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Vestibuloplasty [Sulcoplasty, Sulcus Extension]
• Stability of a denture - improved by deepening the
mandibular sulcus, generating more attached
tissues over the functional ridge
• Mandibular vestibuloplasty - to increase and
maintain the functional alveolar ridge.](https://image.slidesharecdn.com/seminar8-preprostheticsurgeryinomfsfinal-250711153640-6d8e4c86/75/Preprosthetic-surgery-in-Oral-and-maxillofacial-surgery-48-2048.jpg)
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Transpositional Flap Vestibuloplasty
[Lip-Switch Procedure]
Variation of kazanijian and godwin’s technique
• Kethley and Gamble
• Lower lip mucosa incision
• Supraperiosteal dissection to depth of vestibule
• Periosteum incised at crest of alveolus and
transposed and sutured to denuded labial
submucosa
• Mucosal flap sutured to depth of vestibule over
exposed bone](https://image.slidesharecdn.com/seminar8-preprostheticsurgeryinomfsfinal-250711153640-6d8e4c86/75/Preprosthetic-surgery-in-Oral-and-maxillofacial-surgery-57-2048.jpg)
Preprosthetic surgery in Oral and maxillofacial surgery
- 1. 1 Pre-prosthetic surgeries in Oral andMaxillofacial Surgery Guide – Dr. Apoorva Mowar (Professor) Dr. Himanshu Sharma (Associate Professor) Presenter – Dr. Vipul Jain MDS-2022
- 2. 2 Contents • Definition andGoal • Introduction (Types of bone loss, effects of edentulous ridge, ideal mouth) • Objectives • Pre operative evaluation • Various surgical techniques • Conclusion
- 3. 3 Surgical procedures designedto facilitate fabrication of a prosthesis or to improve the prognosis of prosthodontic care.
- 4. 4 To establish afunctional biologic platform for supportive or retentive mechanisms that will maintain or support prosthetic rehabilitation without contributing to further bone or tissue loss. Miloro M. Peterson's principles of oral and maxillofacial surgery. Ghali GE, Larsen PE, Waite PD, editors. London: BC Decker; 2004 Jun 30.
- 5. 5 Amount and sourceof bone loss Primary Secondary • Trauma • Pathology (cysts or tumors) • Periodontal disease • Bone loss associated with extraction and alveoloplasty EDENTULOUS BONE LOSS Depend upon - • Anatomy • Metabolic state • Jaw function • Prior use of and type of prosthesis
- 6. 8 Functional effects ofedentulism • Overclosed appearance (decreased overall lower facial height) • Decreased alveolar support for prostheses • Encroachment of muscle and tissue attachments to the alveolar crest resulting in progressive instability of conventional soft tissue–borne prosthetic devices • Neurosensory changes secondary to atrophy, and • Overall reduction in size and form in all three dimensions. These changes result in an overall decrease in fit and an increase in patient discomfort with the use of conventional dentures
- 7. 9 What is anideal mouth ?
- 8. 10 Ideal mouth fordenture construction • Normal relationship of maxillary and mandibular arch • Alveolar process – as large as possible • Alveolar ridge – U shape, Broad, Sufficient height • Transverse width of maxilla should be as close as possible to mandible • Gingiva over the ridge – Firm and Uniform thickness • Vestibular and Sublingual sulci should be free from scar tissue, polyps, hypertrophic masses • Major and minor salivary glands should have normal secretory function to keep mouth moist for denture retention. Starshak TJ. Oral anatomy and physiology. In: Starshak TJ, Saunders B, editors. Preprosthetic Oral and Maxillofacial Surgery. St. Louis: Mosby; 1980.
- 9. 11 Godwin's criteria foran ideal ridge 1.Adequate height and width of the ridge to support the prosthesis. 2.Smooth, regular, and well-contoured ridge surface. 3.Absence of undercuts or sharp bony prominences. 4.Adequate keratinized mucosa for prosthetic support. 5.Proper interarch space to accommodate the prosthesis. 6.Absence of soft tissue folds or excessive mobility.
