
    Complications: Perforation in thefloor of the sinus: • No specific treatment is required. • Tension free water tight seal closure over the area for 10- 14 days. • Postoperative antibiotics and decongestants should be given for 7 - 10 days postoperatively. • Ask pt. to avoid creation of excessive sinus pressure such as nose blowing for 10 - 14 days.
  • 69.
    4. BUCCAL EXOSTOSIS •Buccal exostoses are more common in maxilla than in mandible. • Buccal exostosis presents problems in denture construction because of the undercut created by exostosis.
  • 71.
    5. MYLOHYOID RIDGEREDUCTION (LINGUAL BALCONY REDUCTION) • It is a prominent internal oblique ridge and it is also called lingual balcony. • These bilateral ridges result from advanced resorption of the alveolar process. Indications for removal • pain when the lingual flange of the denture compresses the intervening soft tissue against it. • Affecting the stability of the denture.
  • 73.
  • 74.
    A. RIDGE AUGMENTATION I.MANDIBULAR AUGMENTATION: • Superior border augmentation. • Inferior border augmentation. • Pedicle or interpositional bone graft (visor osteotomy augmentation). • Hydroxyapatite (HA) augmentation.
  • 75.
    A. RIDGE AUGMENTATION II.MAXILLARY AUGMENTATION: • Onlay bone grating. • Interpositional bone grafting. • Hydroxyapatite (HA) augmentation. • Tuberoplasty.
  • 76.
  • 77.
    INDICATIONS OF RIDGEAUGMENTATION • When there is extreme resorption of the alveolar ridge i.e. when there is less than 2 cm of bone height. AIM OF RIDGE AUGMENTATION • Restoration of ridge height and width, ridge form, vestibular depth and denture bearing area. • Protection of neurovascular bundle. • Establishment of proper interarch relationship. • Improvement of retention and stability of denture.
  • 78.
    MATERIALS USED FORAUGMENTATION 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.
  • 79.
  • 80.
  • 81.
  • 82.
  • 83.
    1. SUPERIOR BORDERGRAFT: • Source of graft material: ribs / iliac crest / freeze dried bone. • Fixation: Circumferential wiring or Tranosseous wiring or Screws or Implants. Advantages • Adds strength / contour / height / preserve mental nerve at the location of mental foramen / decrease inters arch distance.
  • 84.
    Disadvantages • The morbidityassociated with removal of ribs. • Significant postoperative resorption of graft.
  • 85.
  • 86.
    2. INFERIOR BORDERGRAFTS Indication and advantage: • Management of Severely atrophic alveolar ridge in addition to prevention and management of atrophic mand. • This occurs by using a rib for augmentation of inferior border of mand. Disadvantage: • This procedure can't solve the problems of: • Wide interarch space • Irregularities of superior border. • Exposed position of mental nerve at superior border.
  • 87.
    3. MANDIBULAR AUGMENTATION; PEDICLEGRAFT (VISOROSTEOTOMY) • The mandible is split sagitally in the buccolingual dimension and the lingual cortex is moved vertically to gain height.
  • 88.
    4. MANDIBULAR AUGMENTATION INTERPOSITIONALBONE GRAFT • This technique involves a horizontal osteotomy separating the residual ridge of the maxilla or the mandible and bone is grafted into this osteotomy. • The bone graft can be autogenous or allogenic bone.
  • 89.
  • 90.
    5. HA AUGMENTATIONOF THE MANDIBLE: • HA augmentation is done by subperiosteal tunnel technique.
  • 92.
    6. ALVEOLAR SPLITGRAFT (RIDGE SPLIT OSTEOTOMY) • Used to gain width for the alveolar ridge→ expanding the knife edge ridge in a B-L direction. • It is easier in the maxilla. • Requires a minimum of 4 mm wide alveolar crest.
  • 93.
    6. ALVEOLAR SPLITGRAFT (RIDGE SPLIT OSTEOTOMY)
  • 94.
    7. ALVEOLAR DISTRACTION OSTEOGENESIS: •Distraction osteogenesis (DO) is a biologic process of new bone formation between surfaces of bone segments which are gradually separated by traction forces.
