PRE- PROSTHETIC

SURGERY

Dr.SREEJITH V P

Professor & Head

KANNUR DENTAL COLLEGE

Consultant Maxillofacial surgeon

 CONTENTS
● Introduction
● Definition
● Aims of preprosthetic surgery
● Goals of preprosthetic surgery
● Classification
■ Ridge correction procedures
■ Ridge extension procedures
■ Ridge augmentation procedures
● Conclusion
● Previous Question papers
● Take home message
● References
 INTRODUCTION
• Pre-prosthetic surgery is an integral part of
oral and maxillofacial surgery and
prosthodontics.

• It comprises both basic procedures and

sophisticated techniques of reconstructions
and rehabilitation of oral and maxillofacial
region.

• The treatment planning, therefore, should

involve coordination between the
prosthodontist and oral maxillofacial
surgeon.

• As the goal of the prosthetic appliance

construction is to improve functions and
esthetics.
 IDEAL EDENTULOUS RIDGE
Goodsell had recommended the following criteria for a healthy
and ideal edentulous ridge for dental rehabilitation:
• Adequate bony support for the denture- adequate
width,height and U-shape.
• The bone should be covered with adequate soft tissue
• The ridge should not have any undercut or sharp ridges.
• No bony or soft tissue protuberances should be present.
• It should have adequate buccal and lingual sulci depth.
• Ridge Should not have any scar bands that prevent normal
seating of denture.
• No muscle fibers or frena should dislodge the prosthesis.
• Relation of maxillary and mandibular ridge should be
satisfactory in all planes.
• No soft tissue hypertrophies or redundancies should be
present on the ridge or sulci.
 What changes occur once teeth are lost ?

No functional stimulation of alveolar process, so resorption

process dominates

Reduction in height of residual ridges

Increase in interarch distance

Maxillary ach becomes narrower and mandibular arch becomes

wider

Mandible is subjected to early atrophy and to a greater extent

than maxilla
 PREPROSTHETIC SURGERY
“ Surgery performed to reform or redesign soft/hard tissues, by eliminating
biological hindrances to receive comfortable and stable prosthesis.”
GOALS OF PRE-PROSTHETIC SURGERY
1. To modify the oral environment to render it free of disease
and to make its form and possibly the function more
compatible.

1. Provide a broad and flat ridge form with vertical height

(minimum 5 mm) provided by nearly parallel, non-undercut
bony walls in maxilla and mandible.

1. Provide a firm resilient mucosal covering.

1. Provide ideal inter-arch distance (minimum 16-18 mm).

 GOALS OF PRE-PROSTHETIC SURGERY

5. In the severely bony deficient mandible, provide bone

bulk for strength and protection of the neurovascular
bundles in bony dehisced mandibular canals.

5. Provide an arched palatal vault.

5. Provide post tuberosity (hamular) notching to enhance

the posterior border seal and resistance of the denture to
anterior dislodging forces.

8. Freedom from neoplastic disease.

AIM
 CLASSIFICATION OF PREPROSTHETIC
PROCEDURES
Classification I

1. Alveolar ridge correction

- Soft tissues correction
- Hard tissues correction
2. Alveolar ridge extension
3. Alveolar ridge augmentation

Classification II
1. Basic procedures
2. Advanced procedures
1. Alveolar ridge correction
2. Alveolar ridge extension
3. Alveolar ridge augmentation
2. Alveolar ridge extension
3. Alveolar ridge augmentation
 EVALUATION OF SUPPORTING SOFT
TISSUE

● Assessment of quality of tissue

● Differentiating keratinized tissue from poorly

keratinized / freely movable tissue

● Palpation discloses hypermobile fibrous tissue

inadequate for stable denture base

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Vestibular areas:
● Free of inflammatory changes / scarred /
ulcerated areas – denture pressure
● Tissue at depth should be supple without
irregularities
● Tensing – note soft tissue attachments (frena)

Lingual areas:
● Inspect with mouth mirror
● Observe the level of attachment of mylohyoid
muscle to crest of mandibular ridge
● Attachment of genioglossus

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 I.
RIDGE CORRECTION
PROCEDURES
 Ridge correction procedures

1. Alveoloplasty
1.Buccal and labial alveoloplasty
2.Deans interseptal alveoloplasty
3. Obwegeser technique
2.Excision of Tori
1. Torusmandibularis
2. Torus palatinus
3.Reduction of Genial tubercles
4.Reduction of mylohyoid ridge
5.Maxillary tuberosity reduction
6.Exostosis removal
 1.Ridge correction Procedures
1.Excision of Hyperplastic/Hypermobile
tissue
● Infiltration local anesthesia in selected areas.
● Sharp excision parallel to the defect in a supraperiosteal fashion
allows for removal of mobile tissue in accepted levels.
● Beveled incision may be needed to blend the excision with
surrounding adjacent tissue and maintain continuity to the
surrounding soft tissue.
● Closure with resorbable suture to approximate residual tissues.
● Impression for prosthesis should proceed after 3 to 4 weeks.
FIBROUS HYPERPLASIA OF PALATAL
MUCOSA

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FIBROUS HYPERPLASIA OF MANDIBULAR
RETROMOLAR PAD

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18
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2.Maxillary soft tissue tuberosity
reduction