- 10. 12 Objective of Pre-prostheticsurgery 1. Eliminating pre-existent or recurrent pathology. 2. Rehabilitating infected or inflamed tissue. 3. Re-establishing maxillomandibular relationships in all spatial dimensions. 4. Preserving or restoring alveolar ridge dimensions (height, width, shape, and consistency) conducive to prosthetic restoration. 5. Achieving keratinized tissue coverage over all loadbearing areas. 6. Relieving bony and soft tissue undercuts. Starshak TJ. Oral anatomy and physiology. In: Starshak TJ, Saunders B, editors. Preprosthetic Oral and Maxillofacial Surgery. St. Louis: Mosby; 1980.
- 11. 13 6. Establishing propervestibular depth 7. Establishing proper notching of the posterior maxilla and palatal vault proportions. 8. Preventing or managing pathologic fracture of the atrophic mandible. 9. Preparing the alveolar ridge by onlay grafting, cortico-cancellous augmentation, sinus lift, or distraction osteogenesis for subsequent implant placement. 10. Satisfying facial aesthetics, speech requirements, and masticatory challenges. Starshak TJ. Oral anatomy and physiology. In: Starshak TJ, Saunders B, editors. Preprosthetic Oral and Maxillofacial Surgery. St. Louis: Mosby; 1980.
- 12. 14 Medical consideration • Serumcalcium, phosphate level • Albumin • alkaline phosphatase • calcitonin levels. • Decreased renal function and the presence of a vitamin D deficiency should also be ruled out
- 13. 15 Hard tissue examination •evaluation of the maxillomandibular relationship • existing alveolar contour, height, and width • soft tissue attachments • Pathology • tissue health • palatal vault dimension • hamular notching • vestibular depth
- 14. 16 Soft tissue examination •careful visualization, palpation, and functional examination of the overlying soft tissue and associated muscle attachments.
- 15. 17 Radiographic evaluation 1. OPG– best screening source • Identify and evaluate pathology • Estimate anatomic variations and pneumatization of the maxillary sinus • Locate impacted teeth or retained root tips • Helps to see contour, location, and height of the basal bone • alveolar ridge, and associated inferior alveolar neurovascular canal and mental foramina location.
- 16. 18 2. Posteroanterior andlateral cephalometric radiographs • to evaluate inter-arch space • relative and absolute skeletal excesses or deficiencies existing in the maxilla or mandible • orientation of the alveolar ridge between arches 3. 3DCT/CT
- 17. 19 Lekholm and Zarb- bone quality • Type 1: homogeneous compact bone. • Type 2: thick layer of compact bone surrounds a core of dense trabecular bone. • Type 3: thin layer of cortical bone surrounds a core of dense trabecular bone. • Type 4: thin layer of cortical bone surrounding a core of low- density trabecular bone of poor strength.
- 18. 20 Cawood and Howell-residualridge form ■ Class I—dentate ■ Class II—post-extraction ■ Class III—convex ridge ■ Class IV—knife-edge ■ Class V—flat-ridge ■ Class VI—loss of basal bone
- 19.
