05Rahn_05(F) 5/26/09 10:25 PM Page 65

C H A P T E R

5 Pre-prosthetic
Surgical
Considerations
Dr. Henry Ferguson

65
05Rahn_05(F) 5/26/09 10:25 PM Page 66

66 Textbook of Complete Dentures

Surgical goals for treatment of patients should address the following factors: providing
the patient with the best possible tissue contours for prosthesis support, function, and
comfort; maintaining as much bone and soft tissue as possible; and doing this in the
safest, most predictable manner for the patient. With these goals in mind, we can then
work backward, with a concept of the final result, sequencing the treatment(s) that will
realize these goals. These goals can be reached through the achievement of specific
objectives, which include creating a broad ridge form, providing an adequate amount of
fixed tissue over the denture bearing areas, establishing adequate vestibular depth for
prosthetic flange extension, establishing proper inter-arch relationships and spacing,
supporting arch integrity, providing adequate palatal vault form, and when required, to
provide proper ridge dimensions for implant placement.

Patient Evaluation and Expectations

Prior to the performance of any procedure, several key steps must be performed. The
objective of a thorough patient evaluation, review of the past medical history, and physi-
cal evaluation is to identify treatment-modifying factors required for the safe and
uneventful treatment of the patient.
The physical examination includes thorough evaluation of the oral hard and soft
tissues and radiographs. This examination will reveal the difficulty of performing the
desired preprosthetic surgical procedures or even whether they are possible. For
instance, the referring dentist may desire that the patient receive a reduction of the
tuberosities but radiographic evaluation by the surgeon may reveal that this procedure is
not possible because of the position of the maxillary sinus.
Radiographically, the panoramic radiograph is the workhorse image for prepros-
thetic surgery. With this radiograph one can visualize many of the important anatomic
and structural relationships necessary to accurately create a treatment plan for prepros-
thetic procedures. For the mandible and maxilla in general, pathologic lesions, retained
roots, impacted teeth, and overall ridge morphology can be seen. For the mandible, rela-
tionships between the inferior alveolar canal and the ridge crest, and position of the
mental foramina to the ridge crest can be observed. For the maxilla, relationships
between the floor of the maxillary sinus and the alveolar crest, anterior nasal spine, and
the anterior maxillary alveolar crest can be determined. Additionally, the hard tissue
contribution versus soft tissue component of hyperplasic tuberosities can be determined.
Other radiographic images may be required when specific anatomic relationships need
to be observed.
For preprosthetic procedures and treatment plans, which may include implant
placement, more sophisticated, radiographic studies may be required. Tomographic
studies and computerized tomography (CT scans) may be used. The CT scan can provide
cross-sectional detail of the maxilla in both the axial and coronal views. This provides
excellent information regarding such important planning factors as alveolar height and
width, facial, lingual, and palatal alveolar contours, relationships between the maxillary
crests and the sinus floor and nasal floor, and the mandibular inferior alveolar canal and
mental foramina to the crestal bone.
05Rahn_05(F) 5/26/09 10:25 PM Page 67

Pre-prosthetic Surgical Considerations 67

Treatment Planning

With the desired preprosthetic surgery identified, and the physical evaluation and
radiographic examinations completed, a problem list is made. Treatment planning
now becomes the next critical step. No procedures should be performed without a
treatment plan designed to sequence and address the patient’s problem list. Based on
state of health, complexity of treatment plan, and level of anxiety, referral may be made
to place the patient in an environment where all of these important factors can be safely
addressed.
Goals for treatment should address the following factors: providing the patient
with the best possible tissue contours for prosthesis support, function, and comfort;
maintaining as much bone and soft tissue as possible; and doing this in the safest most
predictable manner for the patient. With these goals in mind we can sequence the treat-
ment(s) that will achieve these goals.

