evolution in preprosthetic surgery current trends: a...

Drug Invention Today | Vol 10 • Issue 10 • 20182010

Evolution in preprosthetic surgery current trends: A reviewSahil Choudhari1, V. Rakshagan2, Ashish R. Jain2*

INTRODUCTIONThe preparation of your mouth before the placement of a denture (or prosthesis) is referred to as preprosthetic surgery. Some patients require minor oral surgical procedures before receiving a partial or complete denture, to ensure the maximum level of comfort.[1] A denture sits on the bone ridge, so it is very important that the bone is the proper shape and size. One of several procedures might need to be performed to prepare your mouth for a denture including bone smoothing and reshaping, removal of excess bone, and/or removal of excess gum tissue.[2]

In the average person, satisfactory dentures can be constructed without many difficulties a few weeks or months after being rendered fully edentulous and such dentures usually render several years of trouble-free service.[3] However, if the resorption of the alveolar process progresses at an abnormally fast rate, such as in prolonged use of an ill-fitting appliance and problems associated with poor retention may develop.[4] The alveolar process initially develops as the teeth calcify and erupt, a phenomenon that takes place with both the primary and permanent dentitions. This process stimulates the alveolar process to grow

Review Article

1Department of Prosthodontics and Implant Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India, 2Department of Prosthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India

*Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha University, Poonamallee High Road, Chennai – 600 127, Tamil Nadu, India. Phone: +91-9884233423. E-mail: [email protected]

Received on: 25-04-2018; Revised on: 17-04-2018; Accepted on: 14-06-2018

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Website: jprsolutions.info ISSN: 0975-7619

and leads to the shape of the fully-grown jaws of the adult.[5] This growth is a result of the remodelling of bone and, as in the whole skeleton, is brought about by the processes of resorption and deposition. As soon as the physiological function of the teeth is lost, there is no longer a functional stimulation of the alveolar process, and the resorption process becomes dominant.[6] Differences in the shape of the upper and lower alveolar ridges result in:1. A reduction in the height of the residual ridges2. An increase in inter-arch distance3. A prognathic mandible in profile4. In the horizontal plane, the maxillary arch becomes

narrower and the mandibular arch wider as resorption progresses.[7]

TYPES OF PREPROSTHETIC SURGERY• Respective• Recontouring• Augmentation.

Involved Areas• Osseous tissues• Soft tissues.

Category of Patient• Completely edentulous patient• Partially edentulous patient.

ABSTRACT

The aim of preprosthetic surgery is to prepare the soft and hard tissues of the jaws for a comfortable prosthesis that will restore oral function, esthetics, and facial form. It helps to restore the function of the jaws (mastication of food, speech, and swallowing), preserve or improve jaw structure, improve the patient’s sense of well-being, and improve facial esthetics. One of several procedures might be performed to prepare the mouth for a denture, which includes bone smoothening and reshaping, removal of excess bone, and removal of excess gum tissue. This paper reviews these major procedures briefly outlining the surgical procedure, and discusses the indications and techniques of these procedures.

KEY WORDS: Esthetics, Preprosthetic, Prosthesis

Sahil Choudhari, et al.

2011Drug Invention Today | Vol 10 • Issue 10 • 2018

Alteration of Alveolar Bone• Removing of undesirable features/contours• Osseous plasty/shaping/recontouring• Bone reductions• Bone repositioning• Bone grafting.

Soft Tissue Modifications• Soft tissue plasty/recontouring• Soft tissue reductions• Soft tissue excisions• Soft tissue repositioning• Soft tissue grafting.[8]

The mandible is subjected to the effect of early atrophy to a much greater extent than the maxilla, and many reasons for this are postulated. Most are based on the vascular phenomena related to the changing blood supply to the mandible that occurs with increasing age, with a consequence that periosteal compression by a prosthesis results in ischemia which hastens the rate of bone loss.[9] Studies have shown that diminished blood flow through the inferior alveolar canal may be the cause of reversal in flow from a centrifugal arterial supply to a reduced periosteal supply. This diminished blood supply, possibly due to atherosclerotic changes, is thought to be a prime cause of presenile atrophy of the mandible.[10] In practice, this advanced resorption is seen as knife-edge alveolar ridges and sharp, undercut mylohyoid ridges, and in extreme cases, mental foramina that lie on top of the residual ridge where the pressure of the denture on the mental nerve is a considerable source of discomfort.[11]