- 20. 22 Preprosthetic surgery techniques Hard tissue Alveolar ridge augmentati on Maxilla Mandible Orthognathic surgery Alveolarridge preservation Alveolar ridge correction Soft tissue Vestibuloplasty Frenectomy Redundant tissue excision Mental nerve repositioning • Superior border augmentation • Inferior border augmentation • Visor osteotomy • Interposition bone grafting (modified visor osteotomy) • Alveolar distraction osteogenesis • Onlay bone graft • Interpositional bone graft • Sinus lift • Alveolar distraction osteogenesis • Primary alveoloplasty • Secondary alveoloplasty • Excision of tori • Mylohyoid ridge reduction • Genial tubercle reduction • Maxillary tuberosity reduction • Tuberoplasty •Segmental surgery •Total jaw surgery • Alveolar flabby ridge (hypermobile soft tissue on the alveolar ridge) • Denture granuloma • Epulis fissuratum • Reactive inflammatory hyperplasia of the palate
- 21. 23 Alveolectomy / Alveoplasty Excisionof a portion of the alveolar process. It generally is performed to facilitate the removal of teeth, to correct irregularities of the residual alveolar ridge following removal of 1 or more teeth and to prepare the residual ridge for reception of artificial denture. - Boucher
- 22. 24 • 1853 –AT Willard – removed interdental gingival papilla and alveolar margin • 1876 – Beers – Radical alveolectomy • 1920 – Shearer – External alveolectomy • 1936 – OT Dean – Intra-septal alveolectomy • 1966 – Obwegeser – Modification of Deans alveoplasty
- 23. 25 Objective of alveoplasty Primary By removalof bone and soft tissue, alveolar process can be immediately contoured to facilitate denture construction Excessive removal and resorption of bone must be prevented Secondary U shape alveolar ridge Broad alveolar ridge Sharp edges should be rounded off All or most undercuts removed
- 24. 26 Young bone –More plastic More prone to resorption from atrophy and abuse over longer no. of years than old bone So, remove less bone during alveoplasty
- 25. 27 To avoid bone resorptionand soft tissue proliferation Rest the Mouth
- 26. 28 Intraseptal/ Intercortical/ Deansalveoplasty (1936) • Cancellous bone resorbs more rapidly and more extensively than compact bone. • So preserve cortex at the expense of soft medullary bone
- 27. 29 Limitation of Deanstechnique • V shape anterior ridge instead of U shape
- 28. 30 Obwegeser modification ofDean (1966) Advantage :- Able to recontour both palatal and labial surface of anterior alveolar process and is suitable for extreme premaxillary protrusion
- 29. 31 Genial Tubercle Reduction •Genioglossus (lingual aspect of the anterior mandible) • resorption continues • the genial tubercle becomes more prominent • along with the attached muscles creating a displacement of prosthesis.
- 30. 32 PROCEDURE • A crestalincision (midline to the midbody of mandible) ↓ • dissection in subperiosteal fashion ↓ • exposing the tubercle and the attached muscle. ↓ • Muscle excised from the bony attachment ↓ • The exposed genial tubercle is trimmed by rotary or rongeur ↓ • Closure with resorbable suture (Genioglossus is left to reattatch independently) Anderson proposed reattaching the genioglosus and geniohyoid at lower level
- 31. 35 Tuberosity Reduction Excess inmaxillary tuberosity Encroachment on the interarch space Decrease Freeway space
- 32. 36 Excess in maxillarytuberosity - Bone Soft tissue Both Sounding
- 33.
- 34. 38 • Periosteal dissection •Removal of excess bony anatomy • Sharp undermining of overlying soft tissue – wedge shape • Excess overlying tissue trimmed in ELLIPTICAL fashion • Suturing A B C D E
- 35. 39 Mylohyoid ridge reduction •Acc to Gillies • Howe stated, reduction of mylohyoid ridge is useful for grossly resorbed mandible, as it not only reduces the painful sharp bony edge but the lingual sulcus is also lowered at same time. Mylohyoid ridge should be reduced when ridge is found to be at same/higher level than alveolar process.
- 36. 40 Reduction of Toriand Exostoses Etiology :- • Unknown • Heriditary • Superficial trauma • Malocclusion • Functional response to mastication Benign Slow growing Bony projection
- 37. 41 No treatment isrequired until :- • Large enough to interfere with speech • Mucosa becomes traumatised, ulcerates and fails to heal because of poor vascularity. • If its presence interfere with removable dental prosthesis. • To avoid rocking of denture
- 38.
- 39.
- 40. 44 Redundant tissue excision •Labial frenectomy – Band of fibrous connective tissue, covered with mucous membrane that binds lip to alveolar process. • Z plasty • Block excision • V-Y plasty / V diamond plasty
- 41. 45 • abnormal attachedfrenum • Incision at base of frenum (with Dean scissors.) • Submucosal and supraperiosteal dissection. • Cross-sectional view of submucosal and supraperiosteal tunnels. • Completed frenectomy with the new vestibular height established by periosteal tacking suture.
