SUBMITTED BY THE STUDENT

‫نورهان احمد دعدوش‬

 • Prosthetics is the replacement of missing teeth (lost or
congenitally absent) and contiguous oral and maxillofacial
tissues, with artificial substitute.
• Now, there remains significant number of patients, who can
never be made to use dentures effectively, because of -
➢ Bone atrophy
➢ Soft tissue hypertrophy
➢ or localized soft and hard tissue problems.
INTRODUCTION
• In these patients' pre-prosthetic surgery offers significant
contribution by removing hindrance for prosthesis stability
and retention.
• It is always hoped that the results of the preprosthetic
surgery are acceptable both surgically & prosthodontically.
In this vein, the services of an oral and maxillofacial
surgeon may be required, especially as the surgical
preparation becomes more complicated. In these
instances, a team approach is needed with the surgeon
and the prosthodontist serving as equal members of the
team.
DEFINITION

• Pre-prosthetic surgery is carried out to

reform/redesign soft/hard tissues, by eliminating
biological hindrances to receive comfortable and
stable prosthesis.

• Preprosthetic surgery is defined as surgical

procedures designed to facilitate fabrication of a
prosthesis or to improve the prognosis of
prosthodontic care.
AIMS OF PRE-PROSTHETIC SURGERY

• Provide adequate bony tissue support for the placement of complete

dentures.
• Provide adequate soft tissue support, optimal vestibular depth.
• Elimination of pre-existing bony deformities e.g. tori, prominent
mylohyoid ridge, genial tubercle.
• Correction of maxillary and mandibular ridge relationship.
• Elimination of pre-existing soft tissue deformities, e.g. epulis, flabby
ridges, hyperplastic tissues.
• Maintain function
• Esthetics
SURGICAL METHODS
 Frequently, certain conditions of the denture
bearing tissues require edentulous patients to be
treated surgically. These conditions are the result
of unfavorable morphological variation the
denture bearing area or, more commonly, result
from long term wear of ill-fitting dentures. It is
often far easier to make alterations in the
prosthetic techniques and materials used than to
subject the
 patient to a surgical intervention. The key
consideration is whether a good prosthodontic
prognosis will result from the surgical outcome.
 1. Ridge alveoloplasty with or without extractions
for recontouring of the knife edged ridge or other
ridge deformity or contour problems.
2. Intraseptal alveoloplasty.
3. Maxillary tuberosity reduction.
COMMONLY USED
PERIPROSTHETIC 4. Recontouring of palatal and lateral exostosis and
contour problems these include: mandibular tori
PROCEDURES
removal; maxillary tori removal; mylohyoid ridge
reduction; and genial tubercle reduction.
5. 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 to fit into the
preprosthetic plan, and if the recontouring will be
made at the time of the extraction 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
recontouring, a side cutting rongeur or handpiece and
acrylic resin bur can be used, 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.
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. After adequate removal of bone, finger
pressure is applied in a constant, controlled manner until the
labiocortical plate is greensick fractured and can be positioned
palatally, narrowing the crest and eliminating the undercut. 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 maintain 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
edentulous 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.
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 . A full thickness flap is elevated to
completely expose the involved area. When an envelope flap will not provide the
necessary 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 exostosis, 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 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. 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 interarch distance posteriorly. The
tuberosities can be hyperplasic in the horizontal or vertical
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
contour 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. After making sure that all soft tissue
is protected, instrumentation can start.
 The tuberosity can be recontoured with bone file,
rongeur, or bur if a great deal of bone needs to be
MAXILLARY removed, again as in other procedures, a surgical
guide may be necessary. If the maxillary sinus has
TUBEROSITY pneumatized, care must be taken when removing the
REDUCTIONS bone and the sinus membrane may become exposed.
However, this is not a problem as long as the
membrane is intact.
MANDIBUIAR 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.
After all tori have been removed and bone
smoothed, the flap is repositioned and the lingual
plate palpated to confirm achieving the desired
contours.
MAXILLARY TORI

Maxillary tori may pose a significant problem in the fabrication and

wearing of a maxillary complete denture. The tori may be especially
problematic when it is positioned more posteriorly, creating problems with
posterior palatal seal of the prosthesis 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. 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 pedunculated 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.
MAXILLARY TORI
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 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.
 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

MYLOHYOID 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
RIDGE deviating toward the buccal, to avoid potential injury to the
lingual nerve. The flap is elevated to expose the mylohyoid
REDUCTION ridge and attached muscle. Using sharp dissection, the
tendenous attachments of the mylohyoid muscle are stripped.
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 superior 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. With exposure of the bone and protection 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.
CONCLUSION

The art of designing the soft- and hard-tissue framework for the smooth placement
of the prosthesis is a challenging task. This task is achieved by the meticulous
planning and execution of the planned presurgical procedures in a systematic
manner. The intimidating impressive trends of implantology might have downsized
the charm of preprosthetic surgery, yet in certain avenues the preprosthetic
surgical manoeuvres become inevitable. The magnitude of vestibuloplasty and
ridge augmentation procedures associated with the anticipated patient discomfort
should not demote the benefits of preprosthetic surgery in deserving patients,
where they suffer from pain or embarrassment by a juggling ill-fitting denture.
Such corrections may alter their present situations and successful denture
wearing is ensured. So it is not possible to completely thwart or baffle the
procedures belonging to the preprosthetic surgery as an obsolete one.
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