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Transcript of pre prosthetic surgery
PRE PROSTHETIC SURGERY
INTRODUCTION
Definition: Pre Prosthetic Surgery (GPT 8): The surgical procedure designed to facilitate
fabrication of prosthesis or to improve the prognosis of prosthodontic care.
The majority of patients who require prosthodontic treatment will not require surgical
intervention prior to commencement of their prosthodontics. For many others, however, a
thorough and comprehensive examination, diagnosis and treatment plan will reveal that surgical
intervention can improve the prognosis for the case. Consideration of pre-prosthetic surgery is
one of numerous methods by which a patient’s clinical presentation may be advantageously
altered.
As a general "rule of thumb" the best procedure to consider is the least invasive process
that will produce clinical success. This may mean that it could be a disservice to the patient to
perform surgery when a non-surgical method could be used. It is likewise a disservice to fail to
consider and perform surgery when a non-surgical approach will produce a less than satisfactory
result.
REVIEW OF LITERATURE
1853: Willard stressed the importance of mouth preparation for complete dentures
1876: Beers advocated excision of alveolus after tooth extraction
1935: Kazanjian described a technique. for vestibular deepening
1944: Lisowski introduced tracing instrument to study the morphological changes
following teeth extraction
1951: Mathis & Cooley suggested surgical technique for lowering the mental foramen.
1957: Atwood radio graphically estimated the alveolar ridge resorption following teeth
loss.
1960: Sobolik brought out the effects of constant and intermittent pressure over the
residual ridge.
1965: Obweseger – published contemporary review of indications of soft tissue
reconstruction in the vestibule and floor of the mouth.
1976: Canzona experimented mandibular augmentation
1981: Samit et al described interpositional osteotomy and mandibular vestibuloplasty
1982: Kent advocated the use of hydroxyl apatite for ridge augmentation
1984: Indersano described a technique of open sub mucosal vestibuloplasty
OBJECTIVES
The two main goals of Preprosthetic surgery for completely edentulous arch are:
Provision of a comfortable tissue foundation to support the denture
Enlargement of the denture bearing area in attempt to provide stability for a denture.
The objectives of Pre Prosthetic surgery in partially edentulous arch are:
Restoration of the best masticatory function possible
Restoration or improvement of dental and facial esthetics.
INDICATIONS
Correcting conditions that preclude optimal prosthetic function
Localised/ generalised hyperplastic replacement of resorbed ridges
Epulis fissuratum
Papillomatosis
Unfavorably located frenular attachments
Pendulous maxillary tuberosities
Bony prominences, undercuts, and ridges
Discrepancies in jaw size relationships
Pressure on mental foramen
Enlargement of denture bearing area(s)
Vestibuloplasty
Ridge augmentation
Ridge preservation procedures
Supra mucosal vital root retention
Sub mucosal vital root retention
Root cone implants
Essential features of a denture bearing area
The denture bearing area should have following features:
Alveolar processes should be as large as possible and of the proper configuration.
Ideal ridge- Criteria for an ideal residual ridge (Goodsell- 1955)
1. Adequate bony support
2. Adequate soft tissue coverage
3. No undercuts & protuberances
4. No sharp ridges
5. Adequate vestibular depth
6. No scar bands
7. No high attachments of muscle bands/Freni that dislodges denture during
function
8. Satisfactory relationship of maxilla to mandible
9. No soft tissue folds, redundancies or hypertrophies
10. Free of neoplasm
According to Heartwell: Characteristics of this ideal form which provide for maximum
support and stability and minimum interference with function are:
Ridges are broad and flat with vertical height (minimum of 5mm)
provided by nearly parallel, non undercut, bony walls.
A firm, resilient mucosal covering with nicely shaped buccal and lingual
sulci which are uninterrupted by frenae,scars or redundant tissue folds.
An inter-arch distance (minimum 16 to 18mm) and relationship which
allows room for the denture and its components.
Proper jaw relationship should occur in anteroposterior, lateral and vertical
dimensions.
Adequate attached keratinized mucosa should be in present in primary denture bearing
area.