The resorptive process in the maxilla also results in a decrease in the denture-bearing area as the arch becomes smaller in all dimensions. The incisive foramen comes nearer to the crest of the ridge and, as in the mandible, resorption can also result in a ridge that is “knife-edged.”[12] Frequently, there are sharp spiny processes on the maxillary and palatal bones which may become painful due to the pressure of the denture. Buccally and labially, the vestibules become less pronounced as the adjacent muscles attach relatively high on the alveolar ridge.

All these soft and hard tissue discrepancies make the construction of an ideal prosthesis extremely difficult.[13] The result may even be denture-bearing areas so atrophic that support, retention, and stability of any prosthesis becomes a nightmare, both for the dentist who has to make the denture and for the patient who has to wear it.

Surgical Treatment Includes• Recontouring of alveolar ridges (alveoplasty,

maxillary tuberosity reduction, exostosis, and removal of palatal torus)

• Removal of soft tissue abnormalities (maxillary tuberosity reduction, Unsupported hypermobile tissue, and Inflammatory fibrous hyperplasia)

• Frenectomy• Augmentation/bone grafts/sinus lift• Vestibuloplasty• Vestibule and floor of mouth extension procedures.[14]

OBJECTIVE OF PREPROSTHETIC SURGERYCorrecting conditions that preclude optimal prosthetic function1. Hyperplastic replacement of resorbed ridges2. Unfavorably located frenular attachments3. Bony prominences, undercuts.[15]

ALVEOLOPLASTY [Figures 1-23]An alveoloplasty (also referred to as alveoplasty) is a surgical procedure used to smooth and reshape a

Figure 1: Pre-operative photograph

Figure 2: Alveoloplasty of the maxilla with a continuous suture. (Picture courtesy: Dr. Kambiz Kevin Sadraei, DDS)

Figure 3: Alveoloplasty procedure



patient’s jawbone in areas where teeth have been extracted or otherwise lost.

The purpose of this procedure can be two-fold:1. When performed before (partial or complete)

denture construction, it’s used to optimize the shape of the patient’s jawbone (ridge) so to avoid

complications with appliance insertion, comfort, stability, and/or retention

2. When performed in association with tooth extractions, it also establishes a jawbone shape that helps to facilitate the healing process that follows

3. An alveoplasty also aims to facilitate the healing procedure as well as the successful placement of a future prosthetic restoration.[16]

Faster healing is important for certain people, such as cancer patients. They may need to have decayed teeth extracted before they receive radiation therapy to the head or neck. Radiation can “dry up” the salivary glands and reduce blood flow to the jaw, increasing the risk of further decay and infection of the jaw bones (osteoradionecrosis). Once the teeth are removed,

Figure 4: Implant procedure

Figure 5: Finished alveoloplasty with two implants. (Picture courtesy: Dr. Daniel Fortino, DDS)

Figure 6: Pre-operative photograph

Figure 7: Epulis fissuratum removal and vestibuloplasty

Figure 8: 2 weeks post-operative photograph. (Picture courtesy: Dr. Fidan Berker, prosthodontist)

Figure 9: Pre-operative view of the mandible

Figure 10: Resorbing sutures used in a horizontal manner to retain the lip mucosa to the depth of the vestibuloplasty



radiation therapy cannot begin until the sockets are healed.[17]

REDUCTION OF GENIAL TUBERCLEThe genial tubercles are extremely prominent as a result of advanced ridge reduction in the anterior part of the body of the mandible. If the activity of the genioglossus muscle has a tendency to displace the lower denture, the genial tubercle is removed and the genioglossus muscle detached.[18] Genial tubercles are

the bony projections located on the lingual aspect of the mandible, two on either side of the midline, which gives attachment to the genial muscles. The two genial tubercles located superiorly are more prominent than the inferior ones due to the gross resorption of the mandibular ridge.[19] This may elevate the ridge lingually, giving a shelf-like appearance and making the anterior lingual seal impossible. Genial tubercles are exposed by blunt dissection. Using bur, chisel, or rongeurs, the tubercle is removed, and the rough bony margins are smoothened using file.[4]

