PREPROSTHETIC SURGERYPREPROSTHETIC SURGERY

Dr V.RAMKUMARDr V.RAMKUMAR

CONSULTANT DENTAL&FACIOMAXILLARY SURGEONCONSULTANT DENTAL&FACIOMAXILLARY SURGEON

REG NO:4118-TAMILNADU –INDIA(ASIA)REG NO:4118-TAMILNADU –INDIA(ASIA)

Scope Scope

1.1. Ridge preservation procedures Ridge preservation procedures2.2. Corrective or recontouring Corrective or recontouring

procedures of the defects and procedures of the defects and abnormalitiesabnormalities

3.3. Ridge extension procedures: Ridge extension procedures:a. Relative methods, eg, sulcus a. Relative methods, eg, sulcus

extension (vestibuloplasties)extension (vestibuloplasties)b. Absolute methods, eg, ridge b. Absolute methods, eg, ridge

augmentation proceduresaugmentation procedures

Cont….Cont….

4.4. Reconstructive procedures like correction Reconstructive procedures like correction of abnormal ridge relationshipsof abnormal ridge relationships

5.5. Provision of accessory aids: Provision of accessory aids:

a. Creating favorable under-cutsa. Creating favorable under-cuts

b. Dental implantsb. Dental implants

c. Onlay denturec. Onlay denture

6.6. Modified denture construction procedures, Modified denture construction procedures, eg, immediate denture where construction eg, immediate denture where construction of the denture precedes surgery.of the denture precedes surgery.

Objectives Objectives

It is provide an ideal denture-bearing area It is provide an ideal denture-bearing area which will provide maximum comfort and which will provide maximum comfort and retention of dentures during function.retention of dentures during function.

a.a. The anatomical base should be healthy, The anatomical base should be healthy, firm and smooth.firm and smooth.

b.b. The supporting surfaces must be of The supporting surfaces must be of adequate size, covered by healthy adequate size, covered by healthy mucoperiosteum of even thickness.mucoperiosteum of even thickness.

Cont …Cont …

c.c. Sufficient space must exist between Sufficient space must exist between the alveolar ridges to accommodate the alveolar ridges to accommodate the dentures without any gross the dentures without any gross abnormalities of the jaws and their abnormalities of the jaws and their relationship.relationship.

Evaluation Evaluation

Intra-oral examination:Intra-oral examination:

1.1. Amount and contour of the alveolar Amount and contour of the alveolar ridge and basal boneridge and basal bone

2.2. Quality of the mucosa covering the Quality of the mucosa covering the denture bearing areadenture bearing area

3.3. Depth of the vestibuleDepth of the vestibule

4.4. Presence and location of abnormal Presence and location of abnormal fibrous and muscle attachmentsfibrous and muscle attachments

Cont… Cont…

5.5. Jaw relationship Jaw relationship6.6. Any pathological lesion Any pathological lesion7.7. Alveolar ridge Alveolar ridge

- Inspection, palpation and radiological - Inspection, palpation and radiological examination of the denture bearing examination of the denture bearing

areaarea- Bone ridge contour & form- Bone ridge contour & form- Bony undercuts or bony protuberances- Bony undercuts or bony protuberances- Buccal vestibule- Buccal vestibule- Palatal vault- Palatal vault

Cont…..Cont…..

- Tuberosity area- Tuberosity area

- Location of mental foramen & - Location of mental foramen & mylohyoid mylohyoid

ridgeridge

- Interarch relationship- Interarch relationship

- Appropriate radiographs –OPG- Appropriate radiographs –OPG

- Resorption of alveolar ridge- Resorption of alveolar ridge

- Muscular & mucosal attachments- Muscular & mucosal attachments

Requirements of an ideal ridge :Requirements of an ideal ridge :

1.1. It should have desirable vestibular depthIt should have desirable vestibular depth

2.2. It must provide adequate bony support It must provide adequate bony support for the denturesfor the dentures

3.3. Ideally, alveolar ridge should be as large Ideally, alveolar ridge should be as large as possible, broad and U-shapedas possible, broad and U-shaped

4.4. The ridge should be covered by adequate The ridge should be covered by adequate keratinized mucosal lining of uniform keratinized mucosal lining of uniform thickness and compressibility but thickness and compressibility but immobile so that denture stability is immobile so that denture stability is ensured.ensured.