Adequate bone support for denture. Adequate vestibular depth.
No excessive muscle fibres or frena should be present , which can mobilize the periphery
of prosthesis during function
No evidence of intra- or extra- oral pathological conditions.
No bony or soft tissue protuberances or undercuts should be present.
PATIENT’S EVALUATION
Before any surgical or prosthetic treatment, a thorough evaluation outlining problems to
be solved and a detailed treatment plan should be developed.
History: Patient’s chief complaint, expectations, esthetics, functional goals, psychological
factors, patient’s surgical risk status must be reviewed.
Physical Examination:
– Evaluation of supporting bone by
Visual inspection
Palpation
Radiographic examination
Articulated diagnostic casts
– Evaluation of supporting soft tissues for
Presence of inflammation
Quality of tissues
Depth of the vestibule
Frenal & muscle attachments
Treatment plan
Non surgical
Surgical
Combination of these
NONSURGICAL METHODS :
Rest for Denture Supporting Tissue
Removal of old denture should be done from the mouth usually 48-
72hours before taking impression.
Use the tissue conditioning material inside the old denture.
Rinse the mouth daily with a saline solution frequently.
Regular massage of denture bearing mucosa should be done with finger or
soft tooth brush which stimulates the mucosa to improve blood circulation
and enhances keratinisation.
Correction of Vertical Dimension of Occlusion in Old Prosthesis
An attempt can be made to restore an optimal vertical dimension of
occlusion to the old denture by using an interim resilient lining material.
This enables the dentist to know the amount of vertical facial
support that patient can tolerate and brings back the displaced tissue to
their original form.
Nutritional Care of Patient
Good nutritional program comprising of all essential nutrients must be
emphasized for each edentulous patient, specially for geriatric patient
because:
- Metabolic and masticatory efficiency is decreased in edentulous
patients due to decreased food intake.
Oral signs of nutrient deficiencies:
Protein: decreased salivary flow, enlarged parotid glands.
Vitamin B Complex, Iron & Proteins: Lips show cheilosis, angular scars,
angular stomatitis & inflammation.
Conditioning the Patient’s Musculature
Jaw exercises are used like:
- side to side movements
- protrusive and retrusive movements
- opening and closing of the mouth
to relax the muscles of the mastication and strengthen their coordination.
These also prepare the patient psychologically for prosthetic service.
SURGICAL METHODS
Before surgery certain investigations are required such as:
Routine blood examination like – TLC, DLC, Hb%, ESR, BT,CT
Blood sugar level
Throat swab culture
Allergic tests
Chest X-ray
CLASSIFICATION
Hard tissue surgery
Resective
Augmentation
Soft tissue surgery
Resective
Ridge extension
Miscellaneous
Nerve relocation
Sinus grafting
Tissue relocation
SOFT TISSUE PROCEDURES:
RESECTIVE SURGERIES
HYPERPLASTIC RIDGE
Also known as flabby ridge, it is mobile. There is marked fibrosis, inflammation and
resorption of underlying bones.
Causes
Inadequate rest to the denture bearing area.
Various forces to which the supporting tissues are subjected e.g. natural lower teeth
opposing the upper denture.
Excessive force on limited segments of the dental arches, due to lack of balancing
contacts in eccentric jaw position.
Trauma from denture wearing
Changes in the alveolar socket after extraction.
Treatment
Prevent the causative factor.
If this type of ridge is present in the maxillary anterior region, it is generally
removed surgically.
A satisfactory denture can be made on flabby ridge by using special impression
technique.
Surgical excision of hyperplastic soft tissue can be done to improve the stability and
support to denture and to minimize the alveolar ridge resorption.
o Simple excision :If sulcus depth is adequate
o Excision & alveoloplasty
o Subsequent vestibuloplasty
o Sclerosing (Laskin-1970) If excessive mobile tissues with acceptable
ridge contour with sclerosing agent Sodium Mohurrate
If there is excessive alveolar ridge resorption, bone graft or alloplastic material such
as hydroxyapatite can be used to improve the contour of the alveolar ridge.
EPULIS FISSURATUM
It is irritational fibrous growth of mucosa around the borders of the denture.