- 42.
- 43. 47 Z-plasty technique for eliminationof labial frenum. Small elliptical excision of mucosa and underlying loose connective tissue. Flaps are undermined and rotated to desired position.
- 44. 48 Localized vestibuloplasty with secondary epithelialization Advantageouswhen the base of the frenal attachment is extremely wide
- 45. 49 LASER ASSISTED FRENECTOMY •The tendinous frenum attachment- ablated with the laser • does not require suture re- approximation of the tissue because re-epithelialization occurs from the wound margins
- 46. 50 LINGUAL FRENECTOMY Transverse incisionis made between ventral aspect of tongue and caruncle of submandibular duct. Sectioning of some fibres of the genioglosus muscle - yield greater degree of freedom. Diamond-shaped defect is closed with interrupted sutures.
- 47. 51 Ridge Extension Procedure •Procedures surgically designed to uncover the existing basal bone of the jaw by repositioning the overlying mucosa and muscle attachments to an inferior position in mandible or to a superior position in maxilla. • Helps to accommodate the larger denture flanges
- 48. 52 Vestibuloplasty [Sulcoplasty, SulcusExtension] • Stability of a denture - improved by deepening the mandibular sulcus, generating more attached tissues over the functional ridge • Mandibular vestibuloplasty - to increase and maintain the functional alveolar ridge.
- 49. 53 • Closed submucousvestibuloplasty- OBWEGESER- maxilla (1959), BOERING- mandible(1969) • Open submucous vestibuloplasty- WALLENIUS- used closed view procedure of obwegeser OBWEGESER- open view variation
- 50.
- 51. 55 Vestibuloplasty with secondaryepitheliasation Inflammatory hyperplasia Scar tissue Mucosal advancement is contraindicated Secondary epithelialization is preffered
- 52. 56 Kazanjian (1935) 1.Horizontal incisionon the mucosa of the lip 2.Elevate the labial and vestibular flap 3.Supra-periosteal dissection (do not incise periosteum) till depth achieved 4.Mucosal flap is turned downwards and sutured to the depth of vestibule. 5.Remaining wound is kept raw and heal by 2nd epithelialization
- 53.
- 56. 60 Godwin(1997)- subperiosteal stripping •Flap sutured to connective tissue beyond deepened vestibule Obwegeser (1964)- • modification of clark’s • For maxillary vestibuloplasty Tortorelli (1968)- fenestration made at the base of newly created vestibule parallel with mucogingival junction Free margin sutured to inferior periosteum margin to fix mucosa deep in vestibule
- 57. 61 Transpositional Flap Vestibuloplasty [Lip-SwitchProcedure] Variation of kazanijian and godwin’s technique • Kethley and Gamble • Lower lip mucosa incision • Supraperiosteal dissection to depth of vestibule • Periosteum incised at crest of alveolus and transposed and sutured to denuded labial submucosa • Mucosal flap sutured to depth of vestibule over exposed bone
- 58. 62 Mandibular Vestibuloplasty withGrafting Indications- • in cases where the lip switch procedure not possible due to the inadequate tissue availability. • options - secondary epithelisation or covering the denuded areas with grafts. Advantages- • less relapse (wound contracture) • Early coverage of surgical defect • Less discomfort to patient • Rapid healing • Early construction of prosthesis
- 59. 63 Lingual Vestibuloplasty: AnteriorRegion • The severe atrophy of the mandible in the anterior region makes the genial tubercles prominent and affects the stability of the denture by the attached muscles. • Initially proposed by Kazanjian and later modified by Lewis • Disadvantage - loss of tongue function and difficulty in swallowing, which is encountered if more than half of the muscle is removed.
- 60. 64 • Incision -anterior aspect of the crest of the alveolar ridge and subperiosteal flap is elevated. • Dissection continued till the prominent genial tubercle with the attached muscle is encountered. • The genial muscles are separated from the ridge • tubercle is trimmed • The flap along with the muscle - lowered to the desired depth • maintained in the new position by stent and extraoral sutures. • The exposed area is allowed for secondary re-epithelisation.
