32. Preprosthetic 32. Preprosthetic Surgical ProceduresSurgical Procedures

John Beumer III, DDS, MSJohn Beumer III, DDS, MSDivision of Advanced Prosthodontics, Division of Advanced Prosthodontics,

Biomaterials and Hospital DentistryBiomaterials and Hospital DentistryUCLA School of DentistryUCLA School of Dentistry

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Conventional preprosthetic surgeryConventional preprosthetic surgery Tuberosity reductionTuberosity reduction Elimination of boney undercutsElimination of boney undercuts Removal of palatal papillary hyperplasiaRemoval of palatal papillary hyperplasia FrenulectomyFrenulectomy Removal of epuli (fibrous hyperplasia secondary to Removal of epuli (fibrous hyperplasia secondary to

denture irritationdenture irritation Displacing the inferior alveolar nerveDisplacing the inferior alveolar nerve

Reconstructive preprosthetic surgeryReconstructive preprosthetic surgery Skin graftingSkin grafting Vestibuloplasty and lowering the floor of the mouthVestibuloplasty and lowering the floor of the mouth Bone augmentationBone augmentation Hydroxyl apatite augmentationHydroxyl apatite augmentation ImplantsImplants

Ideal Bearing Surfaces - MaxillaIdeal Bearing Surfaces - Maxilla Ridge form – rounded crest with vertical sidesRidge form – rounded crest with vertical sides Ample keratinized attached mucosaAmple keratinized attached mucosa Displaceable tissues in the posterior palatal seal areaDisplaceable tissues in the posterior palatal seal area Accessible vestibulesAccessible vestibules

Ideal Bearing Surfaces - MandibleIdeal Bearing Surfaces - Mandible Broad, rounded ridge crest form with vertical sidesBroad, rounded ridge crest form with vertical sides Ample amounts of keratinized, attached mucosaAmple amounts of keratinized, attached mucosa Favorable floor of mouth postureFavorable floor of mouth posture Anterior tongue positionAnterior tongue position

Mandibular Bearing Surfaces Mandibular Bearing Surfaces Common ProblemsCommon Problems

Severe ridge resorptionSevere ridge resorption

Consequences:Consequences:a)a) Impaired stability of the dentureImpaired stability of the dentureb)b) Impaired support for the dentureImpaired support for the denturec)c) Pathologic fracture of the mandiblePathologic fracture of the mandible

Severe Resorption - MandibleSevere Resorption - Mandible Definition:Definition: Loss of the mandible to the extent where 10 Loss of the mandible to the extent where 10

mm or less of the vertical height of the mandibular body mm or less of the vertical height of the mandibular body remains.remains.

Precipitating factors Precipitating factors a)a) Loss of the teethLoss of the teethb) Ill fitting denturesb) Ill fitting denturesc) Hormonal influences?c) Hormonal influences?d) Wearing dentures at nightd) Wearing dentures at nighte) Edentulous mandible opposing e) Edentulous mandible opposing dentate maxilla dentate maxilla

Severe Resorption - MandibleSevere Resorption - MandiblePreventionPrevention a)a) Retention of rootsRetention of roots b) Well adapted dentures with b) Well adapted dentures with a coordinated occlusiona coordinated occlusion c) Leaving out dentures at nightc) Leaving out dentures at night d) Use of osseointegrated implantsd) Use of osseointegrated implants e) Removing opposing dentitione) Removing opposing dentition

Mandibular Arch – Common ProblemsMandibular Arch – Common Problems Unfavorable floor of mouth posture and Unfavorable floor of mouth posture and

retruded tongue positionretruded tongue position

Result: Result: a)a) Impaired stabilityImpaired stabilityb)b) Impaired controlImpaired control

Consequences:Consequences:Length of lingual flange Length of lingual flange is minimizedis minimized

Mandibular Arch – Common ProblemsMandibular Arch – Common Problems Reduced amounts of attached, keratinized mucosaReduced amounts of attached, keratinized mucosa

Consequences:Consequences:a)a) Impaired SupportImpaired Support

NoteNote:: Usually occurs Usually occurs coincident with moderate coincident with moderate to severe resorption of the to severe resorption of the alveolar ridgealveolar ridge

Mandibular Arch – Common ProblemsMandibular Arch – Common ProblemsThin, knife edged ridge crestThin, knife edged ridge crest

Consequence:Consequence:a)a) Impaired supportImpaired supportb)b) Pain and discomfortPain and discomfort

Mandibular Arch – Common ProblemsMandibular Arch – Common ProblemsInferior alveolar nerve exposed on the ridge crestInferior alveolar nerve exposed on the ridge crest