Causes Denture irritation due to
o Allergy or reaction to dental material
o Ill fitting denture
o Faulty denture construction
o Progressive resorption
Clinical features
o Continuous mucous fold b/w denture and alveolar process
o Lobulated / Bifid
Treatment
o Keep the denture out from the patient’s mouth to provide rest to the irritated
mucosa.
o Placement of soft liner
o Conventional surgery
Single mass - Simple excision
Multiple - Excision of the complete area
o Electrosurgery
o Surgical splint : Application of surgical stent helps in margin fixation at
desired position
o Full thickness graft - Prevents relapse
FIBROUS HYPERPLASIA
Fibrous hyperplasia of maxillary tuberosity
Causes - Pre existing periodontal disease of molars
Appears as avascular dense tissues at the tuberosity
Bony enlargements can be seen in radiographs
Treatment
– Surgical excision
Elliptical incision
Removal of the elliptic portion
Sub mucosal undermining
Suturing
Fibrous Hyperplasia: Retromolar pad
Causes - Impingement of maxillary molars and long standing irritation over the pad
Prevents posterior extension of mandibular denture
Treatment
– Surgical excision
Wedge incision
Thinning of the flap
Closure
– Complication
Lingual nerve paresthesia
Hyperplastic palatal mucosa
Usually seen on the palatal aspect of maxillary molars
Appears as firm, non tender with undercuts
Causes mechanical interference in denture construction and insertion.
It also results into the narrowing of palatal vault and interferes with speech
Treatment
– Simple excision
o Sub mucosal dissection
– Sloughing due to severing of palatal blood supply
o Stent to be placed for:
– Patient comfort
– Better dietary intake
o Avoid damage to the greater palatine nerve and vessels.
Papillary palatal hyperplasia (Palatal papillomatosis)
Hyperplastic papillary enlargement of tissues
Caused due to:
– Poor oral hygiene
– Continuous wearing of ill fitting dentures
– Candida infection
Treatment
– Electrosurgical excision
Impaired healing
– Muco abrasion technique
Islands of epithelium acts at growth centre
Papilla removed by:
– Sharp bony files
– Dermabrasion brushes
– Relining of dentures by soft liners
HYPERTROPHIC LABIAL FRENUM
Irritation by frenal notch in the denture flange
Treatment
– Relieving the frenal notch
Unesthetic appearance
Mid line fracture of denture
Inadequate border seal during impression making
May dislodge the denture
May create discomfort and ulceration
– Surgical excision
Frenectomy – Excision of frenum
Frenoplasty
– Z-plasty
– Localized vestibuloplasty with secondary epithelialization,
– Localized supraperiosteal dissection removing the fibrous
attachment.
Other frenal conditions affecting denture performance:
Abnormal lingual frenum
High / Prominent buccal frenum
– Affects stability of denture
– Tongue tie & speech impairment
– Poor border seal
Treatment
– Simple excision
PAPILLOMATOSIS
It is chronic inflammation of denture bearing area. It is characterized by finger like
projections which are aggravated by microbial plaque and yeast on the fitting surface of
denture base due to poor oral hygiene.
Cause
It occurs if patient wears denture throughout 24hrs.
Treatment
o Maintenance of oral hygiene and rest to tissues.
o Antifungal therapy
o Surgical removal of papillary projections.
PENDULOUS MAXILLARY TUBEROSITIES
They may occur unilaterally or bilaterally and obliterate the inter-arch space. They
interfere with the denture construction.
Causes
o Formation of excessive soft tissues overlying the bone or
o Due to the excessive bone formation at the site of tuberosity
Determined by
Radiograph
Sharp probe under LA
Treatment – Surgical excision of excessive soft tissue is required to provide adequate inter-
arch space. (Majority of the tissue reduction should be done on the buccal
aspect instead of lingual aspect to reduce the risk of damaging the lingual
nerve and artery).