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 1.Ridge correction Procedures
2.Inflammatory papillary hyperplasia of palate

● Mechanical irritation, poor hygiene, fungal infection

● Appears as multinodular projections in the palatal
tissue
● Treatment
■ Initial stage – denture adjustment with tissue
conditioner
■Electro surgical excision
■Dermabrasion 21
Inflammatory Papillary Hyperplasia
23
1.Ridge correction Procedures

3.Frenectomy
1.Labial Frenectomy

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1.Labial Frenectomy

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Labial frenectomy with
Z-plasty

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2.Lingual frenectomy

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 1.Ridge correction Procedures
4.Surgical repostioning of the mental nerve

● A long incision is made on the crest of the residual

ridge.
● A vertical groove is made in the cortical bone beneath
the mental foramen with a dental drill.

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● The cut is made in the
cortical bone only.
● When the osseous
preparation is completed,
the neurovascular bundle is
repositioned carefully in the
cortical groove of the newly
formed foramen.
● Absorbable hemostatic
gauge such as surgicel may
be placed over the
neurovascular structures to
maintain them in new
position.

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 1.RIDGE CORRECTION PROCEDURES
Hard tissues
1. ALVEOLOPLASTY
● Types of Alveoloplasty :
■ Alveolar compression
■ Simple Alveoloplasty
■ Buccal & labial Alveoloplasty
■ Deans intraseptal Alveoloplasty
■ Obwegeser’s technique
 a. Alveolar compression

● Easiest & quickest form of Alveoloplasty

● Here the inner & outer cortical plates are compressed

between the fingers.

● More effective in young patients, it should be done after

every extraction.

● It reduces the width of socket & eliminates many

undercuts.
 B. SIMPLE ALVEOLOPLASTY
● Done usually in isolated overerupted tooth.
C .BUCCAL & LABIAL ALVEOLOPLASTY
D .DEANS INTRASEPTAL ALVEOLOPLASTY
The principle of this technique are
1) The prominence of the labial & buccal alveolar margin is
reduced to facilitate the reception of denture.

2) The muscle attachment are undisturbed. And periosteum

remains intact.

4) The cortical plates are preserved as a viable onlay bone

graft with intact blood supply.

5) Because cortical plate is spared post operative resorption

is minimum.
4. With periosteal elevator / osteotome placed into the base
of the canine socket bilaterally, labial cortex is
fractured.

5.Digital pressure is used to compress the fractured labial

cortex into palatal direction.

6. Any sharp margins of newly created alveolar crest are

filed with bone file.

7. Interrupted or continuous suturing is carried out.

 E .OBWEGESER’S TECHNIQUE
● Obwegeser further(1966) modified DEAN’S technique
for extreme premaxillary protrusion
1. Teeth are removed atraumatic.
2. Sockets are connected by removing interdental septal
bone with bur or rongeur.
3. With large pear shaped or round bone bur, the sockets
& their interconnecting trough is enlarged.
4. Both labial & palatal plates are cut with burs in the
cuspid area to weaken the bone & to form the three
sided bone flaps in cortical plates.

5. Small mounted disk is inserted into the socket & trough

to score, or groove, labial & palatal plates, horizontally
weakening them along the proposed fracture line.
6. A pair of flat elevators is inserted into the
sockets & their connecting trough, is
used to fracture the labial plate labially &
palatal plate palatally.

7. Finger pressure then is used to mould

the alveolar process in the desired
shape.

8. Sutures close the gingiva over the socket

 2.EXCISION OF TORI

● Torus is exostosis / overgrowth of cortical /

corticocancellous bone, which is localized to particular
area, it is usually benign asymptomatic & slow growing.

● In maxilla usually seen in the midline of palate, in

mandible usually seen bilateral in premolar region on the
lingual aspect.

● usually single smooth elevation to multiloculated

pedunculated bony masses.
A.PALATAL TORUS

1.Bilateral greater palatine & incisive nerve block.

2.Anteroposterior linear incision is made in the midline of the palate.

3.Y shaped releasing incision at one or both the ends of the incision.

4 mucoperiosteal flaps are raised with periosteal elevators.

5.Retraction suture are placed on both the flaps to maximize the

exposure.
6. Division of the torus in multiple segments should be
done with the burs.
7. Small pieces should be removed with chisel and mallet.
8. Final finishing should be done with round bur.
9. Excess soft tissue should be trimmed .
10. Flap should be closed with continuous over & under
suturing.
11. Prefabricated acrylic stent/ splint.
B.TORUS MANDIBULARIS:

● Mandibular torus is an exostosis that usually occurs bilaterally on the

lingual surface of the body.

● Generally located in canine –premolar region.

● Origin unknown, thought to be functional reaction to masticatory stress.

● Composed mainly of cortical bone with minimal medullary bone.

● When they become large they may cause Speech impairment or

difficulty in eating.
● When covering mucosa ulcerates as a result of trauma & fails to heal.

● To facilitate the construction of RPD or CD

TECHNIQUE
1. Area is anaesthetized
2. Incision is made on the crest of the alveolar process
from molar to incisor.
3. Mucoperiosteal flap is reflected care full as the mucosa
is very thin over the tori.
4. Make a purchase point / groove with the bur, on the
medial aspect of the tori parallel to the medial aspect
from base to the superior margin.
5. Cleavage taken with osteotome placed in the purchase
groove.