Cont…Cont…

5.5. The ridge should be free from any The ridge should be free from any unfavorable hard and soft tissue unfavorable hard and soft tissue protuberances or undercutsprotuberances or undercuts

6.6. It should be free from abnormal muscle It should be free from abnormal muscle attachments or scar bands which may attachments or scar bands which may disturb the peripheral seal of the disturb the peripheral seal of the denturedenture

7.7. The relationship between maxillary and The relationship between maxillary and mandibular ridges must be satisfactory mandibular ridges must be satisfactory three-dimensionally-anteroposteriorly three-dimensionally-anteroposteriorly (horizontal), transversely and vertically.(horizontal), transversely and vertically.

Preventive measures (Ridge preservation)Preventive measures (Ridge preservation)

Preventive measures start even when Preventive measures start even when the decision is taken to make the the decision is taken to make the patient edentulous.patient edentulous.1.1. Raising the quality of dental Raising the quality of dental extraction seems to be the simple and extraction seems to be the simple and yet the most effective way.yet the most effective way.2.2. During dental extractions, the During dental extractions, the alveolar socket, which expands, must alveolar socket, which expands, must be carefully compressed back into the be carefully compressed back into the place. Sharp margins should be place. Sharp margins should be trimmed.trimmed.

Cont…. Cont….

3.3. If the soft tissue flap has a tendency If the soft tissue flap has a tendency to gape open, sutures must be to gape open, sutures must be loosely applied to preserve the loosely applied to preserve the desired shape of the alveolar ridgedesired shape of the alveolar ridge

4.4. A little forethought during A little forethought during extractions will help to eliminate the extractions will help to eliminate the probable prosthetic difficulties like probable prosthetic difficulties like irregular alveolar ridge, bulbous irregular alveolar ridge, bulbous tuberosity, unfavorable undercuts tuberosity, unfavorable undercuts and fibrous bands.and fibrous bands.

Ridge corrective procedures Ridge corrective procedures

They are mainly aimed at altering, They are mainly aimed at altering, improving or even replacing the improving or even replacing the tissues of the denture-bearing area.tissues of the denture-bearing area.

When they are done during dental When they are done during dental extractions or before inserting the extractions or before inserting the denture for the first-time, they are denture for the first-time, they are called primary procedures.called primary procedures.

Soft tissue proceduresSoft tissue procedures

Labial Frenectomy: Labial Frenectomy: Labial frenum consists of thin bands of Labial frenum consists of thin bands of

fibrous tissue and a few muscle fibers fibrous tissue and a few muscle fibers covered by mucous membrane.covered by mucous membrane.

It usually extends from the upper lip to It usually extends from the upper lip to the crest of the alveolar ridge. the crest of the alveolar ridge. Sometimes it may extend till the incisive Sometimes it may extend till the incisive papilla.papilla.

Causes denture instability by interfering Causes denture instability by interfering with the peripheral sealwith the peripheral seal

Can be traumatized –ulcers may form, Can be traumatized –ulcers may form, which are painful.which are painful.

Procedure Procedure

LALA Vertical, long, elliptical incision made around Vertical, long, elliptical incision made around

the fibrous bands extending from alveolar the fibrous bands extending from alveolar ridge to the anterior nasal spine.ridge to the anterior nasal spine.

Frenum and muscular components are Frenum and muscular components are dissected from the periosteum deep to dissected from the periosteum deep to vestibular sulcusvestibular sulcus

Sutures – catgut.Sutures – catgut. Suture length can be Improved by Z plasty orSuture length can be Improved by Z plasty or

V-Y procedures.V-Y procedures.

Lingual Frenectomy Lingual Frenectomy

It is necessary when the attachment It is necessary when the attachment of the lingual frenum is high enough of the lingual frenum is high enough to displace the lower denture during to displace the lower denture during functionfunction

Lingual frenum can interfere with Lingual frenum can interfere with speechspeech

This condition is called ankyloglossia, This condition is called ankyloglossia, where tongue movements may be where tongue movements may be restricted.restricted.