Consequences:Consequences:a)a) Severe discomfort upon application of pressureSevere discomfort upon application of pressureb)b) Inability to tolerate the lower dentureInability to tolerate the lower denture

Maxillary Arch – Common ProblemsMaxillary Arch – Common ProblemsSeverely resorbed, flat ridges and lack of vertical sidesSeverely resorbed, flat ridges and lack of vertical sides

Consequences:Consequences: a)a) Impaired stabilityImpaired stabilityb)b) Difficulty in maintaining sealDifficulty in maintaining seal

Precipitating Factors:Precipitating Factors:a)a) Loss of teethLoss of teethb)b) Hormonal influences?Hormonal influences?c)c) Ill fitting denturesIll fitting denturesd)d) Wearing dentures at nightWearing dentures at nighte)e) Opposing arch withOpposing arch with natural natural

dentitiondentition

Severe Resorption - MaxillaSevere Resorption - Maxilla Retention of rootsRetention of roots Well adapted dentures with coordinated occlusionWell adapted dentures with coordinated occlusion Leave dentures at nightLeave dentures at night Use of osseointegrated implantsUse of osseointegrated implants Removing opposing dentitionRemoving opposing dentition

Prevention:Prevention:

Redundant tissues - PremaxillaRedundant tissues - Premaxilla

The entire premaxillary segment is fibrous connective tissue in this patient. The underlying bone has resorbed. It is not advisable to remove this cushion of tissue, however, because the residual ridge crest beneath these soft tissues is likely to be knife edged.

Maxillary Arch – Common ProblemsMaxillary Arch – Common ProblemsBilateral undercuts*Bilateral undercuts*

Consequence: a) Impaired

adaptation and retention

*Can be prevented during extraction by alveolar compression and primary closure (Obwegeser, 1966)

Maxillary Arch – Common ProblemsMaxillary Arch – Common ProblemsLow frenum attachmentsLow frenum attachments

Consequences:a) Sealb) Fracture of denture

Maxillary :Arch – Common ProblemsMaxillary :Arch – Common ProblemsInflammatory palatal papillary hyperplasiaInflammatory palatal papillary hyperplasia

Consequences:a) Prevents proper adaptation of the denture base compromising support

Preprosthetic SurgeryPreprosthetic Surgery Goals – Improve the denture foundation area Goals – Improve the denture foundation area

so as to facilitate the support, retention, and so as to facilitate the support, retention, and stability provided for removable prosthesesstability provided for removable prostheses

MethodsMethods

a) Minor soft tissue proceduresb) Minor osseous proceduresc) Vestibuloplastyd) Bone augmentatione) Implants

Conventional Preprosthetic SurgeryConventional Preprosthetic Surgery Epulis fissuratum removalEpulis fissuratum removal FrenectomyFrenectomy Treatment of palatal papillary hyperplasiaTreatment of palatal papillary hyperplasia Tuberosity reductionTuberosity reduction Removal of maxillary and mandibular toriRemoval of maxillary and mandibular tori Removal of boney undercutsRemoval of boney undercuts Displacing the inferior alveolar nerveDisplacing the inferior alveolar nerve

Epulis Fissuratum (Inflammatory Fibrous Epulis Fissuratum (Inflammatory Fibrous Hyperplasia)Hyperplasia)

Etiologya) Persistent denture irritation that is not resolved

Treatmenta) Surgical excision and primary closure*

*These lesions are generally pedunculated and are easily removed with scissors.

Low Frenum AttachmentsLow Frenum Attachments

Problems:a) Sealb) Fracture

Treatment: Frenum are comprised of epithelium and fibrous connective tissue, not muscle, so surgical excision is quite effective.

Palatal Papillary Hyperplasia and Associated Palatal Papillary Hyperplasia and Associated Candida Albicans InfectionCandida Albicans InfectionEtiology

a) Poorly adapted denturesb) Candida albicans

Worsened by: a) Poor oral hygieneb) Wearing dentures at night

EarlyEarly AdvancedAdvanced

*Corner of mouth usually infected with fungus as well

Therapeutic Approaches – Palatal Papillary Therapeutic Approaches – Palatal Papillary Hyperplasia**with Associated Candida AlbicansHyperplasia**with Associated Candida Albicans

Antifungal therapy*a) Nystatin powder (100,000 units per gram) Apply to undersurface of

denture three times per day for 3-4 weeksb) Nystatin cream – Best used for lesions associated with the corners of

the mouthc) Reline denture with temporary reline materiald) Reline or remake denture

Surgical excision with electrosurgery (when antifungal Surgical excision with electrosurgery (when antifungal therapy has reached an end point)therapy has reached an end point)

*Nystatin rinse is generally ineffective. Nystatin oral or vaginal suppositories used as an oral lozenge are reserved for fungal infestations that extend beyond the denture bearing surfaces.