6. Gentle tapping to excise the entire torus.

7. Smoothening with round bur / bone file.

8. Irrigation and suturing done

 3.REDUCTION OF THE GENIAL TUBERCLES

● Due to gross resorption of the mandibular ridge, the level of

tubercle will be seen at the crestal level at lingual aspect, which
become a area of interference.

● Indications for removal are :

■ Dislodgement of the lower denture with slight amount of tongue
movement.
■ ulceration is also seen over the tubercle area.
1. A mucoperiosteal flap is raised lingually to expose the genial
tubercle.
2. Muscle attachment is removed with sharp dissection.
3. Excision of the tubercle is done with the dental bur or rongeurs.
4. Smoothening is done with bone file and Incision is sutured
4.REDUCTION OF THE MYLOHYOID RIDGE
● Alveolar atrophy some time accentuates the mylohyoid
ridge,
● which can be palpated along the lingual surface of the
mandible in 2nd & 3rd molar region.
● Indication for removal
1. Negative ridge due to resorption
2. Frequent ulcerations
Removal of Mylohyoid ridge
5.ELIMINATION OF MANDIBULAR UNDERCUTS
 II. RIDGE
EXTENSION
PROCEDURES
 1.Mandibular procedures

Labial procedures Lingual procedures

(Transpositional flap
vestibuloplasty, 1. Trauner procedure
Lip switch procedure) 2. Caldwell procedure
1. Kazanjian’s procedure
▪ Godwin’s modification
2. Clark’s technique
▪ Obwegeser’s modification

• Obwegeser’s Total vestibuloplasty & Lowering of the Floor of

the Mouth procedure
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 Maxillary Procedures

● Submucosal vestibuloplasty of Obwegeser

■ Closed View
■ Open View

● Grafting
■ Mucosa
■ Skin
■ Xenografts

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RIDGE EXTENSION PROCEDURES

1.Vestibuloplasty procedures

A.Mucosal advancement C.Grafting vestibuloplasty

⚫ Skingrafts
● Closed submucous vestibuloplasty ⚫ Dermal grafts
● Obwegeser - maxillary ⚫ Mucosal grafts
● Boering - mandibular ⚫ Buccal
● Open view submucous vestibuloplasty ⚫ Palatal
● Wallenius ⚫xenografts
● Obwegeser D.Lingual sulcus vestibuloplasty
Anterior lingual – cooley
⚫

B.Secondary epithelialization ⚫ Posterior lingual

(reepithelilization) E.Caldwell
● Kazanjian F.Trauner
● Godwin
● Lipswitch
● Clark’s
● Obwegeser
● Tortorelli
● Labial palatal advancement vestibuloplasty
● Edlan’s operation
● Submental vestibuloplasty with muscle
repositioning
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 Vestibuloplasty

“ Vestibuloplastyis a surgical procedure used to increase the size

of the denture-bearing area and the height of the residual alveolar
ridge (sulculoplasty or sulcus deepening procedure)”

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 VESTIBULOPLASTY

1.Secondary epithelialization procedure

■ Kazanjian (1935)
■ Godwin modification (1947)
■ Clarke(1953)
2. Lipswitch Procedure
● Howe(1966) and Kethley and Gamble(1978)
3. Submucosal vestibuloplasty
● Obwegeser(1959)
4.Grafting Vestibuloplasty

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 Submucosal vestibuloplasty

• To provide adequate vestibular depth without producing an abnormal appearance of

the upper lip.
• Procedure of choice for correction of soft tissue attachment on or near the crest of the
alveolar ridge of the maxilla
• Useful when maxillary alveolar ridge resorption has occurred but the residual bony
maxilla is adequate for proper denture support.
• Underlying mucosal tissue is either excised or repositioned, allowing for direct
apposition of the labial vestibular mucosa to the periosteum of the remaining maxilla.
 A. Closed Submucous Vestibuloplasty

● It was described by Obwegeser(1959).

Objectives:
● To extend the vestibule to provide additional ridge height

● To excise or transfer the submucous connective tissue and the adjacent muscles to a
position farther from the crest of the ridge to prevent relapse of the vestibule to its pre-
operative condition

● After injecting sufficient local anaesthetic solution, a vertical incision is made in the
midline extending from the mucogingival junction upto the lip
● With the lip everted in horizontal plane, a scissor is introduced
through the incision, and by blunt spreading dissection the mucosa is
separated from the submucosa on the right and left sides.

● After the submucous tunnels have been completed, vertical incision

is deepened to periosteum at the midline.

● Supraperiosteal tunneling is done as far as the proposed vestibular

depth.

● A wedge- shaped strip of connective tissue remains between the two

tunnels; which may be excised and permitted to retract into the lip
and cheek.

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60
 B. Open view submucous vestibuloplasty

● Wallenius in 1963.
● A horizontal incision is made along the mucogingival junction through the
mucosa only.
● The mucosa is dissected from the submucosa far out into the lip so that a large
flap of mucosa is mobilised.
● Supraperiosteal dissection is then performed to the extent desired for the
proposed vestibular extension.
 2.Secondary epithelization vestibuloplasty

● Its indicated when sufficient bone is present but the mucosa is

either insufficient in quantity or of poor quality.