- 61. 65 Lingual Vestibuloplasty: PosteriorRegion • If the amount of the resorption is severe - displacement of the denture by the action of mylohyoid- So, lowering of the mylohyoid muscle should be considered. • done alone or in combination with labial vestibuloplasty. ASSESMENT- • Place a gloved finger along the lingual side of the mandible and asking the patient to touch the palate with the tip of the tongue. • If this action displaces the finger, lowering the floor of mouth should be considered.
- 62. 66 TRAUNER’S TECHNIQUE • Incision- retromolar area to the premolar area of the lingual aspect of the alveolar crest. • Mucoperiosteal flap raised • mylohyoid and the overlying periosteum exposed. • Dissection in supraperiosteal plane (avoiding damage of the lingual nerve) • The muscle with the flap is lowered to the desired depth. • Sutures are passed through the mylohyoid and mucosa and secured to the skin extraorally. • The exposed area is allowed for secondary re- epithelisation
- 63. 67 Other Variations Include Brown— •incision similar to Trauner’s • full-thickness mucoperiosteal flap reflected to reveal the mylohyoid ridge • muscle detached from mucosa • ridge smoothed. • The difference here is the sulcus is not deepened, but the problem with the ridge prominence is solved.
- 64. 68 Caldwell— • crestal incisiongiven • supraperiosteal dissection to access the mylohyoid ridge and the attached muscle. • flap is sutured to the original position. • Then new position of loose mucosa is secured by a stent or a modified denture. • Instead a polyethylene tubing can be also used to maintain the position
- 65. 70 Hopkin— it uses thecombined modalities like labial vestibuloplasty, submucous sulcoplasty to remove the buccinator insertion and bilateral mylohyoid ridge reduction.
- 66. 71 Ridge Augmentation Procedures •In severe resorbed and atrophic ridges of Cawood and Howell classes IV—VI, augmentation became mandatory. • Autogenous bone grafting remains the ideal option to rectify the deficiency Disadvantages – • need for hospitalisation and general anaesthesia, • donor site morbidity, • extensive surgical procedure, • professional expertise and • patient compliance
- 67. 72 Classification of alveolarridge deficiency Kent et al. • Class 1:The alveolar ridge is adequate in height but inadequate in width, often with lateral deficiencies or undercut areas. Treatment: Patients typically receive hydroxyapatite alone. • Class 2:The alveolar ridge is deficient in both height and width and presents a knife- edge appearance. Treatment: Patients also receive hydroxyapatite alone.
- 68. 73 • Class 3:Thealveolar ridge has been resorbed to the level of the basilar bone, resulting in a concave form in the posterior mandible and a sharp bony ridge with bulbous mobile soft tissues in the maxilla. Treatment: Patients receive hydroxyapatite with or without autogenous cancellous bone. • Class 4:There is resorption of the basilar bone, producing a pencil-thin flat mandible or maxilla. Treatment: Patients require both hydroxyapatite with autogenous bone.
- 69.
- 70. 80 Inferior Border Augmentation •The procedure was originally proposed by Marx and Sanders and later modifed by Quinn.
- 71. 81 Advantages – • Non-obliterationof the sulcus • allowing the placement of the interim denture • making the secondary vestibuloplasty easier. Disadvantages- • extraoral scar and the chance of altering the facial appearance. • Procedure does not correct superior border irregularities
- 72. 82 INCISIONS USED FORRIDGE AUGMENTATION • Supraclavicular incision- extends from the anterior border of sternocleidomastoid to the opposite counterpart. • Sanders – a continuous submandibular incision from angle to angle is sufficient. • Ridley and Mason- use of three small submandibular incisions connected by subperiosteal tunnels (high chance of resorption by the pressure on the graft)
- 73. 83 • Two ribsof 15 to 20 cm long are harvested (5 to 9th rib) • bent to adapt the shape (vertical scoring or KERFING of internal surface of 1 rib) • 3 or 4 transosseous holes drilled in lower border of mandible and wires are passed through these holes. • One rib is placed against the lingual aspect and the other abutted against the buccal aspect. • The space between the ribs is packed with available cortical chips. • Ribs are secured in place by interosseous wires in circumferential pattern.