**Is this a premalignant lesion? No!!!!

Case ReportCase Report

Note the chamber inscribed into the upper denture(A) and the corresponding tissue hyperplasia. Such chambers are ill advised.

Case Report – Palatal Papillary HyperplasiaCase Report – Palatal Papillary HyperplasiaA severe case of palatal papillary hyperplasia. A combination of antifungal therapy and surgical excision is recommended for this patient.

Palatal Papillary Hyperplasia – Surgical Palatal Papillary Hyperplasia – Surgical RemovalRemovalThe preferred method for surgical removal is with electrosurgery. Following removal, islands of epithelium remain which grow, expand and eventually coalesce.

Etiologic factorsa) Combination syndrome -Edentulous

maxilla opposing distal extension RPD where occlusion is not balanced (Inflammatory fibrous hyperplasia)

b) Supereruption of unopposed molars and upon extraction the bone associated with the tuberosity is left untrimmed (arrow)

Enlarged or Hyperplastic Tuberosities

Hyperplastic TuberositiesHyperplastic Tuberosities

When this patient assumes a protrusive position, the maxillary denture was tipped anteriorly leading to resorption of bone of the premaxilla and fibrous hyperplasia of the maxillary tuberosity

Enlarged Tuberosities – Criteria for ReductionEnlarged Tuberosities – Criteria for Reduction

Lack of sufficient space at the proper vertical dimension of occlusion to cover both tuberositiesLack of sufficient space at the proper vertical dimension of occlusion to cover both tuberosities Inability to extend the maxillary denture base into the hamular notch Inability to extend the maxillary denture base into the hamular notch Inability to cover the retromolar pad.Inability to cover the retromolar pad.

The preferred method is excision of the underlying fibrous connective tissue with a scalpel and The preferred method is excision of the underlying fibrous connective tissue with a scalpel and primary closure.primary closure.

Fibrous Hyperplasia

Conventional Preprosthetic Surgery – Conventional Preprosthetic Surgery – Boney ProceduresBoney ProceduresExostoses and toriExostoses and tori

Indications for removal:a) When they become so large as to interfere with speechb) When the mucosa becomes traumatized, ulcerates, and fails to

heal because of its poor vascularityc) When the torus interferes with the design and construction of a

removable partial denture or a complete denture

Palatal Tori - Criteria for RemovalPalatal Tori - Criteria for Removal Height of torus exceeds that of the alveolar ridgeHeight of torus exceeds that of the alveolar ridge Torus extends to the vibrating line preventing Torus extends to the vibrating line preventing

development of posterior palatal sealdevelopment of posterior palatal seal

The palatal torus on the left should be considered for removal while the small one on the right need not be removed.

Removal of Palatal ToriRemoval of Palatal Tori

The torus is removed with a burr and chisel. Note that the mucosal flaps are supported by a palatal stent (arrow) so as to prevent formation of a hematoma.

Removal of Palatal ToriRemoval of Palatal Tori

This torus was removed with a burr and chisel. The mucosal flaps should be supported by a palatal stent so as to prevent formation of a hematoma.

Mandibular Tori – Criteria for RemovalMandibular Tori – Criteria for Removal Mucosa is thin and easily ulcerated and coverage by a Mucosa is thin and easily ulcerated and coverage by a

complete denture or a major or minor connector of an complete denture or a major or minor connector of an RPD is usually not tolerated by the patient.RPD is usually not tolerated by the patient.

Removal is accomplished with burrs and chisels

AlveoloplastyAlveoloplasty Alveolar compressionAlveolar compression Reduction of the knife-edged or saw-tooth ridgeReduction of the knife-edged or saw-tooth ridge Elimination of undercuts**Elimination of undercuts**

**Only half of the desired amount should Only half of the desired amount should be removed because of the resorption that be removed because of the resorption that follows reflection of the periosteum and the follows reflection of the periosteum and the surgical removal of bonesurgical removal of bone

Study casts should be made to Study casts should be made to properly plan the procedureproperly plan the procedure

Repositioning the Inferior Alveolar NerveRepositioning the Inferior Alveolar Nerve

Surgically possible, but there is risk of permanent injury to the Surgically possible, but there is risk of permanent injury to the nerve. The resultant anesthesia, dysethesia, or hyperesthesia can nerve. The resultant anesthesia, dysethesia, or hyperesthesia can be quite debilitating to the patient.be quite debilitating to the patient.

Preferred solution: Placement of 4-5 implants anterior to the mental foramen and fabrication of a fixed edentulous bridge