● There are two basic techniques:

1) Kazanjian 1935
2) Clark 1953
A.Kazanjian’s technique 1924
• Incision is made in the mucosa of
the lip
• A large flap of labial and vestibular
mucosa is reflected
• Supraperiosteal dissection
• The flap of mucosa is turned
downward from its attachment on
the alveolar ridge and is placed
directly against the periosteum to
which it is sutured

B.Godwin’s technique 1947

• The vestibule is deepened by means
of subperiosteal stripping instead of
a supraperiosteal dissection
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C. Clark’s technique 1953

• An incision is made on the alveolar ridge and a supraperiosteal dissection is

made to the depth desired.

• The mucosa of the lip is undermined to the vermillion border.

• The soft tissue side of the vestibule is covered with mucosa, where as the
osseous side the raw periosteal surface is left to granulate and epithelialize.

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Clark based his technique on four principles:

● Raw surfaces on connective tissue contract, where as the same

surfaces undergo minimal contraction when covered with
epithelium.

● Raw surfaces overlying bone cannot contract.

● Epithelial flaps must be undermined sufficiently to permit

repositioning and fixation without tension.

● Over correction and firm fixation are necessary.

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Clark technique
Clark technique
Clark technique
 3.Lip switch vestibuloplasty

● Howe (1965) and Kethley and Gamble (1978)

● Flap is developed same as suggested by Kazanjian.

● The periosteum is incised high on the alveolar ridge just below

the crest, and is reflected from the bone.

● The flap consisting of periosteum, connective tissue and muscle

is transposed outwardly and sutured to the margin of raw wound
in the lip.

● Mucosal flap is turned downward against the bare bone and

sutured to the periosteum deep in the vestibule.
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 4.Labial Palatal advancement Vestibuloplasty

● Godwin (1947) suggested a method of maxillary

vestibuloplasty that incorporates two mucosal flaps.
 5.EDLAN’S OPERATION

● Edlan combines Lipswitch vestibuloplasty with floor of the mouth procedure.

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 6.Grafting Vestibuloplasty
● When there is an inadequate amount of bone to compensate for relapse after
vestibuloplasty.
● When a bone graft has been placed previously in the surgical site.
● when a large surgical defect would otherwise be present, epithelial grafting should
be considered.

Advantages:
● Less relapse
● Early covering
● Rapid healing
● Decreasing patient discomfort

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A. Skin graft vestibuloplasty

Technique:
• Donor site is prepared.
• Skin graft of .012 to .015 inch thickness is harvested, rolled in gauge
and kept moist with saline solution.
• An incision is made from the right molar to left molar area at the
junction of the attached and unattached mucosa.
• Labiolingual, submucosal and supraperiosteal dissection are carried out;
and the mucosal flap is sutured to the periosteum at the depth of the
newly created vestibule.

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● Care is taken to remove all excess soft tissue from the exposed periosteum.

● An impression is made of the extended alveolar ridge and deepened vestibule.

● The stent is painted with tincture of benzoin compound which will act as an
adhesive for the skin graft.

● After the adhesive has dried, the skin graft is placed on the stent so that the raw
side will be in contact with the periosteum and skin graft is trimmed.

● The stent carrying the graft then is carefully seated on the ridge and secured with
circumferential wires.

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Skin Graft

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Skin grafting vestibuloplasty
B.Mucosa graft Vestibuloplasty
● Donoff (1976) stated that it was the dermal layer of the skin graft that inhibited wound
margin contracture.

● Graft can be Buccal or Palatal mucosa

● Free gingival grafts offer several advantages over split thickness skin grafts.

● First, the graft is usually full thickness or thicker, which reduces the amount of contraction
during healing and remodeling. Second, these grafts have no necessary skin appendages
that may cause hair growth, excessive keratinization or malodor.

● Free gingival grafts are also comprised of masticatory mucosa, which is similar to gingiva in
form consistency and color.

● The most common donor site is the palate, and buccal mucosa ( not suitable as a bearing
tissue for the prosthesis.)

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C. VESTIBULOPLASTY WITH XENOGRAFTS

● Porcine skin is available commercially.

● The frozen split thickness porcine strips are rinsed in iodophor solution, rolled
onto a net backing, sealed in plastic containers, and sterilized by radiation.
● Frozen porcine skin may be stored at regular freezer temperature (-18 o C) for
upto 18 months.
● To thaw the frozen porcine skin, the sterile container is opened and the contents
are immersed in saline solution.
● After thawing, the skin may be kept in a refrigerator at 50C
for upto 14 days.

● The porcine graft is easy to handle and can be trimmed to

the desired shape and size.

● It is applied to the open oral wound with its raw surface

adjacent to the periosteum, muscle or submucosa
depending on the site of wound.

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D.Vestibuloplasty with allografts

● The amnion has the following advantages:

○ it promotes secondary epithelialization, vascularize healthy granulation tissue
○ stimulate the neovascularisation in neighbouring tissues and it is antibacterial.
○ Another characteristic of amniotic membrane is the lack of immunogenicity as
it did not express antigens of histocompatibility,
○ the allograft was never rejected.