VESTIBULOPLASTYVestibuloplasty should be performed in case of the shallow vestibule to widen denture-bearing area. There

Figure 11: 3-week follow-up photograph showing healing of the site. (Picture courtesy: Dr. Onur, DDS)

Figure 12: Bilateral fibrous tuberosities

Figure 13: Reduction of tuberosities. (Picture Courtesy: www.exodontia.info)

Figure 14: Lower jaw tori

Figure 15: Tori bone removed. (Picture courtesy: Dr. Ramsey Amin, DDS)

Figure 16: Frenectomy pre-operative photograph



are different techniques of vestibuloplasty. Most of them provide access from the buccal aspect of the mandible.[4]

KAZANJIAN VESTIBULOPLASTYA mucosal flap pedicled from the alveolar ridge is elevated from the underlying tissue and sutured to the depth of the vestibule. The inner portion of the lip is allowed to heal by secondary epithelialization.[4]

CLARK VESTIBULOPLASTYClark’s vestibuloplasty technique uses mucosa pedicled from the lip. Horizontal incision is performed from

canine to canine between immobile gingiva and mobile gingiva.[4] After supraperiosteal dissection the mucosa is sutured at the depth of the vestibule. The denuded periosteum heals by secondary epithelialization. It is possible to use tissue graft on exposed periosteum. The healing process is more rapid in this situation.[3]

CORN VESTIBULOPLASTYThis vestibuloplasty is similar to Clark’s vestibuloplasty. Difference: Horizontal incision is through soft tissue/mucosa and periosteum/to the mucoperiosteal flap is dissected, and the bone is exposed. Disadvantages: More painful procedure; The healing process is longer.[3]

OBWEGESER VESTIBULOPLASTYVestibuloplasty described by Obwegeser is the method in which labial extension procedure and Trauner’s procedure provide a maximal vestibular extension to both the buccal and lingual aspects of the mandible.[3]

MAXILLARY TUBEROSITY REDUCTION: (SOFT TISSUE)The primary objective of soft tissue maxillary tuberosity reduction is to provide adequate interarch space for proper denture construction in the posterior area and a firm mucosal base of consistent thickness over the alveolar ridge denture-bearing area.[3] Maxillary tuberosity reduction may require the removal of soft tissue and bone to achieve the desired

Figure 17: 2 weeks post-operative photograph. (Picture courtesy: Dr. Daniel Lapalma)

Figure 18: Maxillary horizontal ridge augmentation

Figure 19: Bone grafting

Figure 20: Post-operative photograph. (Picture courtesy: Dr. Mark Hennis, DDS)

Figure 21: Knife-edge residual alveolar ridge

Figure 22: Residual alveolar ridge being augmented

Figure 23: Post-operative photograph. (Picture courtesy: Dr. Brian T. Young, MS)



result. The amount of soft tissue available for reduction can often be determined by evaluating a pre-surgical panoramic radiograph.[3] If a radiograph is not of the quality necessary to determine soft tissue thickness, this depth can be measured with a sharp probe after local anesthesia is obtained at the time of surgery. Local anesthetic infiltration in the posterior maxillary area is sufficient for a tuberosity reduction.[20] An initial elliptic incision is made over the tuberosity in the area requiring reduction, and this section of tissue is removed. After tissue removal, the medial and lateral margins of the excision must be thinned to remove excess soft tissue, which allows further soft tissue reduction and provides a tension-free soft tissue closure.[20] This can be accomplished by digital pressure on the mucosal surface of the adjacent tissue while sharply excising tissue tangential to the mucosal surface. After the flaps are thinned, digital pressure can be used to approximate the tissue to evaluate the vertical reduction that has been accomplished.[21] If the adequate tissue has been removed, the area is sutured with interrupted or continuous suturing techniques. If too much tissue has been removed, no attempt should be made to close the wound primarily. Sutures are removed in 5–7 days, and impressions can generally be taken 3–4 weeks postoperatively.[21]