  • 95.
  • 96.
  • 97.
    1. ONLAY BONEGRAFTING: • We use 2 ribs or iliac crest bone graft fixed with screws to the atrophic maxillary arch.
  • 98.
    2. INTER POSITIONALBONE GRAFT (LE FORT I OSTEOTOMY). • We use iliac crest bone graft. • Augmentation is completed by down fracturing maxilla (le fort I osteotomy) and placing interpositional graft using autogenous iliac crest bone graft.
  • 100.
    3. MAXILLARY HAAUGMENTATION: • Subperiosteal tunnel technique is used.
  • 102.
    4. TUBEROPLASTY • Tuberoplastyis designedto deepen the hamular notch by fracturing the pterygoid plate and hamulus and positioning them in a post. direction to deepen the notch and to improve denture retention. Indication: • Adequate ridge and palatal vault but inadequate notching in tuberosity hamular area, so no peripheral seal of Max denture. Disadvantage: • Risk of hemorrhage. • Unpredicted deptli.of nothcing after healing.
  • 104.
  • 105.
    • By definition,it is surgical deepening of the vestibule without any addition of bone. Idea • It is the repositioning the overlying mucosa, or muscle attachments, to a lower position in the mandible or to a superior position in the maxilla leading to larger denture flange. Requirements • Adequate alveolar bone with sufficient height remaining. i.e. 15 to 20 mm or greater of the denture bearing area is present. • If the bone is less than 15 mm ridge augmentation is the treatment of choice.
  • 107.
  • 108.
    1. Lingually basedflap vestibuloplasty (Kazanjian) (secondary epithelialization vestibuloplasty).
  • 109.
    1. Lingually basedflap vestibuloplasty (Kazanjian) (secondary epithelialization vestibuloplasty). Indication: • Adequate mandibular ridge height. (15 mm at least). • Inadequate vestibular depth in buccal side due to high mucosal and muscle attachment. • Adequate vestibular depth from lingual side.
  • 110.
    2. Trans positionalflap vestibuloplasty (lip switch):
  • 111.
    2. Trans positionalflap vestibuloplasty (lip switch):
  • 112.
    2. Trans positionalflap vestibuloplasty (lip switch): • It is a modified kazanjian procedure. • Incising periosteum at crest of the alveolar ridge and suturing free periosteal edge of this periosteal flap to exposed labial tissue. • Then mucosal flap is sutured over the exposed bone to the periosteal junction at depth of the vestibule.
  • 113.
    Advantages • Do notrequire hospitalization. • There is no donor site surgery. • Does not require prolonged periods without a surgery. Disadvantages • Unpredictability of the amount of relapse of the vestibular depth. • Scarring at the depth of the vestibule. • Problems with the adaptation of the peripheral flange area.
  • 114.
    3. SUB MUCOSALVESTIBULOPLASTY
  • 115.
  • 116.
    1. SUB MUCOSALVESTIBULOPLASTY Indications • Adequate underlying bone is present, but the clinically apparent ridge is shallow. Examination • A useful test is to push a mirror superiorly into the labial sulcus; if the lip is not inverted or drawn by the mirror leading to sufficient mucosa for this type of surgery.
  • 118.
    1. SUB MUCOSALVESTIBULOPLASTY
  • 119.
  • 120.
    • Donor sitesof mucosal grafts are varied. Such as the inside of the cheek (obtained by the mucotome), a full thickness mucosa could be removed from the palatal mucosa. Types of grafts: • Skin graft • Palatal graft. • Mucosal graft (cheek). • Allogenic dermal grafts.
  • 121.
    Skin graft vestibuloplsaty Advantages: •For cases which require more covering than mucosal graft. • Skin resists mechanical insult such as pressure better than mucosa. Requirements • The graft should be obtained from a hairless area (e.g.) the inner thigh, the medial side of the forearm. • A thin graft is preferable to a thick one. • The recipient area should have a good blood supply and be free from infection. • The graft should cover all the raw area and should be immobilized with great care under moderate pressure.
  • 123.