- 74. 84 Superior Border Augmentation •In cases where the patient suffers from pain during mastication, secondary to the pressure on the mental neurovascular bundle • Potential risk of fracture
- 75. 85 • Crestal incisionfrom the retromolar area to the opposite retromolar area • The existing superior border is exposed and prepared to receive the graft. • The lingual flap is reflected to the level of the mylohyoid muscle.
- 76. 87 Interpositional Grafting Horizontal osteotomy achievedby an incision made inferior to the crest of the ridge. • The length -determined by the area to be augmented. • Incision -retromolar area to the other. • A buccolabial mucoperiosteal flap is raised and the flap is undermined to get adequate coverage of the graft.
- 77. 88 • The horizontalosteotomy - burs and osteotomes, saws. • The cut may be placed either above or below the canal, depending on the proximity to the inferior border. • Transosseous holes are drilled in the lower and upper segments. • The harvested graft is interposed between the osteotomised segments (SANDWICH AUGMENTATION) and stabilised by the wires.
- 78. 89 The Vertical orVisor Osteotomy • Sagittal cut - between the buccal and lingual cortical plates (3rd molar to the opposite 3rd molar) • The lingual segment- pedicled to the mylohyoid, digastrics and genial musculature and the soft tissues- elevated vertically -fixed in the preplanned position with wires through the transosseous holes. • The lateral aspect of the elevated segment filled with the cancellous bone to compensate the height deficiency created by the vertical repositioning. - Sladen and peterson
- 79. 91 • Bosker -combine osteotomy and the vestibuloplasty and lowering of the floor of the mouth in a one-stage procedure. Advantage - • it needs only single operation and hospitalisation of the patient • prosthesis can be made in 4–6 weeks sooner, • operative procedure is simpler.
- 80. 94 Graft Materials • Iliacbone crest and rib grafts (5th -9th ) • Boyne - bone regeneration method, which employs a vitalium mesh tray containing haematopoietic bone marrow encased in a nylon-reinforced Millipore filter. • The filter prevents the connective tissue elements accessing the defect and thereby enhances the osseous regeneration. • The concern regarding the graft material is the resorption shrinkage in the future.
- 81. 95 • Notched ribcan be contoured to the arc of the mandible, but 50% loss by shrinkage is a great disadvantage with rib. • So, the literature suggests the use of pure cancellous iliac graft, iliac cortical— cancellous sectional grafts with appropriate immobilisation showing excellent healing even in the event of occasional incision dehiscence
- 82. 96 Augmentation with Synthetic GraftMaterials • Resorbable materials- application in periodontal pockets • Non resorbabale materials- extensively used in the management of alveolar atrophy. • Hydroxyapatite has been successfully using for decades. • Kent et al- hydroxyapatite + corticocancellous autogenous bone
- 83. 97 • When anteriormandible needs augmentation- single midline vertical incision is used • For complete augmentation of mandible- bilateral vertical incisions anterior to mental foramen are used • A subperiosteal tunnel is formed, which can be assessed by a dental mirror and the syringe loaded with graft material is inserted through the tunnel and delivered in place. • After the tunnel is filled with graft material, the incision is closed with interrupted or horizontal sutures.
- 84. 98 • Denture canbe placed at about 1 month in cases where augmentation is carried out by hydroxyapatite alone or 6– 8 weeks in which both hydroxyapatite and bone are used together. • If vestibuloplasty is planned, Kent advocated a waiting period of 8 weeks after graft placement.
- 85. 99 Guided Bone Regeneration (Osteopromotion) •By placing a membrane covering over a bone graft, faster-growing fibroblasts and epithelial cells can be walled off, allowing bone to grow in a relatively protected environment without epithelial ingrowth. • Expanded poly-tetra-fluoro-ethylene or Gortex is the most popular non-resorbable membrane. • The resorbable membranes, synthetic polymers such as polylactin, and collagen have been used with increased frequency.