RIDGE EXTENSION SURGERIES
Compensates for alveolar atrophy
• Vestibuloplasty
• Secondary epithelialization procedures
• Zygomaticoplasty & Tuberoplasty
Repositions:
• Overlying mucosa
• Frenal attachments
• Muscle attachments
Advantages:
Large denture base area
More retention & stability
VESTIBULOPLASTY
This exposes the bone still present. Healing is by secondary epithelialization. Skin
or mucosal graft can be used. Complications are loss of sensation, sagging of chin and
hypotonia of circumoral muscles
Sub mucosal vestibuloplasty (Obwegeser-1951)
Indications
– Small clinical ridge
– Sufficient healthy overlying mucosa
Procedure
– Infiltration anesthesia
– Midline vertical incision from nasal spine to incisive papilla
– Sub mucosal dissection & tunneling
– Closure & stabilization with stent
Secondary epithelialization procedures
Indications
– Excessive scarring of tissues
– Epulis fissuratum
– Insufficient height of bone with adequate mucosa
Kazanjian’s method
– Incision through mucosa of inner surface of lip
– Dissection of mucosa back to the crest of the ridge
– Supra periosteal dissection
– Suturing of flap to the periosteum
– Circumferential suturing of the rubber tube
– Secondary epithelialization of labial mucosa
Clarke’s technique
– Secondary epithelialization of alveolar ridge
– Procedure
Incision slightly labial to the ridge crest
Supra periosteal dissection & sulcus deepening
Undermining the lip mucosa till vermillion border
Mucosal flap held by circumferential sutures
Disadvantages
– 50% relapse in maxilla within 3 years
– 80-90% in mandible
Transpositional flap vestibuloplasty (Lip switch)
Indication sufficient alveolar height
sufficient vestibular depth
especially indicated in mandibular arch
Procedure - a split thickness mucosal flap is dissected from a periosteal flap. The
periosteal flap is used to cover the raw soft tissue surface and the mucosal flap to
cover the raw bony surface.
Epithelial graft vestibuloplasty
Uses grafts over exposed tissues
– Skin
– Mucosa
Increases
– Support
– Stability
– Retention of denture
Tissue graft vestibuloplasty
A. Partial thickness skin graft
Indications:
– Insufficient bone height
– Correction of relapse following epithelialization procedures
Advantages:
– Decreased wound contracture
– Rapid healing & early construction of dentures
Disadvantages:
– Grafted area will become dry & non-resilient
– Requires special instruments
B. Buccal mucosa graft
Advantages:
– Smooth transition b/w attached & free mucosa
– Vestibule remains displaceable and enhances denture retention
Disadvantages:
– Contracture
– Difficult to work with
– Chances of relapse is greater
C. Free palatal graft
Used in mandible
Tough, resistant & resists forces
Easy to obtain
Undergoes less contracture
Disadvantages:
– Healing of donor site is delayed and extremely painful
ZYGOMATICOPLASTY & TUBEROPLASTY
For increasing vestibular height in atrophic maxilla
Increases lateral stability of denture
Prevents anterior displacement of denture
LOWERING THE FLOOR OF THE MOUTH
As the alveolar bone is resorbed, the attachments of the mylohyoid and
genioglossus muscles may interfere with the lingual aspect of the denture.