Review of Flaps

Access to and exposure of the surgical site is critical. The clinician’s tool for adequate
exposure is the full thickness mucoperiosteal flap. This aggressive surgical approach with
its greater visibility, protection of adjacent tissues, time efficiency, and more routine post-
operative course is far more valuable and less traumatic to the patient than other less
effective techniques. Diagnostic casts are excellent aids in outlining areas of surgical
focus and for flap design.
For most of the procedures a midline crestal incision is recommended. In edentu-
lous areas, there is usually a dense scar band on the crest of the ridge (Figure 5–1). This
tissue is stronger, more resistant to tears, and holds sutures well. When teeth are present

Figure 5–1 Midline crestal incision is recommended for

most flap procedures.
05Rahn_05(F) 5/26/09 10:25 PM Page 68

68 Textbook of Complete Dentures

and the surrounding soft tissues are to be included in the flap, a sulcular incision sharply
to bone is recommended. The reflection should be subperiosteal and deliberate. When
working around teeth, the papillae should be gently reflected, then the remaining
attached tissues in a uniform plane before attempting to reflect more apically. Being
deliberate, precise, and having patience will reward the clinician with a clean subpe-
riosteal dissection. The dissection should proceed apically as far as needed to visualize
the area of concern. Dissection antero-posteriorly should be made as necessary to
allow for elevation of the flap and appropriate exposure without placing tension on the
flap. Although envelope flaps are usually adequate for most procedures, if access is
a problem, both anterior and posterior releasing incisions are recommended. The base
of the flap must be wider than the crestal aspect so that blood supply to the flap will not
be compromised.
When the procedure is completed and the flap is repositioned, the clinician must
feel the underlying bony contours through the flap to ensure that the intended goal has
been reached. Then the flap is reelevated and copiously irrigated along the entire length
of the flap to remove all debris. Once the flap is anatomically repositioned, a suture is
used to secure the flaps position. Sutures are placed to approximate and not strangulate
the tissues.

Commonly Used Preprosthetic Procedures

Common preprosthetic procedures include ridge alveoloplasty with extraction(s);

ridge alveoloplasty without extractions for recontouring of the knife edged ridge or
other ridge deformity or contour problems; intraseptal alveoloplasty; maxillary tuberos-
ity reductions; recontouring of palatal and lateral exostosis and contour problems;
mandibular tori removal; maxillary tori removal; mylohyoid ridge reduction; and genial
tubercle reduction. Soft tissue procedures might include maxillary tuberosity soft tissue
reduction, maxillary labial frenectomy, mandibular lingual frenectomy, and excision of
redundant tissue.

Ridge Alveoloplasty with Extraction

After extraction of a tooth or teeth, the clinician must make a determination about the
appropriateness of the remaining ridge contour(s) to fit into the preprosthetic plan, and
if the recontouring will be made at the time of the extraction(s) or at a later time. If more
than finger compression is needed, a full thickness flap should be elevated to a point
apical to the area in need of recontouring. Depending on the amount of recontouring
needed, a bone file may be sufficient to produce the desired contours. For greater recon-
touring, a side cutting rongeur or handpiece and acrylic resin bur can be used (Figure
5–2). When using these burs, always use copious irrigation to avoid overheating the bone
and subsequent bony necrosis. Irrigation also cleans the flutes of the bur and carries away
debris. After bulk recontouring, a bone file is uses to “fine tune” the recontouring. Bone
files or rasps give the clinician a great tactile sense and good control. When finished, the
flap is repositioned, contours palpated to verify that a desired endpoint has been
reached, and is approximated primarily (Figure 5–3). When soft tissue recontouring is
needed, reposition the flap; observe where the adjustments are needed, and use a sharp
05Rahn_05(F) 5/26/09 10:25 PM Page 69

Pre-prosthetic Surgical Considerations 69

Figure 5–2 Bone rongeur used to accomplish bone reduc-

tion during a ridge alveoplasty along with extractions.

pair of scissors or surgical blade to make the cuts. It is usually more prudent to sequen-
tially remove small amounts of tissue than to remove too much at one time.
Consideration must also be given to maintenance of vestibular depth and form when
trimming and approximating the flap.

Intraseptal Alveoloplasty

When the ridge has acceptable contour and height but presents an unacceptable
undercut, which extends to the base of the labial vestibule, the intraseptal alveoloplasty
might be considered. This procedure is best accomplished at the time of extraction
or early in the postoperative healing period. After extraction of the teeth, the crestal
tissue is slightly elevated to fully expose the extraction sockets. Using a small rongeur
or handpiece and bur, the intraseptal bone is removed to the depth of the socket

Figure 5–3 Primary closure of the flap following extrac-

tions and ridge alveoplasty.
05Rahn_05(F) 5/26/09 10:25 PM Page 70

70 Textbook of Complete Dentures

Figure 5–4 Interseptal alveoplasty during extraction

procedures.