- 86. 100 Alveolar Distraction Osteogenesis •Biologic process of new bone formation that occurs between bone segments that are separated by gradual incremental traction. - Peterson • Avoids graft related complication
- 87. 101 Technique • Under LA,crestal mucoperiosteal incision is made followed by labial oblique mucoperiosteal incisions placed anterior and posterior to distraction zone • A round bur used to make small trough along the crest. • Bone cuts are made through the trough, and through the anterior and posterior vertical incision without stripping mucoperiosteum using chisel and mallet.
- 88. 102 • An osteotomeis introduced crestally and the buccal plate is “green stick” fractured buccally. • The distractor is tapped into place • Wound approximated with sutures
- 89. 103 • Latency period– 7 days • Distraction – 2 turns per day (0.5mm * 2) • Consolidation period – minimum 3 months (Bony regenerate visibile at the time of distractor removal)
- 90. 104 CONCLUSION • The ultimategoal of pre-prosthetic surgery is to bridge the gap between surgical reconstruction and prosthetic rehabilitation, offering patients improved quality of life through enhanced mastication, speech, and aesthetics. A multidisciplinary approach, incorporating advancements in surgical techniques and biomaterials, continues to refine outcomes, making pre- prosthetic surgery an indispensable aspect of modern oral and maxillofacial surgery.
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Editor's Notes
- #4 Acc to Cawood.
- #5 Before planning treatment, its important to consider the etiology of edentulous state due to bone loss. Anatomically, individuals with long dolichocephalic faces typically have greater vertical ridge dimensions than do those with short brachycephalic faces. In addition, those with shorter faces are capable of a higher bite force. Metabolic disorders can have a significant impact on a patient’s potential to benefit from osseous reconstructive surgery. Nutritional or endocrine disorders and any associated osteopenia, osteoporosis, and especially osteomalacia must be addressed before beginning bone reconstruction.
- #7 All these factors contribute to alveolar bone loss.
- #8 All these bone loss factors lead to a state of edentulism. Now what are the effects of edentulism ? Now after knowing about the problems faced after having edentulous ridge, we should know what is an ideal ridge.
- #9 After the effects of edentulism, Now what is an ideal edentulous mouth ?
- #11 These criteria guide surgeons in planning pre-prosthetic surgeries like alveoloplasty, vestibuloplasty, or ridge augmentation to achieve an ideal ridge for prosthetic rehabilitation.
- #12 With this the objective of Pre-prosthetic surgery is -
- #14 comprehensive workup of the patient’s predilection for metabolic disease should be done.
- #20 ■ Class I—dentate ■ Class II—postextraction ■ Class III—convex ridge form, with adequate height and width of alveolar process ■ Class IV—knife-edge form with adequate height but inadequate width of alveolar process ■ Class V—flat-ridge form with loss of alveolar process ■ Class VI—loss of basal bone that may be extensive but follows no predictable pattern
- #21 The thicker line illustrates the amount of attached mucosa, which decreases with progressive resorption.