HARD TISSUES SURGERIES
RESECTIVE SURGERIES
BONY SPICULES, PROMINENCES, UNDERCUTS & SHARP SPINY RIDGES
– Meyer’s classification
Saw tooth like
Razor like
Discrete spiny projections
Treatment
– Cortical alveoloplasty
Localized spicules & prominences
Incision
Trimming of bone & soft tissues
Irrigation & linear closure
– Inter cortical alveoloplasty
Prominent & irregular alveolar process
Removes undesirable undercuts
Removal of septa
Collapsing of labial / buccal cortical plates
ENLARGED TUBEROSITY (BONY ENLARGEMENT)
Enlargement may be:
– Buccal
– Palatal -- Unilateral
– Vertical -- Bilateral
– Combination
Radiographs to rule out:
– Molar impaction
– Pneumatized tuberosity
– Other bony lesions
Treatment
– Surgical excision
Crestal incision behind the tuberosity
Removal of excess bone
Sub mucosal dissection
Irrigation & closure
– Alveoloplasty
– Posterior maxillary osteotomy
Entrance into the sinus
PROMINENT / SHARP MYLOHYOID RIDGE
Maximum lingual extension of denture
– Counteract loss of tonicity of mylohyoid muscle
– Enhances stability & denture retention
Severe undercuts due to alveolar atrophy
Treatment
– Surgical excision
– Lingual sulcus deepening
Transposition of mylohyoid ridge & securing by circum mandibular
ligature wiring
PROMINENT GENIAL TUBERCLE
Constant source of mucosal irritation under the flange
Treatment
– Surgical reduction
Removal of tubercles and allowing reattachment
Removal of tubercles and repositioning of muscles by percutaneous
sutures
Sectioning of tubercles and trans positioning it along with the muscles to
the inferior border & securing it with ligature wiring
EXOSTOSES
Mandibular tori
– Single -- Multiple
– Unilateral -- Bilateral
Indications for removal:
– Interference in denture fabrication
– Constant ulceration under flanges
– Interferences in speech & deglutition
Treatment
– Surgical excision
Palatal Torus
– Indications for removal
Interference in the placement of PPS
Inadequate posterior extension of denture
Undercuts that trap food
Chronic inflammation of overlying mucosa
– Treatment
Surgical removal
– Complication
Oro-nasal fistula (Traumatic cleft palate)
CYSTS AND TUMORS
Odontogenic or Non odontogenic
Enucleation and marsupalisation
Excision or hemimandilectomy & RND
RIDGE AUGMENTATION PROCEDURES
Corrects the atrophic residues ridges surgically
Seibert’s classification of ridge defects
– Class-I defect
Facio lingual loss of tissue width with normal ridge height
– Class-II defect
Loss of ridge height with normal ridge width
– Class-III defect
Combination of loss in both directions
ONLAY BONE GRAFTING
Maxilla - Rib
Mandibular superior border - Rib or iliac crest
Mandibular inferior border - Rib
Direct Augmentation of Superior Border of Mandible
Procedure
– Infiltration anesthesia
– Incision from one retro molar pad to other
– Releasing incision for greater mobilization
– Lowering of mental nerve to prevent stretching
Autogenous rib
– 2 ribs of 15cm long
– Vertical scoring adaptation – 1st rib
– 4-6 mm pieces – 2nd rib
– Closure by continuous mattress suture
Iliac crest
– 3 ´ 8 cm block removed
– Cut into 1-1.5 cm pieces, contoured & adapted
– Fastening with circum mandibular wiring
– Packing of cancellous bone into the dead spaces
– Closure with continuous mattress suture
Disadvantage:
– Extensive surgical procedure
– Lip paresthesia
– 67-70% relapse in 3 years
Direct Augmentation of Atrophic Maxilla
Crestal incision from tuberosity to tuberosity
Autogenous rib contoured and fastened by intra osseous wiring
Cancellous chips filled in the dead space
Closure by continuous mattress suture
Advantages:
– Resorption less than that in mandible
Disadvantages:
– Postoperative sequestration
– Infection
Augmentation of Inferior Border of Mandible
First attempted by Canzona in 1975
Procedure:
Continuous sub mandibular incision from angle to angle
Autogenous rib 15-20 cm long
Removal of inner cortex, scoring & contouring
Fastening by transosseous wiring
Dead space filled with inner cortical pieces
Closure of wound in layers
Advantages:
– Non obliteration of vestibule
– Interim denture can be worn
– No changes in vertical dimension of occlusion
– Graft not subjected to direct masticatory stress.
Disadvantages:
– Extra oral scar
– Possibility of altering the facial appearance (lower 3rd)
INTERPOSITIONAL BONE GRAFTS
Augmentation with Interpositional Bone Grafts
Indication:
– Reasonable bone above the mandibular canal
Procedure:
– Horizontal osteotomy above the mandibular canal
– Corticocancellous struts placed in canine & molar region
– Cancellous chips placed in b/w the struts
– Closure
Advantages:
– Resorption less than 2mm in 1-5 years
OSTEOTOMY
Mandibular "visor" Osteotomy
Segmental Osteotomy for partially edentulous arch
Maxillary Osteotomy with advancement with classic Lefort I osteotomy
Horizontal osteotomy : An adequate vertical height of mandible must exist so that the
mandible can be cut horizontally. This cut is placed below the level of the mandibular canal
and mental foramen to avoid injury to the mandibular nerve.