(Figure 5–4). After adequate removal of bone, finger pressure is applied in a constant,
controlled manner until the labiocortical plate is greenstick fractured and can be posi-
tioned palatally, narrowing the crest and eliminating the undercut. If significant resist-
ance is encountered, a vertical cut in the bone can be made using osteotome or bur from
inside the most distal sockets outward, carefully scoring the bone. Periosteum and soft
tissue should not be violated. Finger pressure should be applied to the area of the verti-
cal bone cut to achieve mobility of the segment and guide its repositioning. A bone file
can be used to smooth roughened edges, and the site can be irrigated. The crestal soft
tissue can now be approximated and closed with interrupted or continuous sutures.
Ideally, a surgical stent or soft-tissue-lined immediate denture can be inserted to main-
tain the repositioned bony segment until the initial stages of healing have taken place, at
about two weeks after the procedure.

Edentulous Ridge Alveoloplasty

For routine elimination of sharp (knife-edged) ridges and removal of undesirable

contours, undercuts, or prominences, direct vision and frequent palpation until the
desired endpoint is reached will be sufficient. When the mandibular or maxillary eden-
tulous ridges require multifocal, moderate, or greater amounts of recontouring, use of
diagnostic casts to identify areas of concern, and fabrication of surgical guides, are
recommended. In this way, the clinician has a model with the specific areas outlined to
assist in the exact orientation once tissues are reflected and, if necessary, a surgical guide
to assist with the detailed removal and recontouring of the bone.
The edentulous ridge alveoloplasty begins with identification of the areas of
concern. A full thickness flap is designed and implemented to fully expose the targeted
areas. Using bone files/rasps, rongeurs handpiece, and burs or combinations, the
targeted areas are recontoured. Digital palpation with the flap in place is done until the
desired endpoint is achieved. The site is irrigated and close primarily with an interrupted
or continuous suture technique.
05Rahn_05(F) 5/26/09 10:25 PM Page 71

Pre-prosthetic Surgical Considerations 71

Figure 5–5 Marking the midline crestal incision to be

used for access to remove buccal exostosis on the
mandibular ridge.

Buccal Exostosis

This approach can be used on either arch and for irregularities on the palatal aspect of
the maxillary alveolus. A crestal incision is made to extend beyond the margins of the
areas requiring recontouring (Figure 5–5). A full thickness flap is elevated to completely
expose the involved area (Figure 5–6). When an envelope flap will not provide the neces-
sary exposure without placing tension on the flap, a releasing incision, as described
earlier, may be incorporated into the flap design. For gaining assess to a palatal exosto-
sis, make the incision longer and reflect more tissue to gain enough relaxation in the
flap. Because of the greater palatine and incisive branch anastomosis, vertical releases in

Figure 5–6 Elevation of full thickness flap to expose

buccal exostosis, which will be recontoured prior to
prosthodontic procedures.
05Rahn_05(F) 5/26/09 10:25 PM Page 72

72 Textbook of Complete Dentures

Figure 5–7 Exposed exostosis demonstrating the use of a

rotary instrument for recontouring. Note retractor provid-
ing exposure of operating site and protecting adjacent soft
tissue.

the palate area not recommended. Once the irregularity is exposed, the tissue is elevated
and protected, and the appropriate instrument is used to recontour the bone to the
desired endpoint (Figure 5–7). The area is palpated through the flap to confirm
adequate reduction or recontouring. When completed, the area is irrigated and closed.

Maxillary Tuberosity Reductions

Maxillary hyperplasic tuberosities present real problems for gaining appropriate inter-
arch distance posteriorly. The tuberosities can be hyperplastic in the horizontal or verti-
cal planes, and may involve osseous hyperplasia, soft tissue hyperplasia, or both. To
identify the hard tissue and soft tissue component that requires recontouring, a
panoramic radiograph will usually suffice. This will provide information about the hard
and soft tissue contributions and the overall contours of the tuberosity and proximity to
the maxillary sinus. It is important to remember that maxillary sinuses may pneumatize
into the tuberosity areas. A crestal incision is made from a point anterior to where the
recontouring will start, over and up behind the tuberosity. Tissue must be elevated on
both the buccal and palatal aspects to fully expose the tuberosity (Figure 5–8). After
making sure that all soft tissue is protected, instrumentation can start (Figure 5–9). The
tuberosity can be recontoured with bone file, rongeur, or bur (Figures 5–10 and 5–11).
If a great deal of bone needs to be removed, again as in other procedures, a surgical
guide may be necessary. If the maxillary sinus has pneumatized, care must be taken when
removing the bone, and the sinus membrane may become exposed. However, this is not
a problem as long as the membrane is intact.