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2.Lingual sulcoplasty ( Floor of mouth plasty)

● Anterior lingual sulcoplasty

■ Cooley (1952) suggested lingual frenectomy and transplantation of superficial
fibers of the genioglossus muscle.

● Posterior lingual sulcoplasty

■ Caldwell’s procedure
■ Trauner’s procedure
■ Obwegeser’s procedure
 Caldwell’s procedure (1955)

● Method of lowering the floor of the mouth and at the same

time reducing a prominent or sharp mylohyoid ridge.

● A long incision is made on the crest of the posterior ridge, and

a full thickness flap is reflected medially.

● Subperiosteal stripping is done the mylohyoid muscle detached

inferiorly.
 Caldwell technique
(Posterior lingual sulcoplasty)

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 Trauner’s procedure(1952)

● Indicated if the mucosa of the floor of the mouth

■ rises as high as the mandibular ridge when the tongue is elevated
■ if the mylohyoid muscle is attached at the level of the residual alveolar
ridge.

● An incision is made in the floor of the mouth close to the

mandible from the third molar region on one side to the
same location on the opposite side.

● The mucosa of the floor of the mouth is retracted

medially, and the mylohyoid muscle is exposed.
● A curved hemostat is passed through the mylohyoid
muscle in the canine region and is directed posteriorly
under the muscle close to the mandible.
● The muscle fibers are incised over the hemostat to
avoid injury to the periosteum.

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Trauner’s procedure(1952)

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 Obwegeser’s procedure 1963
● Described a method of combining a skin graft labiobuccal vestibuloplasty
with a lowering of the floor of the mouth that is similar to Trauner’s
procedure.
 III.
RIDGE
AUGMENTATION
 A.MANDIBULAR AUGMENTATION

1. SUPERIOR BORDER
AUGMENTATION
4. VISOR OSTEOTOMY
A. Bone Grafts
B. Cartilage Grafts a.horizontal
C. Alloplastic Grafts b.Vertical
c.Modified visor osteotomy

2. INFERIOR BORDER
AUGMENTATION
A. Bone Grafts (autogenous or 5. ONLAY GRAFTING
allogenic freeze dried cadaveric A.autogenous
mandible) B.alloplastic
B. Cartilage Grafts C.allogenic materials

3. INTERPOSITIONAL OR SANDWICH
BONE GRAFTS
A. Bone Grafts
B . Cartilage Grafts
C. Hydroxyapatite blocks
B. MAXILLARY AUGMENTATION
1. Onlay Bone Grafting – autogenous / allogenic grafts
2. Onlay Grafting of alloplastic material
3. Interpositional or sandwich grafts
4. Sinus lift procedure

C. AUGMENTATION IN COMBINATION WITH

ORTHOGNATHIC SURGERY
1. Mandibular osteotomy procedure
2. Maxillary osteotomy procedure
3. Combination procedure

D. DISTRACTION OSTEOGENESIS
 MATERIALS USED FOR AUGMENTATION OF
ALVEOLAR RIDGE

1. AUTOGENOUS BONE GRAFT

- Iliac crest, Rib Graft
2. ALLOGENIC BONE GRAFT
- Freeze dried cadaver bone
3. ALLOPLASTIC MATERIAL
- Silastic, Carbon-impregnated Teflon Foam(Proplast)
Ceramic materials
Hydroxyapatite (Calcitite)
4. Metal Mesh with
a. autogenous cancellous bone
b. hydroxyapatite
 1.SUPERIOR BORDER AUGMENTATION
BY RIB GRAFT
● Davis in 1970, described this technique for ridge augmentation.

● Preoperative consideration
○ Remaining height of the body of edentulous mandible is less then 10mm.
○ Consider the patient’s ability to tolerate the procedure psychologically &
physically.

● Donor consideration
○ 2 Rib segments about 16 cm long are taken anywhere from the 5th to 9th ribs
may be used.
● After harvesting bone may be contoured by vertical, superior & inferior scoring (
KERFING ) of the internal surface of one rib to allow bending to ridge shape.
● 2nd Rib is cut into small pieces about 2 X 3 mm to facilitate placement.

KERFING:
Note that the vertical
removal of the
Bone on the internal surface
is carried out through the
superior and inferior
Edges.
4. Extent of the periosteal dissection
should be lateral height of
mandible.
5. At this point, a releasing incision
should be made in buccal areas of
periosteum.
6. The lingual flap usually will be
elevated in the plane of the
mylohyoid muscle.
7. If the anterior part of the mandible is
higher than the posterior part, a
groove is cut in the anterior portion.
8. A aluminium template is used to
measure the length of the rib strut.
9. Rib is ligated with wire or
absorbable sutures.

10. This forms the pocket into

which the bone particles
may be placed. Most of the
particle are placed Buccal &
labial side of strut.

11. Closure is begun at one

retromolar pad, a continuous
horizontal mattress suture is
started & continued for about
a centimetre.
12.Running spiral suture is
placed for tight closure.
 DISADVANTAGE

1. Donor site morbidity.

1. Secondary surgical site necessary.

1. Continued resorption of the grafted sites.

1. Soft tissue dehiscence.

 2. INFERIOR BORDER AUGMENTATION

● First described by Marx & Saunders in 1986.