- #27 Rest the mouth – means remove denture several hours each day instead of regular wear
- #29 Aka Crush technique – Buccal/Labial bone is crushed inwards Mackay modification of dean – cracked cortical plate is pulled outwards and then compressed palatally – allow freely movable and tension free onlay of bone
- #32 Muscle excised from the bony attachment by monoplanar electrocautery with care to be taken to achieve haemostasis or else chance of airway embarrassment by the occurrence of expanding hematoma. The exposed genial tubercle is trimmed by round or fssure bur. Further smoothening is made by bone fle
- #36 Intermaxillary distance - at least 1 cm when patients are placed into the correct or planned vertical dimension of occlusion. Elliptical design is selected, the width of the ellipse is estimated by the magnitude of anticipated tissue removal. When minimal reduction is anticipated, a single crestal incision is sufficient Before flap elevation, excess fibrous tissue is removed by undermining the mucosa with a beveled incision and excising a wedge on the palatal side of the wound and, if indicated, on the buccal side as well In the case of solely soft tissue tuberosity reduction, excess tissue can be removed by simple wedge resection. Tension free closure is then achieved by undermining the buccal and palatal flaps subperiosteally. Additional submucosal tissue can be undermined and re
- #38 (A) Beveled incision to eliminate bulky tissue while preserving mucosa. (B) Elevation of buccal and palatal mucoperiosteal flaps. (C) Removal of excess bone from the tuberosity. (D) Closure with interlocking continuous suture technique. (Courtesy of [A] Alan Samit, DDS, West Orange, NJ; and From [B, C] Peterson LJ, Ellis E, Hupp JR, et al, with six contribu
- #40 Exostosis is a benign slow growing bony projection , that can occur in any part of jawbone. Exostosis can occur in any part of jawbone but TORI refers to bony growth at lingual (torus mandibularis) and palate (Torus palatinus) Dense cortical bone with minimal cancellous bone
- #42 Linear midline incision is given with anterior and posterior releasing incision Subperiosteal dissection Small Bone removed with bur Large bone removed with sectioning with fissure bur and osteotome
- #51 to accommodate the larger denture flanges, thus contributing to stability and retention
- #56 Horizontal incision on the mucosa of the lip Elevate the labial and vestibular flap Supra-periosteal dissection (do not incise periosteum) till depth achieved Mucosal flap is turned downwards and sutured to the depth of vestibule. Remaining wound is kept raw and heal by 2nd epithelialization DISADVANTAGE – Relapse of the labial vestibuloplasty due to contraction by 2nd epithelialization
- #61 The technique involves the administration of local anaesthesia followed by mucosal incision. The mucosal fap is elevated and pedicled near the crest of the ridge (Fig. 17.11a and b). An incision is placed near the superior portion of the periosteum. A supraperiosteal dissection is carried in the inferior direction, thereby removing the attachments of the muscular and connective tissues to the indicated vestibular depth. The labial periosteal margin is sutured to the incised lip mucosa. This is followed by the suturing of the pedicled fap to the periosteum at the depth of the vestibule
- #62 Here, the desired alveolar height between the mental foramina is not less than 10 mm in contrast to the minimum of 15 mm in lip switch.
- #63 The exposure of the tubercles and the detachment of the genial muscles are accomplished by the procedure of lingual vestibuloplasty.
- #71 Unfortunately, this area of preprosthetic surgery has gained little attention, possibly there seemed to be no effective operation for ridge augmentation using an extraoral method; moreover, the penetration into the oral cavity during the procedure was deemed tanta- mounting to failure, as the surgeons are reluctant to perform the elective augmentation of mandible. Augmentation grafting adds strength to an extremely deficient mandible and improves the height and contour of the available bone for implant placement on denture-bearing areas. Sources of graft material include autogenous or allogeneic bone and alloplastic materials. Historically, autogenous bone has been the most biologically acceptable material used in mandibular augmentation. Disadvantages of the use of autogenous bone include the need for donor site surgery and the possibility of resorption after grafting. The use of allogeneic bone eliminates the need for a second surgical site and has been shown to be useful in augmenting small areas of deficiency in the mandible. 19 The increased popularity of implants has renewed enthusiasm for use of autogenous bone grafts alone or in combination with other biologic materials for bony augmentation.
- #74 Augmentation grafting adds strength to an extremely deficient mandible and improves the height and contour of the available bone for implant placement on denture-bearing areas. Sources of graft material include autogenous or allogeneic bone and alloplastic materials. Historically, autogenous bone has been the most biologically acceptable material used in mandibular augmentation. Disadvantages of the use of autogenous bone include the need for donor site surgery and the possibility of resorption after grafting. The use of allogeneic bone eliminates the need for a second surgical site and has been shown to be useful in augmenting small areas of deficiency in the mandible. 19 The increased popularity of implants has renewed enthusiasm for use of autogenous bone grafts alone or in combination with other biologic materials for bony augmentation.
- #84 Superior border grafting of atrophiC mandible. Corticocancellous iliac crest contoured to adapt to configuration of mandible; stabilized with rigid fixation screws.