Mandibular Tori

In the dentate arch, tori pose few, if any, problems. Occasionally tori can be large enough
to interfere with tongue mobility and speech, and the thin mucosa overlying the tori
may be chronically irritated or injured when eating certain foods. In the edentulous arch,
tori may pose significant interference when wearing a removable prosthesis and often
must be removed.
05Rahn_05(F) 5/26/09 10:25 PM Page 73

Pre-prosthetic Surgical Considerations 73

Figure 5–8 Arrow indicates a bony undercut on the lateral

surface of the maxillary tuberosity.

Figure 5–9 Tissue flap is elevated to expose bony under-

cut (arrow) that requires recontouring.

Figure 5–10 Arrow indicates recontoured buccal bone

with the undercut eliminated.
05Rahn_05(F) 5/26/09 10:25 PM Page 74

74 Textbook of Complete Dentures

Figure 5–11 Before (A) and after (B) recontouring the

buccal bone to eliminate an undercut on the lateral aspect
of the maxillary tuberosity.

A midline crestal incision is made to extend about 1.0 -1.5 cm distal to the most
posterior tori, to decrease tension and tearing of the flap. A full thickness lingual
mucosal flap is slowly elevated. Because the tori may be pedunculated, dissection of the
very thin mucosa located in the undercuts may be tenuous. However, like other proce-
dures discussed, patience and a steady hand will prevail. After elevating all mucosa off of
the tori(s) to a point below the tori where normal lingual cortical anatomy is found, a
tissue retractor must be placed to maintain exposure and protect the flap. If an
osteotome slips, it should hit the retractor and not perforate the floor of the mouth.
Similarly, the tissue must be out of the way when using a rotary instrument and bur. For
smaller tori, bone file and rongeur or rotary instrument and bur may be used for bone
reduction (Figure 5–12).

Figure 5–12 Removal of a mandibular tori. The arrow

(A) indicates the reflected tissue flap and the arrow (B)
indicates the bony projection to be removed with the
osteotome.
05Rahn_05(F) 5/26/09 10:25 PM Page 75

Pre-prosthetic Surgical Considerations 75

After all tori have been removed and bone smoothed, the flap is repositioned and
the lingual plate palpated to confirm achieving the desired contours. Use the suture
technique of choice, but because of the length of the incision, a continuous suturing
technique with good margin inversion is recommended. To minimize hematoma forma-
tion 4x4 gauze is rolled into the appearance of a cigar, the tongue is elevated to the roof
of the mouth, and the gauzed is placed under the anterior aspect of the tongue over the
repositioned sutured flap. Have the patient lower the tongue. The weight of the tongue
will push the gauze down and forward, pushing the gauze against the flap and the flap
against the bone. These will tamponade any small oozing and eliminate dead space.

Maxillary Tori

A maxillary tori may pose a significant problem in the fabrication and wearing of a maxil-
lary complete denture. The tori may be especially problematic when it is positioned more
posteriorly, creating problems with posterior palatal seal of the prosthesis (Figure 5–13).
A midline incision is placed over the torus with oblique releasing incisions at each end.
When the tori are multilobulated and pedunculated, elevation of the thin mucosa may
be difficult. After the torus is exposed, adequate flap control for best visualization is
important (Figure 5–14A). An excellent method of keeping the flaps open is to suture
the margin of the flap to the crest of the ridge on the same side. For some larger pedun-
culated multilobulated tori, a midcrestal incision with elevation of the entire palatal
mucosa is recommended. This dissection must stay subperiosteal to avoid injury to the
palatal blood supply. The desirable end point is for the palatal vault to be smooth and
confluent with no undercuts or elevations (Figure 5–14B).
The margins of the flap are digitally positioned and pressed against the bone.
Removal of redundant tissue can now be performed, keeping in mind that all bone must
be covered with tension-free closure. Also keep in mind that the thin mucosa overlying
the torus does not hold a suture well, so margin trimming should be conservative or not
at all (Figure 5–15). Hematoma formation in the palate under the flap is a great concern.
Excellent methods of applying pressure are with the placement of a temporary denture