● Modified by Quinn in 1991.

1.Indications:
1.Augmentation of the severely atrophic edentulous
mandible.
2.Prevention of the pathologic fracture of severely atrophic
mandible.
3.Management of nonunion or malunion of fractures in
severely atrophic edentulous mandible.
2. ADVANTAGES

1. Extraoral approach does not obliterate the vestibule, as does

the intraoral technique. Therefore the patient can wear a
relined interim Mandibular prosthesis soon after the grafting.
2. No mucosal dehiscence with this technique.
3. There is little orofacial pain with this technique & patient can
take oral fluids & food orally without risk of damage to or
contamination of the wound site.
4. This technique will not alter the vertical dimension of occlusion,
so no change in interocclusal space.
5. Secondary lingual vestibuloplasty often not necessary.
6. The technique is excellent for fracture stabilization in
severely atrophic edentulous mandible without need of
additional splints or IMF.

7. Since there is no masticatory force applied directly to the rib

graft bone resorption when compared with other technique is
acceptable.

8. In patients for whom skin grafting has been performed

several years previously & who has encounter the
subsequent bone resorption, inferior rib grafting can be done
without violating with graft.
9. Used in augmentation of ‘pencil thin’ atrophic mandible.

10. Skin graft vestibuloplasty is much easier to perform with

the bone graft on the inferior border.
3.DISADVANTAGES

1. A procedure require a large extraoral incision which

resultant into scarring.

1. Patient must have some redundant, loose

submandibular & submental soft tissues to accumulate
the rib graft placement.

1. The procedure does not correct any superior border

irregularities.
3.TECHNIQUE:
1. Bilateral continuous submandibular incision.
2. One rib is abutted against the lingual aspect of he inferior
border, the other against buccal aspect of the inferior
border.
3. The space between the ribs is filled with cortical
segments that were removed during preparation of the
ribs.
4. The ribs are fixed with both circumferential & intra -
osseous wiring.
5. Wound is closed by layers.
 2.INTERPOSITIONAL OR SANDWICH BONE
GRAFTS

● Horizontal osteotomy is
performed.
● Splitting of the residual maxilla
or mandible & bone graft is
placed into the osteotomy gap.

● In mandible this technique is

mainly used for augmentation of
the anterior mandible, between
the mental foramina.
● Autogenous, allogenic or
hydroxyapatite grafts can be
successfully used.
 3.VISOR OSTEOTOMY

● Originally described by Harle (1975).

● Goal is to increase the height of the mandibular ridge for

denture support.

● Alveolar ridge of the mandible is osteotomized & moved

on the principle of a visor.

● Consists of central splitting of mandible in the

buccolingual dimension & the superior positioning of the
lingual section of the mandible & is wired in position
 PROCEDURE
1. Initial step is to obtain bone
from the ilium (No Cortical
bone, only cancellous marrow
is obtained 15-20ml).
2. Incision is placed over alveolar
crest slightly lingually from one
side of retromolar pad
another.
3. Buccal mucoperiosteal flap is
reflected.Leaving the lingual
soft tissue attached.
4. A narrow vertical lingual
subperiosteal tunnel is made
from crest of the ridge to the
inferior border of mandible
in3rd molar region
5. The bony cuts begin with the
posterior vertical osteotomy.

6. There is frequently a depression

between the internal & external
oblique ridge. Using a bur hole
held vertically, one makes an
osteotomy from the depth of this
depression lingually, through the
internal oblique ridge.

7.It continues through the lingual

cortex plate until the inferior border
is reached.

Vertical osteotomy cuts extends from Retromolar triangle to retromolar triangle and
from the crest of the ridge to the inferior border of the mandible.Two vertical
Osteotomy cuts are made posteriorly to connect the crestal osteotomy to the inferior border.
8. This cut is performed bilaterally.

9. Sagittal cut is performed with

reciprocating saw between the
lingual & Buccal cortical plates.

10. The osteotomy passes just

lingual to the mental foramen &
bisect the buccolingual width in
symphysis region.

11. Once the osteotomy is completed Osteotomy must be angled

Laterally so that it will extend
with the saw, small thin chisels Completely to the inferior
are used to complete the Border.
osteotomy.
12.Mobilized pedicled segment is
elevated in its new superior
position & secured with sutures.

13. Closure is accomplished from

posterior to anterior with a
running horizontal mattress
suture. As the closure advances
anteriorly, the cancellous
marrow from the illium is
packed against the lateral
aspect of the superior segment.

Cancellous marrow from the

ilium is placed on the lateral
aspect of the elevated flap.
 4.MODIFIED VISOR OSTEOTOMY

1. It was proposed Peterson & Salde in 1977.

1. This procedure done to achieve the advantage of both

approaches.

1. Vertical osteotomies would be performed in the body regions

posterior to mental foramen, with a horizontal osteotomy is
performed in between the foramina in symphysis region.

1. This technique would provide protection to the nerve during

mastication with dentures & would provide a rather normal
ridge in the anterior region of mandible.
 5.ONLAY GRAFTING

● When adequate height is present, but width is inadequate for

prosthesis in the maxilla or mandible, the option of onlay
grafting should be considered.

● Oldest technique.

