GOOD MORNING PREPROSTHETIC SURGERY INTRODUCTION Preprosthetic surgery is
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GOOD MORNING
PREPROSTHETIC SURGERY
INTRODUCTION Preprosthetic surgery is that part of oral & maxillofacial surgery that restores oral function and facial form rendered deficient through loss or absence of teeth and associated structures as a result of disease, trauma or elective surgery for tumor and other conditions. This is concerned with surgical modification of the alveolar process and its surrounding structures to enable the fabrication of a well fitting comfortable and aesthetic dental prosthesis.
The goal of preprosthetic surgery is to prepare a mouth to receive a dental prosthesis by redesigning and smoothening bony edges or areas and removing excess of flabby soft tissues.
According to Weintraub JA and Burt BA et al in 1985, nearly 10% of the American population, including 35% of those over age of 65, are currently totally edentulous and millions of people have experienced a partial loss of their dentition.
OBJECTIVES OF PREPROSTHETIC SURGERY Objective of the preprosthetic surgery is that to provide a better anatomic environment and to create proper supporting structures for denture construction Preprosthetic surgery is carried out to reform/redesign soft/hard tissues, by eliminating biological hinderances to receive comfortable and stable prosthesis.
CHARACTERISTICS OF IDEAL DENTURE BASE 1. Adequate bone support broad U shaped alveolar ridge with buccal and lingual/palatal cortices as parallel to each as possible. 2. Adequate firm soft tissue coverage – the ridge must have adequate coverage of keratinized firm mucosa with uniform thickness.
3. No bony or soft tissue undercuts or prominences. 4. No sharp ridges. 5. No presence of peripheral fibrous tissue bands(scars)to prevent proper seating of a denture. 6. No high muscle or frenal attachments at the crest of ridge to dislodge the denture. 7. No soft tissue redundancies or hypertrophies on the ridges or in the sulci. 8. No intraoral or extraoral pathology. 9. Proper alveolar ridges relationship in all three planes.
AIMS OF PREPROSTHETIC SURGERY Ø Provide adequate bony tissue support for the placement of RPD/CD(optimum ridge height and width and contour). Ø Provide adequate soft tissue support. Optimum vestibular depth. Ø Estimation of pre existing bony deformities e. g. tori, prominent mylohyoid ridge, genial tubercle.
AIMS OF PREPROSTHETIC SURGERY Ø Correction of maxillary and mandibular ridge relationship. Ø Elimination of pre existing soft tissue deformities, e. g. epulis, flabby ridges, hyperplastic tissues. Ø Relocation of frenal/muscle attachments. Ø Relocation of mental nerve. Ø Establishment of correct vestibular depth.
CAUSES OF ATROPIC & UNEVEN EDENTULOUS RIDGE Due to certain pathological diseases like osteomalacia and osteoporosis, the residual alveolar ridge might resorb. Nutritional deficiency leads to ridge resorption. Prolonged usage of denture. Extraction of mandibular or maxillary teeth in groups or singly at different periods of life may lead to differential resorption of the ridge resulting in a ‘roller – coaster’ type or ‘hills and valleys’ type of ridge.
CAUSES OF ATROPIC & UNEVEN EDENTULOUS RIDGE Improper alveoloplasty techniques. Chronic periodontal diseases results in vertical or horizontal loss of alveolar bone. Presence of sharp buccal plate after extraction. Disuse of alveolar ridge.
RATE OF RIDGE RESORPTION Resorption tend to affect the mandible more severely than the maxilla because of the decreased surface area and less favorable distribution of occlusal forces. Tallgren in 1972, stated that most of the bone loss occurs in the first year of denture wearing and it is ten times greater, than loss seen in the following years.