Figure 5–13 Maxillary tori extending into the posterior

palatal seal area.
05Rahn_05(F) 5/26/09 10:25 PM Page 76

76 Textbook of Complete Dentures

Figure 5–14 Pedunculated bony tori exposed by elevating

subperiosteal flaps (A) Smooth palate created by the tori
removal (B)

with soft reline material over the surgical site or with a well-fitting, surgical guide with soft
reline placed over the area. The pressure should be maintained for several days. The
patient can remove the appliances for local wound care and oral rinsing.

Mylohyoid Ridge Reduction

In the mandibular post-extraction ridge remodeling sequencing, the alveolar bone and
external oblique ridge resorb because of lack of stressing and functional remodeling.
The mylohyoid ridge, which supports the attachment of the mylohyoid muscle, remains
relatively intact, and becomes a prominent feature in the posterior mandible.
After providing profound anesthesia, a midcrestal incision is made anterior to the
site of ridge reduction and carried posteriorly gradually deviating toward the buccal, to

Figure 5–15 Primary closure achieved after bony recon-

touring is complete.
05Rahn_05(F) 5/26/09 10:25 PM Page 77

Pre-prosthetic Surgical Considerations 77

avoid potential injury to the lingual nerve. The flap is elevated to expose the mylohyoid
ridge and attached muscle. Using sharp dissection, the tendenous attachments of the
mylohyoid muscle are stripped. The muscle will retract into the floor of the mouth and
reattach during healing. A bone bur can be used to reduce the ridge to the desired
height. A bone file can be used to fine-tune the contouring. When completed, the area
should be copiously irrigated and closed primarily with interrupted or continuous
sutures. Once the flap has been closed, ideally a denture with a soft reline is placed to
allow for the lingual flange to help with displacement of the detached mylohyoid muscle.

Genial Tubercle Reduction

In the post-extraction ridge remodeling of the anterior mandible, the alveolar ridge and
tooth-bearing areas resorb because of lack of stressing and functional loading. The supe-
rior pair of genial tubercles provides insertion for the paired genioglossus muscles, while
the lower paired tubercles provide insertion for the paired geniohyoid muscles. Because
of the constant movement of the tongue and stressing of the tubercles once the alveolus
has resorbed and remodeled, the genial tubercles can become very prominent structures
in the anterior mandible and impede proper seating of the denture.
The clinician must be aware that this surgical site lies between two moving
structures—the tongue and the lip. Therefore this is an area that may be prone to wound
dehiscence, making this a very difficult surgery.
A full thickness flap is elevated to expose the genial tubercle and genioglossus
muscle attachments. The tendenous muscular attachments are sharply detached from
the bone to randomly reattach more inferiorly. With exposure of the bone and protec-
tion of the flap, the bone height can be reduced with the instrument of choice to the
desired level. The wound is copiously irrigated and closed primarily.

Soft Tissue Procedures

With loss of teeth, bony resorption, and remodeling, soft tissue relationships that existed
with teeth and were not problematic may become concerns. With reduction of ridge
height and contour, soft tissue and muscular attachments change. These muscular and
soft tissue changes are often deleterious to prosthesis stability and function, and require
removal or alteration. Additionally, with the potential trauma and chronic irritation
caused by ill-fitting prostheses, the development of hyperplastic tissues in the denture-
bearing and peripheral tissue areas may occur. These hyperplastic tissues contribute to
lack of denture fit and stability, and can contribute to patient discomfort.
Because it is very difficult to replace oral mucosa after it has been removed, the
treatment plan must detail the sequence in which the soft tissue abnormalities will be
addressed. Treatment will usually address the bony abnormalities first, to achieve normal
bone healing with good soft tissue coverage. Additionally, if implant placement is part of
the treatment plan, bone augmentation may be required. Preserving redundant soft
tissue to provide coverage for bone augmentation should be considered. The soft tissue
issues may be addressed after the grafting and or implants have healed. In general,
excised, redundant hyperplastic soft tissues are the result of chronic irritation from an ill-
fitting prosthesis. However, because of the chronic irritation, pathologic changes within
05Rahn_05(F) 5/26/09 10:25 PM Page 78

78 Textbook of Complete Dentures

the tissues can occur. Therefore, as a rule, a portion of all excised hyperplastic tissues
should be submitted for histopathologic examination.