Procedure Procedure

LA / GALA / GATongue fixed with a stay sutureTongue fixed with a stay sutureSimilar to labial frenectomy.Similar to labial frenectomy.Care taken to avoid injury to papilla Care taken to avoid injury to papilla

of submandibular ductof submandibular ductAchieve hemostasisAchieve hemostasis

Mobile soft tissue on the alveolar Mobile soft tissue on the alveolar ridge:ridge:

The mobile and unsupported soft The mobile and unsupported soft tissues are often found in the tissues are often found in the anterior maxillary alveolar ridge due anterior maxillary alveolar ridge due to ill-fitting dentures. to ill-fitting dentures.

There may be associated resorption There may be associated resorption of the bone. of the bone.

The mobile soft tissues are The mobile soft tissues are compressible and hence the denture compressible and hence the denture becomes very unstable. becomes very unstable.

Cont…..Cont…..

Rocking movements of the denture Rocking movements of the denture leads to gradual resorption of the leads to gradual resorption of the underlying bone and may even be underlying bone and may even be exposed in the midline anterior to exposed in the midline anterior to the nasal spine. the nasal spine.

The overlying mucosa becomes The overlying mucosa becomes traumatized leading to ulcer traumatized leading to ulcer formation.formation.

Procedure Procedure

Under LA, a linear wedge excision is Under LA, a linear wedge excision is done.done.

To facilitate approximation of the To facilitate approximation of the wound margins, submucous excision wound margins, submucous excision of the fibrous tissue on either side is of the fibrous tissue on either side is done adequately, limiting such done adequately, limiting such dissection to the mobile alveolar soft dissection to the mobile alveolar soft tissues. tissues.

Suturing done. Suturing done.

Denture Granulomas:Denture Granulomas:

Howe classification:Howe classification:

Class I: granulomas of the Class I: granulomas of the masticatory mucosamasticatory mucosa

Class II: granulomas of the lining Class II: granulomas of the lining mucosamucosa

Class III: granulomas at the vestibule, Class III: granulomas at the vestibule, obliterating the sulcusobliterating the sulcus

Cont….Cont….

Usually, surgical defects in class I Usually, surgical defects in class I heal well with minimal scarring.heal well with minimal scarring.

In class II lesions, wound should not In class II lesions, wound should not be closed under tension.be closed under tension.

Sometimes, wide undermining of the Sometimes, wide undermining of the adjacent mucosa may be necessary.adjacent mucosa may be necessary.

Class III lesions will require epithelial Class III lesions will require epithelial cover.cover.

Enlarged Tuberosity:Enlarged Tuberosity:

Idiopathic fibrous hyperplasia found in Idiopathic fibrous hyperplasia found in relation to the maxillary posterior teeth may relation to the maxillary posterior teeth may persist even after the removal of these teeth. persist even after the removal of these teeth.

Such enlarged tuberosity may render the Such enlarged tuberosity may render the denture unstable. denture unstable.

It is seen more on the palatal aspect. It is seen more on the palatal aspect. A three dimensional reduction of such A three dimensional reduction of such

enlarged tuberosity is required to provide enlarged tuberosity is required to provide adequate denture space at the posterior adequate denture space at the posterior region.region.

Procedure Procedure

Under LA, a wedge of soft tissue from Under LA, a wedge of soft tissue from the first molar to tuberosity region is the first molar to tuberosity region is excised. excised.

A cushion of tissue from the A cushion of tissue from the undersurface of the palatal undersurface of the palatal mucoperioseum is also trimmed so mucoperioseum is also trimmed so that wound margins can be that wound margins can be approximated without any tension.approximated without any tension.

Enlarged Retromolar Pad:Enlarged Retromolar Pad:

This is very similar to the enlarged This is very similar to the enlarged maxillary tuberosity, preventing the maxillary tuberosity, preventing the posterior extension of the denture base. posterior extension of the denture base.

Under LA, an elliptical incision is made Under LA, an elliptical incision is made around this hyperplastic region and the around this hyperplastic region and the excess tissue is excised. Thinning of the excess tissue is excised. Thinning of the flap may be necessary. flap may be necessary.

Care to be taken not to remove excess Care to be taken not to remove excess tissue on the lingual side to avoid injury to tissue on the lingual side to avoid injury to the lingual nerve and vessels.the lingual nerve and vessels.

Suturing done.Suturing done.

Thank youThank you