Vertical or Visor Osteotomy
Advocated by Harle & modified by Peterson & Slade
Indications:
– Insufficient vertical height of bone in mandible
– Scope of performing horizontal osteotomy & interpositional graft is limited
– Minimum of 10mm width of bone is present
Procedure:
– Mandible split vertically
– Lingual section is elevated ( because the lingual section can be raised so it is
called as visor)& secured by trans osseous wiring
– Closure
AUGMENTATION WITH SYNTHETIC GRAFTS
Ceramic bone grafts
– Resorbable
β tri calcium phosphate
Porous hydroxyl apatite
Indications:
Bony defects in periodontal pockets
– Non resorbable
Non porous hydroxyl apatite
Indications:
Alveolar ridge atrophy
Hydroxyl apatite
Prototype of non resorbable ceramic bone substitute
– Calcium phosphate identical to:
Enamel
Cortical bone
– Available in 2 gm vial
Granular form
Application done after mixing with:
– Normal saline
– Venous blood
– Placed via syringe
Procedure:
– Vertical incision lateral to the labial frenum in maxilla
– Bilateral vertical incision anterior to mental foramen in mandible.
– Sub periosteal tunneling
– Placement of hydroxyl apatite slurry by a syringe
– Closure
– Complications
– Dehiscence & extrusion of particles
– Migration
– Abrasion of mucosa during tunneling causes extrusion of particles
– Infection
– Abnormal colour
– Mental nerve neuropathy
– Advantages:
– Highly biocompatible
– Local augmentation possible
– Metallic implants can be inserted later
– Simple office procedure under LA
RIDGE PRESERVATION PROCEDURES
SUPRA MUCOSAL VITAL ROOT RETENTION
– For over denture construction
– Increased
Proprioception
Masticatory efficiency
Retention & stability
No risk for rejection
Psychological benefits to patient
– Disadvantages
Caries & periodontal disease
Increased treatment costs
SUB MUCOSAL VITAL ROOT RETENTION
Reduction of roots 2 mm below crestal bone
Water tight closure of mucosa
– Criteria of teeth selection (Garver)
Teeth should have / be
– Not more than 1 mm horizontal mobility
– No infrabony pockets
– Healthy circum muco gingival tissues
– Vital & asymptomatic
Advantages
– Preservation of alveolar bone height
– Preservation of bony contour
– Enhanced denture retention
– Proprioception
– Decrease in loss of vertical face height
Complications
– Immediate:
Tissue dehiscence due to closure under tension
Immediate post surgical exposure of root requires RCT
Pressure pain
– Delayed:
Small dehiscence over individual roots
Fistula
ROOT CONE IMPLANTS
– Calcium phosphate group of biomaterials
Nonporous hydroxyl apatite
Tooth root analogues made of calcium phosphate group of biomaterials
Non porous hydroxyl apatite – frequently used
Procedure:
– Prophylactic removal of teeth to maintain alveolar height
– Solid cones of non porous HA implanted
– Elevation of muco periosteum & covering the implants
– Healing by secondary intention
Advantages:
– No inflammatory response induced
– Acts as a nidus for new bone growth
– Osseo integration occurs
– Height & width of ridge preserved
– Excellent biocompatibility
– Undergoes no resorption
– Binds chemically to bone
– DISTRACTION OSTEOGENESIS
Principle:
– Application of stress / tension induces osteogenesis
Devices
– Lead ‘R’ system by Chin
– Robinson inter Oss alveolar device
– ACE distraction device
Procedure:
– Horizontal osteotomy
– Insertion of distraction rod from crestal direction
– Fastening of transport plate on transport segment with bone screws
Advantages:
– No donor site morbidity involved
– Quality of bone formed ideal for implant placement
– Increased vascularity & cellularity
– Vertical graft stability
– Shorter treatment time ( 1 mm bone regenerated/day)
Disadvantages:
– VD compromised
– Unesthetic appearance