INDICATIONS Complete or partial edentulism secondary to early tooth loss. Naturally occurring reduction of the residual bony ridge. a. Jaw atrophy b. Mucosal atrophy c. Interarch changes d. Muscle hypotonia e. Facial changes
INDICATIONS Pain due to – a. Mucositis b. Neuropathy c. Temporomandibular joint pain d. Dental roots Dysfuntion of – a. Mastication b. Speech c. Deglutition
PREPROSTHETIC SURGICAL PROCEDURES Classified as : basic procedures advanced surgery procedures The procedures can be carried out for the following: 1. Alveolar ridge correction 2. Alveolar ridge extension 3. Alveolar ridge augmentation. (i) (ii)
ALVEOLAR RIDGE CORRECTION
ALVEOLAR RIDGE CORRECTION BONY SURGERIES i. Labial alveolectomy ii. Primary alveoloplasty iii. Secondary alveoloplasty iv. Excision of Tori v. Reduction of genial tubercle vi. Reduction of mylohyoid ridge vii. Maxillary tuberosity reduction and exostosis removal. SOFT TISSUE SURGERIES i. Removal of redundant crestal soft tissue ii. Frenectomy labial and lingual iii. Excision of epulis fissurata and palatal papillary hyperplasia
BONY SURGERIES ALVEOLECTOMY Surgical removal or trimming of the alveolar process is termed as alveolectomy
ALVEOLOPLASTY Alveoloplasty refers to surgical recontouring of the alveolar process. Primary alveoloplasty is always done at the time of multiple extractions or single extraction.
Anesthesia (local infiltration) Incision & Mucoperiosteal flap reflection (scalpel & periosteal elevator)
Bone removal (chisel & mallet / rongeur) Bone smooth (bone file)
ALVEOLOPLASTY PERFORMED AT TIME OF EXTRACTION
ALVEOLOPLASTY PERFORMED ON THE EDENTULOUS RIDGE
DEAN’s INTRASEPTAL ALVEOLOPLASTY
DEAN’s INTRASEPTAL ALVEOLOPLASTY
OBWEGESER’s MODIFICATION FOR INTRASEPTAL ALVEOLOPLASTY
ALVEOLOPLASTY AFTER THE POST EXTRACTION HEALING Usually done in cases of multiple extractions carried out at different times.
REDUCTION OF GENIAL TUBERCLES
REDUCTION OF MYLOHYOID RIDGE There will be concavity present immediately below the alveolar crest with prominence of mylohyoid ridge below.
EXCISION OF TORI
PALATAL TORUS EXCISION INCISION SEGMENTING WITH FISSURE BUR FLAP REFLECTION
REMOVAL OF BONE SMOOTHENING SUTURING
INDICATIONS FOR EXCISION OF TORI An extremely large torus, filling the palatal vault. A large torus, that may extend beyond the post dam area. Ulceration/ traumatization/ hyperkeratinization of the overlying mucosa. Deep bony undercuts. Interference with the function, speech & deglutition. Psychological consideration malignancy/cancer phobia. Food lodgement under the folds and projection of the tori
EXCISION OF MANDIBULAR TORI PRE OP RADIOGRAPH MANDIBULAR TORI
UNDERMINE THE TORI WITH FISSURE BUR REMOVE THE BONE WITH CHISEL
SUTURING POST OP RADIOGRAPH
MAXILLARY TUBEROSITY REDUCTION
SOFT TISSUE SURGERIES 1. Removal of redundant crestal soft tissue 2. Denture granuloma or hyperplasia 3. Excision of epulis fissurata 4. Palatal papillary hyperplasia 5. Frenectomy
SOFT TISSUE SURGERIES Removal of redundant crestal soft tissue
FRENECTOMY INDICATIONS – High attachments of labial frenum or fibrous bands attached near the alveolar crest in the buccal regions, often displace the dentures during function.
LABIAL FRENECTOMY Whenever there is lot of tissue is available then a cross diamond excision is used. The base of the frenum at the alveolar crest is grasped with hemostat and incision is taken below and above the hemostat. The surgical defect is created by excision of fibrous band. The closure can be done by interrupted sutures. The small defect at the alveolar crest can be left to granulate.
Aim of surgery 1. To correct speech 2. Prior to denture construction 3. To improve the tongue mobility
TECHNIQUE LA bilateral lingual nerve block with local infiltration. Tongue traction suture is taken to improve visibility and control and stabilization of the tongue during procedure. One hemostat can be placed at the anterior attachment of the frenum to the tongue and another hemostat be placed at the inferior attachment to the ridge. A cross diamond incision along the edge of both the hemostats is made. Submucosal dissection on either sides to undermine lingual and sublingual mucosa is carried out. Dissection of genioglossus muscle fibers is done, if necessary. Care is taken to avoid damage to the submandibular duct orifice. Suturing done in vertical manner.
COMPLICATIONS Intraoperative complications Injury to superior lingual vessels Injury to Wharton's duct/papilla. Postoperative complications Hematoma in the floor of the mouth Pain, restricted tongue movements Partial dysphasia.