Maxillary Soft Tissue Tuberosity Reduction

Interarch distance is a critical element for proper fabrication of denture bases, and
hyperplastic maxillary tuberosity tissues often impinge on adequate interarch distance.
To determine if the reduction will be primarily bone or soft tissue, a panoramic radi-
ograph that can discriminate the soft tissue shadow from bone is required. If not avail-
able, sounding of the soft tissue with the anesthesia needle after the region is
anesthetized will provide the clinician with detail of the tissue thickness. If a great deal
of tissue removal is anticipated, a surgical guide is recommended.
A midline elliptical incision is made sharply to bone with the widest part of the
ellipse directly over the area where the most tissue is to be removed. The anterior and
posterior portions of the ellipse should taper into the normal portions of the ridge ante-
riorly and to the posterior tuberosity posteriorly. The ellipsed portion is elevated and
removed. The clinician can now look into the area made by the removed section of tissue
and evaluate the tissue height above the bone. Directing attention to the buccal and
palatal edges of the incision, the clinician will thin the tissue by removing a uniform
thickness—staying an even distance from the surface and remembering to adjust the
angle while thinning around the curve. Buccally, there are no structures of concern to
the clinician as he/she makes contact with the bony lateral aspect of the ridge. Palatally,
the clinician needs to be careful not to extend the thinning too deep into the palatal
aspect of the ridge because of the greater palatine neurovascular bundle. Once the
excess tissue has been removed and there is a uniform thickness of mucosa, digital pres-
sure will approximate the buccal and palatal flap margins to evaluate the amount of verti-
cal reduction that has been accomplished. Having the patient close down gently on the
clinician’s fingers will allow for evaluation of the change in interarch distance. If the verti-
cal reduction is acceptable, the wound margins are approximated and trimmed to get a
tension-free butt joint closure. The wound is closed with an interrupted, or continuous,
suture technique.
If the tissue has been thinned and no additional vertical change is possible within
the soft tissue, and yet more is needed, then the flaps will need to be reflected buccally
and palatally. Bony reduction will need to be done to achieve the desired vertical change.
(Refer back to bony tuberosity reduction).

Maxillary Labial Frenectomy

Labial frenal attachments are thin bands of fibrous tissue/muscle covered with mucosa
that extend from the lip or cheek and attach into the periosteum on the sides of, or the
crest of, the alveolar ridge. Except for frenal attachments, which attach at the incisive
papillae and contribute to the midline diastema, most frenal attachments—like other
soft tissue structures—are of little consequence when teeth are present. On the edentu-
lous ridge, which has experienced resorption and remodeling, the muscular and soft
tissue attachments may directly affect the seating, stabilization, and construction of the
prosthesis, as well as subject the patient to reduced function and discomfort. Although
this is a simple technique, it yields great benefit.
Although other techniques exist, the following is recommended for a simple
frenectomy. Infiltration anesthesia to the lip around the frenum is usually adequate.
05Rahn_05(F) 5/26/09 10:25 PM Page 79

Pre-prosthetic Surgical Considerations 79

Injecting directly into the frenum may distort the anatomy. After achieving good anes-
thesia, two small, curved hemostats are placed with the curved sides against the tissues
over the superior aspect of the frenum and the inferior aspect of the frenum. The tips of
the hemostats will touch in the deep aspect near the vestibule. A surgical assistant should
suction and retract the lip superiorly. Holding the top hemostat, the clinician will use a
surgical blade and follow the curvature of the upper hemostat, cutting through the
upper aspect of the frenum (Figure 5–16). This is repeated for the lower hemostat. The
frenum will now be excised, leaving a diamond-shaped wound (Figure 5–17). Exploring
the wound, any frenal remnants should be excised directly to periosteum. A suture is
placed through the wound margin engaging the periosteum in the depth of the vestibule
right below the anterior nasal spine. A knot is tied and the margins will be drawn
together and pulled down to the periosteum in the depth of the vestibule. Additional
sutures are placed in a similar manner so that the diamond-shaped wound now closes in
a linear manner (Figure 5–18). If the frenum extended to the crest of the ridge and was

Figure 5–16 Maxillary labial frenectomy using two curved

hemostats as guides for tissue excision.