– Sufficient width for bone placement
– Frequent post op visits
MISCELLANEOUS
Nerve relocation
Problem is persistent discomfort under denture
Sinus grafting or Maxillary sinus lift
Success rate ranging from 75-100%
Indicated in atrophic maxilla for the placement of endosseous implants
Procedure: Incision parallel to alveolar crest and creation of a 2-3 mm window above the
sinus floor. In fracture of window , Dissection of sinus membrane ,Creation of space for graft
placement (Cancellous chips) ,Tears in membrane sealed with collagen tape and Closure
Tissue sclerosing with sclerosing agent Sodium morrhuate can produce fibrosis in soft
hyperplastic tissue
PRE PROSTHETIC SURGERY FOR SPECIFIC PROSTHESES
Over denture:
Selection of teeth that should be retained that offers broad support
Thorough oral prophylaxis
Endodontic therapy
– For lowering crown not ratio (1:5)
Periodontal therapy
– To attain optimal level of attachment of attached gingiva
Amalgam plugs / cast copings with studs / bar attachments for increased retention
Immediate dentures
Thorough oral prophylaxis reduces post surgical edema and infection
Teeth modification
– To avoid interferences in determining VD
Patient planned for single immediate denture requires:
– Restorations
– Crowns
– RPD
– Endodontic treatment (immediate over denture)
– Other hard & soft tissues procedures
Implants
CAT scans (Simplant software)
– Detailed evaluation of:
Alveolar contour
Neurovascular positions
Sinus anatomy
Path of insertion of Zygomatic implants
– Information regarding bone volume & quality
– Fabrication of surgical stent
PREPROSTHETIC SURGERY FOR PARTIALLY EDENTULOUS ARCH
Extraction with alveolectomy
Removal of residual roots
Impacted & malposed teeth
Cysts and tumours
Exostoses & tori
Hyperplastic tissue
Muscle and freni attachments
Bony spines & knife edge ridges
Polyps, papillomas & traumatic hemangioma
Hyperkeratoses, Erythroplasia, and Ulcerations
Dentofacial deformity
Osseointegrated devices
Augmentation of alveolar bone
Periodontal surgeries
Crown lengthening surgeries
PREPROSTHETIC CONSIDERATIONS IN MAXILLOFACIAL SURGERIES
Team approach
Never cut interdentally , it can jeopardize adjacent tooth rather cut intradentally.
More conservative
Modification of prosthesis design
Ridge relationship discrepancies by orthognathic surgeries. For maxillary advancement
Lefort I osteotomy and for mandibular advancement and retrusion sagittal split osteotomy
is performed.
POST OPERATIVE VISIT
Diet – Soft diet wherever indicated, nutrient rich diet must be advocated.
Medication- analgesics and antibiotics
Oral irrigation during checkups
Rest
Splint and oral fixation wherever indicated
CONCLUSION
When severe bony atrophy exists, treatment must be directed at correction of the bony deficiency
and alteration of the associated soft tissue. When adequate bony tissue remains, improvement of
the denture-bearing area may be accomplished either by directly treating the bony deficiency or
by compensating for it with soft tissue surgery. The patient's health status must be carefully
evaluated, along with the ability and willingness to undergo these procedures including possible
long periods without dentures during healing phases.
REFERENCES:
1. Mandibular Cortical Bone Graft Part 2: Surgical Technique, Applications, and Morbidity;
Compendium • May 2007;28(5):274-281
2. Williamson RA. Rehabilitation of the resorbed maxilla and mandible using autogenous
bone grafts and osseointegrated implants. Int J Oral Maxillofac Implants. 1996;11:476-488.
3. Atwood DA. Bone loss of edentulous alveolar ridges. J Prosthet Dent 1971; 26: 266-271.
4. Wise M D. Stability of gingival crest after surgery and before anterior crown placement. J
Prosthet Dent 1985; 53: 20-23.