● Augmentation with allograft, i.e, hydroxyapatite is advocate

by Obwegeser via submucosal vestibuloplasty.

● After creating a tunnel via midline, a putty is formed of

hydroxyapatite crystals, mixed with saline/blood, & is
injected via syringe into the submucosal tunnel
Advantages :
Improves the height & width of the maxillary alveolar bone.
Can be used in both anterior & posterior region.

Technique :
1. a high vestibular incision is taken to facilitate good water
tight closure & to achieve good undermining of the tissues
for relaxation.
2. Mucoperiosteal flap is reflected to expose the defect.
3. Small perforations are made in the external cortex by
using small bur to create bleeding and promotion of clot
formation and neovascularization.
4. The grafting material is placed / moulded over the
external cortex.
 6.MAXILLARY RIDGE AUGMENTATION

Preparation of the Titanium Mesh Tray :

● A working model of the maxilla is made in plaster or stone & the area
to be reconstructed by the bone graft is build up in wax on the model
to the desired post operative height, width & the contour.
● This waxed up model is duplicated in acrylic.
● A sheet of base plate wax is then adapted to the acrylic model in
the shaped of the desired mesh tray, which will be used in the
containment of the bone graft.
● The wax pattern is removed from the model, flattened & placed
against a flat stock of titanium mesh 0.015 inch thick.
● The titanium mesh is cut to the desired size & swedged onto the
acrylic model.
● The mesh is smoothed, cleaned & autoclaved.
TECHNIQUE:

1. Particulate cancellous bone marrow is harvested from the ilium.

1. Crestal mucoperiosteal incision is made from maxillary

tuberosity to contralateral side.

1. Palatal mucoperiosteal flap is reflected posteriorly, should stop

short of greater palatine foramina.

1. Labial mucoperiosteal mucosa reflected anteriorly and

superiorly.
5. After reflection, tray is secured with 7-10mm titanium
screw in the midline of the palate.

6. Bone graft material is placed into the tray & condense

firmly.

7. Titanium screw is tightened to secure the tray in

position.

8. Vertical matress suture are used to close the soft tissue.

 7. MAXILLARY AUGMENTATION IN
COMBINATION WITH ORTHOGNATHIC
SURGERY
1. Anterior maxillary osteotomy.
2. Lefort I osteotomy, can be used along with
interpositioning of grafts.

Problems encountered with augmentation technique are

1. Inadequate soft tissue covering.
2. Rejection of autograft
3. Dehiscence
4. Migration of graft material
5. Resorption of graft material
B
 8.SINUS LIFT PROCEDURES

● The various method that are used these days for sinus lift
may include :

1. Direct sinus lift procedures

1. Indirect sinus lift procedures

1.Direct Sinus Lift
 2.Indirect sinus lift
● A crestal incision.

● A full-thickness flap is raised to expose the

alveolar ridge.

● Preoperative bone height underneath the sinus

is measured to determine the desired depth for
osteotome extension.

● An osteotome of the smallest size is then

tapped into place by a mallet or drill into the
bone.

● The goal is to extend the instruments just shy

of the sinus membrane.
● Osteotomes of
increasing sizes are
introduced sequentially
to expand the
alveolus.
● With each insertion of
a larger osteotome,
bone is compressed,
pushed laterally and
apically .
 9.Alveolar Distraction osteogenesis

● Alveolar distraction offers some advantages over the traditional bone

grafting techniques.

■ No donor site morbidity

■ Shorter duration than bone grafting and remodelling techniques

 Alveolar distraction

Osteotomy site marked Cuts made plate

 Alveolar distraction

Segment mobilized Distractor placed

 Alveolar distraction

Pre-Distraction Post-Distraction
● Augmentation of atrophic posterior
mandible - challenging- extensive
bone deficiency and IAN
● ADO offers vertical augmentation
with simultaneous soft tissue
expasion
● Indicated in moderate - severe
deficiency of over 7 mm

Amundson, M. et al. (2020) “Three-dimensional computer-assisted surgical planning, manufacturing, intraoperative navigation,
and computed tomography in maxillofacial trauma,” Atlas of the Oral and Maxillofacial Surgery Clinics, 28(2), pp. 119–127.
 Tenting - initial reconstruction and subsequent regeneration of maxillofacial defects

Tent - pole technique Screw-tenting technique. Cortical autogenous tenting

- Fixation of a block of
cortical bone with titanium
screws a few millimeters
from the bone to make the
gap
- Filled with bony
materials.

Dental implants are used to make a gap between the - Titanium screws are used to make the gap.
periosteum and the bone - The gap is filled with bony materials
In most cases the gap is filled with bone grafts - A Membrane is used to prevent the migration of
epithelial cells

Pourdanesh, F., Esmaeelinejad, M. and Aghdashi, F. (2017) “Clinical outcomes of dental implants after use of tenting for bony
augmentation: A systematic review,” British Journal of Oral and Maxillofacial Surgery, 55(10), pp. 999–1007.
-They are effective options for
vestibuloplasty.

-CO2 laser, 10.6 nm wavelength, 2 Watts

power, noncontact, focus mode, was used.

- PRF membrane is applied on the

denuded periosteum.