Figure 5–17 Maxillary labial frenectomy after tissue

excision prior to primary closure.
05Rahn_05(F) 5/26/09 10:25 PM Page 80

80 Textbook of Complete Dentures

Figure 5–18 Maxillary labial frenectomy primary closure

with sutures.

excised thorough attached tissue, all parts of the wound will close primarily except that
part in the attached tissue. No attempt should be made to close that area and it should
be left to granulate and heal by secondary intention.

Excision of Redundant/Hypermobile Tissue Overlying the Tuberosities

Redundant hypermobile tissue is often the result of ill-fitting dentures, ridge resorption,
or both. After identifying the area to be excised, parallel incisions on the buccal and
lingual or palatal aspects of the tissue are made sharply to bone. The incisions will taper
into each other posterior to the area to be incised. The excised piece of tissue will be
dissected from the bone and removed. Digital pressure is applied to check for primary
closure of the wound margins. If additional tissue needs to be removed, tangential inci-
sions on the buccal and palatal, or lingual, sides of the wound are made to remove and
thin out additional tissue. This is done carefully until the wound margins approximate
primarily. The wound is irrigated and closed primarily. Care should be taken to avoid
significant undermining of the buccal/facial aspects of the flaps, and loss of vestibular
depth when closing the wound.

Excision of Inflammatory Fibrous Hyperplasia (Epulis Fissuratum)

Inflammatory fibrous hyperplasia is a generalized hyperplastic enlargement of the

mucosa and fibrous tissue in the alveolar ridge and vestibular area. The etiology is most
closely associated with chronic trauma to the involved areas from ill-fitting prosthesis.
Inflammatory fibrous hyperplasia progresses in stages, and the surgical procedure indi-
cated varies with the stage. For those lesions in the early stages, there is not a significant
degree of fibrosis of the involved tissues, and nonsurgical therapies may be effective.
In the later stages where there is significant fibrosis and hyperplastic changes, excision of
the hyperplastic mass of tissue is the treatment of choice (Figure 5–19).
Several treatment options exist based on the size of he hyperplastic mass of tissue
to be removed. If the tissue mass is not extensive, use of lasers or electrosurgery
05Rahn_05(F) 5/26/09 10:25 PM Page 81

Pre-prosthetic Surgical Considerations 81

Figure 5–19 Inflammatory fiberous hyperplasia in the

maxillary labial vestibule.

techniques provides good results for tissue excision. For more extensive tissue masses,
the margins of the tissue mass are elevated using tissue forceps, and an incision is made
at the base of the mass, but not through the periosteum. A supraperiosteal dissection is
made under the entire mass of the hyperplastic tissue, and the mass is removed.
The normal mucosal margins are sutured in place, and the superior margins are
sutured to the depth of the vestibule. In order to minimize soft tissue creeping and loss
of vestibular height with secondary intension healing, a surgical stent with an extended
anterior flange lined with soft tissue conditioner, or the existing denture with the flange
extended to engage the height of the vestibule. A soft tissue conditioner should be
placed, and the prosthesis should only be removed for wound care and rinsing, and
cleansing of the intaglio surface of the prosthesis. Secondary epithelialization will take
four to six weeks.

Inflammatory Papillary Hyperplasia of the Palate

Inflammatory papillary hyperplasia of the palate is a condition affecting the palatal