RIDGE EXTENTION PROCEDURES
RIDGE EXTENSION PROCEDURE INDICATIONS – Whenever there is an inadequate vestibular depth present. To increase the retention and stability of the denture. Deepening of the vestibule is considered
VESTIBULOPLASTY Deepening of the vestibule without any addition of the bone is termed as vestibuloplasty or sulcus deepening procedure. Mandibular techniques are further divided into two categories: 1. Those done on the labial side 2. Those done on the lingual side
LABIAL VESTIBULAR PROCEDURES 1. Kazanjian Technique(1924) 2. Godwin's Modification (1947 ) 3. Clark's Technique 4. Obwegeser's Modification (1959)
LINGUAL VESTIBULOPLASTY v. Floor of the mouth extension or floor of the mouth lowering can be done by following methods: 1. Trauner's Technique 2. Caldwell's Technique
OTHER VESTIBULOPLASTY TECHNIQUES Obwegeser's technique (Combination of Buccal and Lingual Vestibuloplasty) Submucosal Vestibuloplasty Technique Maxillary ’pocket inlay’ vestibuloplasty (obwegeser)
Kazanjian Technique (1924) Uses mucosal flap from the inner aspect of the lower lip to increase the depth of the anterior mandibular labial vestibule. Carried out in premolar to premolar region only. Raw area is left on the lip side to heal by secondary intention. Periosteum on the bone is left intact.
PROCEDURE A submucosal dissection is done from the inner aspect of the lower lip to the mucogingival junction, near the alveolar crest on the labial side. A supraperiosteal dissection is directed inferiorly to remove muscle and connective tissue attachments to the desired vestibular depth. The raised mucosal flap is adapted to the depth of the new vestibule and fixed with the sutures or a stent. The raw area on the lip is left alone.
DRAWBACK – Severe scarring of the lip mucosa, may decrease the flexibility of the lower lip Poor long term results.
GODWIN'S MODIFICATION (1947) Mucosal incision on the inner aspect of the lip is designed longer than the proposed vestibular depth to be achieved.
CLARK'S TECHNIQUE Supraperiosteal flap based on the inner aspect of the lip. Leaves raw surface on the bone, covering the inner lip surface, thereby reducing bleeding, postoperative pain and scarring. An incision is started slightly labial to the crest along the alveolar ridge.
Mucosal flap based on the inner aspect of the lip is undermined, till vermilion border, to ensure adequate mobility and overcorrection. Supraperiosteal dissection is done, along the labial surface of the alveolar bone till the desired vestibular depth.
CLARK’s TECHNIQUE Edge of the mobilized flap is pushed into the new vestibular depth area and held in position by sutures passed through the chin area extraorally and tied around cotton roll or rubber catheter placed below the chin. As the alveolar bone is covered by periosteal layer, it heals quickly by granulation. Success rate is better than Kazanjian method.
CLARK’s TECHNIQUE
Obwegeser's Modification (1959) Similar to Clark's method, except the area of the alveolar bone with it's periosteal attachment is covered with a split thickness skin graft and held in position by sutures or stent constructed preoperatively. Instead of skin, mucosal graft has also been tried. Covers the bone and ensures faster healing. Reduces chances of postoperative infection Less bone loss and scarring
LINGUAL VESTIBULOPLASTY TRAUNER’s TECHNIQUE Used for increasing the depth of the floor of the mouth in the mylohyoid region Incision given over lingual side of the alveolar ridge bilaterally, in the posterior region or from second molar to second molar region Supraperiosteal dissection is done to identify mylo hyoid muscle Instrument is passed below mylohyoid muscle and muscle separated from the bony attachment
Care is taken to avoid lingual nerve damage. Fixation of incisal edge of the mylohyoid muscle to a new desired vestibular depth on lingual side by: a. Sutures passed extra orally over the skin at the inferior border of the mandible b. Placement of the skin graft and preformed denture / stent.
CALDWELL'S TECHNIQUE Entire lingual mucoperiosteal flap is reflected from molar to molar region. Mylohyoid ridge is reduced/removed along with the reduction of genial tubercle.