- The PRF membrane could reduce pain

and relapse rate, and promoted wound
healing

Keerativittayanun, S., Kiatkamonmarn, S. and Pripatnanont, P. (2017) “The clinical effect of carbon dioxide laser and platelet-rich
fibrin on vestibuloplasty,” International Journal of Oral and Maxillofacial Surgery, 46, pp. 109–110.
● Bone grafting using iliac crest followed by
ADO
● After ADO- Endosseous implants placed
followed by prosthetic rehabilitation
● Vertical augmentation upto 14 mm and
correction of intermaxillary relationships
● Indicated in cases of severe alveolar bone
deficiency often accompanied by soft tissue
changes like collapse of lower lip.

Rachmiel, A. et al. (2018) “Two-stage reconstruction of the severely deficient alveolar ridge: Bone graft followed by alveolar
distraction osteogenesis,” International Journal of Oral and Maxillofacial Surgery, 47(1), pp. 117–124.
● Indication: In maxilla with bilaterally
enlarged maxillary sinuses, close to the
cortical surface of the atrophic ridge.
● The transcendent aspect of elevation,
preservation of maxillary sinus and nasal
mucosa, modifying the sandwich technique
by the useful of bone scrapers and
piezosurgery is highlighted
● 1-stage approach using corticocancellous
bone blocks through which implants are
placed
● It provides the desired gain of bone,allows
for the ideal placement of dental implants,
and improves any discrepancy between the
upper and lower arches
- Cold plasma improve - surface roughness -PGLA- stimulate -
adhesion - osteogenic mediators.
- It accelerates the biodegradation of the barriers
- new PLGA membrane after being treated with oxygen plasma (PO2
) plus silicon dioxide (SiO2 ) layers for guided bone regeneration
(GBR) processes.
- Incorporation of silica dioxide layers onto PLGA membranes
modified with PO2 improves the results of bone regeneration
- Addition of SiO2 nanoparticles to PLGA membranes’ surfaces
stimulates the new bone formation, mineralisation, and
osteosynthetic activity
● Assessment of pre-implant bone quality and quantity
using appropriate three-dimensional CBCT radiographs
● 1 to 2 mm of bone should be present between implant
apex and the sinus floor level.
● Sinus lift procedures performed only with residual bone
height of 10 mm or less
● Appropriate sinus lift procedure in accordance with the
available pre-implant residual bone height as well as the
necessary amount of increase in that bone height
● Combination of autogenous and alternative bone grafts is
often recommended

Al-Dajani, M. (2014) “Recent trends in sinus lift surgery and their clinical implications,” Clinical Implant Dentistry and Related
Research, 18(1), pp. 204–212.
● Human AM has low immunogenicity, low cost, availability,
epithelialization-stimulating potential, and
anti-inflammatory properties
● ADM has easy handling, keratinization inducing nature,
appropriate root coverage, and scar-relieving potential
make it a promising substitute for other covering materials
in the dental and oral surgeries
● ADM is as effective as cryopreserved AM - maintaining
the postoperative vestibular depth.
● Labial vestibular depth was elevated using the Clark’s
technique followed by posed periosteum was covered
with ADM and cryopreserved human AM
● Faster postoperative healing onset when ADM was used
than when cryopreserved human AM was applied on the
periosteum
Osteotome sinus floor elevation was a less invasive
one-stage technique

A crestal approach using a non-traumatic drill to

decrease the risk of tearing the sinus membrane was
suggested

In posterior edentulous maxilla, implants were first

placed in the ulna. After 6 weeks, bone blocks
containing implants were harvested and transplanted
into the sinus area protruding 3 to 4 mm.

Use of a tilted (angulated) implant in the posterior

maxilla was suggested to avoid sinus augmentation.
● High palatoglossal arch as a rare and new
cause of loss of posterior palatal seal
treated by pre-prosthetic surgery
● Drape of the soft palate in relation to the
hard palate, shape of palatal vault - factors
affecting palatal seal
● V-shape and the class III nature of the soft
palate having narrow posterior palatal seal.
● Palatoplasty was performed by incising the
palatoglossal arch fibres which inserted
high, anteriorly on the lateral surface of the
tongue using soft tissue laser till the tension
on the soft palate was relieved bilaterally.
● Effectiveness of piezoelectric device in
performing ridge split using single-stage
approach and assessed the outcomes
● The initial ridge width: 1 - 3.5 mm,

Final width: 5.5 - 8 mm.

Bone gain upto 7 mm

● Survival rate - 100%

● Self-threaded titanium implant was
inserted
● The space between the expanded bony
plates and implants was packed
precisely using synthetic bone substitute
and covered with membrane
 Conclusion

● Pre prosthetic surgery is a rapidly changing area of oral and maxillofacial

reconstructive surgery, and knowledge of the range, capabilities, and limitations of
the available surgical procedures is a must to achieve the best overall result.

● With evolution and success of

○ implants technology,
○ GTR,
○ Genetically engineered growth factors such as BMP,current indications for
grafting and augmentation are usually related to implants.
- Peterson priciples of OMFS vol-1
● .
 Take home message

● Team work OMFS & Prostho

● Plan the question properly before writing.

● What to write and how much to write is important.

● One’s attitude determines his/ her altitude

● Be proactive rather than reactive.

● Beg Borrow Steal

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