mucosa, thought to be caused by ill-fitting prosthesis, poor hygiene, or fungal infections
and the associated inflammation. Its clinical presentation appears as multiple nodular
projections in the palatal mucosa. The lesions may be erythematous or may have normal
palatal mucosal coloration (Figure 5–20).
Early treatment consists of prosthesis adjustments, tissue conditioner, and proper
oral hygiene. In more advanced presentations, several treatment options have been
suggested. Because this is primarily an inflammatory disorder, there is no need to excise
the full thickness of the palatal tissue. In any of the described treatment options, the
superficial inflamed layers of the palatal mucosa are removed leaving the palatal perios-
teum intact to heal by secondary intension. These techniques include removal of the
inflamed mucosa with electrosurgery loops, laser ablation of the superficial layers, sharp
dissection, use of coarse fluted burs, or dermabrasion brushes to bur or abrade this layer,
and cryotherapy (Figure 5–21). As mentioned earlier, no matter which technique is used,
care should be taken to ensure that the periosteum is not violated and the underlying
bone is not involved. The palate is covered with a surgical stent or denture with a soft
05Rahn_05(F) 5/26/09 10:25 PM Page 82

82 Textbook of Complete Dentures

Figure 5–20 Inflammatory papillary hyperplasia of the

palate.

Figure 5–21 Inflammatory papillary hyperplasia removed

using cryotherapy.

tissue conditioner to assist with patient comfort and provide coverage while secondary
epithelialization takes place in the following four to six weeks.

Surgical Guides (Templates)

When moderate amounts of bone recontouring are required and the treatment plan
requires a degree of precision in the amount and location of bone to be removed, surgi-
cal guides are excellent adjuncts. Using a duplicated diagnostic cast, the areas of concern
are modified to achieve the ideal ridge form. A clear rigid guide is then fabricated using
a vacuum-formed technique. During the surgical procedure, after recontouring has been
accomplished, the surgical guide is placed over the area with the flap repositioned, and
05Rahn_05(F) 5/26/09 10:25 PM Page 83

Pre-prosthetic Surgical Considerations 83

areas of soft tissue blanching are observed. These blanching areas represent areas where
additional removal of bone and recontouring are still required. This procedure is
repeated until no blanching exists and the surgical guide is stable when seated. Soft tissue
trimming, if necessary, can now be done.

References
Miloro, M., Ghali, G.E., Larsen, P.E., Waite, P.D.: Peter’s Principles of Oral and Maxofillial Surgery,
Hamilton, Ontario: BC Decker Inc., pp. 157-188.
Ochs, M.W., Tucker, M.R.: Preprosthetic Surgery In: Contemporary Oral and Maxillofacial Surgery,
4th Ed, St. Louis, MO: Mosby Publishing pp. 248-304.
Peterson, L. J., Indresano, A.T., Marciani, R.L., Roser, S.M.: Principles of Oral and Maxillofacial
Surgery, Volume 2, Philadelphia, PA: Lippencott Company, pp. 1103-1132.
Spagnoli, D.B., Gollehon, S.G., Misiek, D.J.: Preprosthetic and Reconstructive Surgery
In: Principles of Oral and Maxillofacial Surgery 2ed., Hamilton, Ontario: B.C. Decker, Inc.,
pp. 157-187
Tucker, M.R.: Ambulatory Preprosthetic Reconstructive Surgery In: Oral and Maxillofacial Surgery
Volume 3, St Louis, MO.: Mosby Publishing, pp. 1103-1132.

QUESTIONS

1. What other diagnostic imaging might be used for preprosthetic surgery treat-
ment planning besides typical panographic radiographs?
2. Surgical access is often gained through the use of full thickness mucope-
riosteal flaps. What are the advantages to this surgical approach over other
flap techniques?
3. What three instruments are commonly used for recontouring bone during
preprosthetic surgery?
4. True or False: Maxillary tori may present more of a problem for a complete
denture patient if it extends past the vibrating line where the posterior
palatal seal is usually placed.
5. What techniques can be used to remove inflammatory papillary hyperplasia
after controlling the causative factors?
05Rahn_05(F) 5/26/09 10:25 PM Page 84

84 Textbook of Complete Dentures

ANSWERS
1. Tomographic studies and computerized tomography (CT Scans) may be
used. The CT scan can provide cross-sectional detail of the maxilla in both
the axial and coronal views.
2. This aggressive surgical approach with its greater visibility, protection of adja-
cent tissues, time efficiency, and more routine post-operative course is far
more valuable and less traumatic to the patient than other less effective
techniques.
3. a. bone file b. side-cutting rongeur c. handpiece and bur
4. TRUE
5. a. electrosurgery loops b. laser ablation c. sharp dissection to periosteum
d. dermabrasion brushes e. cryotherapy