Mylohyoid muscle and superficial fibres of genio glossus muscles are pushed inferiorly. Rubber tubing placed in the lingual vestibule and the flap is held in position at the vestibular depth, by sutures passed through the skin extraorally, at the inferior border of the mandible
OBWEGESER'S TECHNIQUE (COMBINATION OF BUCCAL AND LINGUAL VESTIBULOPLASTY) Incision is given on the alveolar ridge Mucosal flap raised buccally and lingually Mylohyoid muscle attachment and only superficial fibres of genioglossus muscle are separated on the lingual side
OBWEGESER'S TECHNIQUE (COMBINATION OF BUCCAL AND LINGUAL VESTIBULOPLASTY) Edges of buccal and lingual flaps attached/ sutured to each other, below inferior border of the mandible Skin graft is placed over entire alveolar ridge Preformed acrylic stent/ denture placed and fixed to the mandible, with circummandibular wiring.
SUBMUCOSAL VESTIBULOPLASTY TECHNIQUE
RIDGE AUGMENTATION PROCEDURES
RIDGE AUGMENTATION PROCEDURES AIMS – Restoration of optimum/near optimum ridge height and width, ridge form, vestibular depth and optimum denture bearing area Protection of neurovascular bundle Establishment of proper interarch relationship Improvement of retention and stability of denture Improve the patient comfort for wearing the denture.
RIDGE AUGMENTATION PROCEDURES A. Mandibular augmentation 1. Superior border augmentation a. Bone grafts b. Cartilage grafts c. Alloplastic grafts. 2. Inferior border augmentation a. Bone grafts (autogenous or allogenic freeze dried cadaveric mandible) b. Cartilage grafts. 3. Interpositional or Sand witch bone grafts a. Bone grafts b. Cartilage grafts c. Hydroxyapatite blocks. 4. Visor osteotomy. 5. Onlay grafting autogenous, alloplastic, allogenic material.
RIDGE AUGMENTATION PROCEDURES B. Maxillary augmentation 1. Onlay bone grafting autogenous I 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.
MATERIALS USED FOR AUGMENTATION OF ALVEOLAR RIDGE Autogenous bone graft iliac crest, rib grafts. Allogenic bone grafts freeze dried cadaver bone. Alloplastic material hydroxyapatite. Metal mesh with autogenous cancellous bone. Metal mesh with hydroxyapatite.
MANDIBULAR AUGMENTATION Superior border grafting/augmentation
INFERIOR BORDER GRAFTING Indicated when the alveolar ridge is less than 5 to 8 mm in height and is at a risk of pathologic fracture. First described by Marx and Saunders (1986) Modified by Quinn (1991) – used for augmentation of atrophic ridge and subsequent placement of implants.
INTERPOSITIONAL BONE GRAFTS (SANDWICH GRAFTING) A horizontal osteotomy is performed, splitting of the residual maxilla or mandible and bone is grafted into this osteotomy gap. In mandible, sandwich technique is mainly used for augmentation of the anterior mandible, between the mental foramina.
ADVANTAGES Less resorption rate than onlay grafting. More predictable long term results. Decreased incidence of nerve paraesthesia than the. visor osteotomy. Can be used in conjunction with osseointegrated implants
VISOR OSTEOTOMY The Visor osteotomy consists of central splitting of the mandible in buccolingual dimension and the superior positioning of the lingual section of the mandible, which is wired in position. Cancellous bone graft material is placed at the outer cortex over the superior labial junction for improving the contour.
MODIFIED VISOR OSTEOTOMY Consists of splitting of mandible buccolingually by vertical osteotomy only in the posterior regions and a horizontal osteotomy in the anterior region
MODIFIED VISOR OSTEOTOMY Advantage – Eighty per cent of the height is maintained at the end of 3 5 years. Disadvantages – Nerve paraesthesia and dysaesthesia. Need for hospitalization. Donor site morbidity. Inability to wear the dentures for 3 to 5 months following surgery.
SINUS LIFT PROCEDURE It is mainly used to assist with the placement of osseointegrated implants in the posterior maxilla. Due to pneumatization of the maxillary sinus and atrophy of the ridge, the sinus floor is lowered almost to the crest of the alveolar ridge in the posterior region.
SINUS LIFT PROCEDURE In order to improve the implant support, the bone graft is placed between the sinus lining and the inner aspect of the alveolar crest or floor of the maxillary sinus in the posterior maxilla.
BIBLIOGRAPHY CONTEMPORARY ORAL & MAXILLOFACIAL SURGERY – Larry J Peterson ORAL & MAXILLOFACIAL SURGERY – Daniel M Laskin AN INTRODUCTION TO ORAL & MAXILLOFACIAL SURGERY – David A Mitchell OSSEOUS SURGERY - Xudong Wang, DDS, MD
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