MANDIBULAR TORIMandibular tori are bony exophytic growths that are present on the lingual aspect of the mandible, opposite to the bicuspids. They present in early midlife and tend to grow with age. Mandibular tori occur in 6–7% of the population. The etiology of exostosis is multifactorial including genetic and functional influences.[21]

TORI CAN BE CATEGORIZED BY THEIR APPEARANCE1. Flat tori - arising as a broad base and a smooth

surface, are located on the midline of the palate and extend symmetrically to either side

2. Spindle tori - have a ridge located at their midline3. Nodular tori - have multiple bony growths that each

have their own base4. Lobular tori - have multiple bony growths with

a common base. The torus may be bosselated or multi-lobulated, but the exostosis is typically a single, broad-based, smooth-surfaced mass, perhaps with a central sharp, and pointed projection of bone-producing tenderness immediately beneath the surface mucosa.[21]

It is believed that mandibular tori are caused by several factors. They are more common in early adult life and are associated with bruxism. The size of the tori may fluctuate throughout life, and in some cases, the tori can be large enough to touch each other in the

midline of mouth.[21] Consequently, it is believed that mandibular tori are the result of local stresses and not solely on genetic influences.

INDICATION FOR REMOVAL OF MANDIBULAR TORI1. Interfere with tongue positioning2. Speech interference3. Prosthodontic reconstruction4. Patient with poor oral hygiene around the lower

posterior teeth5. Traumatic ulceration from mastication.[22]

FRENECTOMYA frenectomy is the surgical alteration of a frenum which is a fold of tissue which restricts movement. In the mouth, this is generally a small portion of tissue related to the upper lip, the tongue, or the lower lip.[22]

Usually, one end of the frenum is connected to a muscular part of the body, such as the tongue or lip and the other to a relatively static part such as the floor of the mouth in the case of the tongue, or to the gums in the case of the upper lip.[22]

Too much restriction of movement of the tongue, for example, is not necessarily a good thing since it can interfere with normal function and this is why a frenectomy may be required.

There are three types that vary on the location of the problem in the mouth:1. Sometimes the frenum associated with the upper lip,

which is in the midline, tends to cause or exacerbate spacing between the upper two front teeth (central incisors) and this may be considered unpleasing to the eye. Such a marked frenum extending well down into the gum can also be a barrier to an orthodontist being able to close up a mid-line gap between the front teeth and so a maxillary frenectomy would be indicated.[22]

2. There is sometimes a similar situation in the lower jaw where an extensive frenum can be associated with the separation of the incisor teeth or can cause the gum to pull away (recede) from the neck of one or more lower front teeth. This would invite food debris to lodge and gum disease to follow so is again an indication for a frenectomy.[22]

3. The third most common type of undesirable frenum in the mouth is that which connects the underside of the tongue to the floor of the mouth. If this is extensive, running almost up to the tip of the tongue, it can seriously restrict its movement, causing speech difficulties, and adversely affecting oral hygiene.[23] This condition is termed ankyloglossia, or more commonly being “tongue-tied.” The



condition is usually noticed in the young child when difficulty feeding or learning to speak become apparent. A “lingual” frenectomy is required here.

The surgery is a straightforward and quite common dental procedure performed both on children and sometimes adults. A child might receive speech therapy first before resorting to the procedure although it is not a major operation by any means.[22,23]

Adults who have no natural teeth remaining and require full dentures may need a frenectomy in one or more locations if a marked frenum is tending to unseat a denture. This is more common in the lower jaw where the amount of bony ridge to hold a denture is much less than in the upper jaw.[21-23]

RIDGE AUGMENTATIONSuperior Border AugmentationIt was described by Davisin the year 1970. This procedure is indicated when mental foramen is situated in the superior border. In this procedure, autogenous bone graft is used. The rib graft can be fixed to the superior border of the mandible.[20-23] Two segments of the rib, about 15 cm long, are obtained from the 5th to 9th ribs. The rib is contoured by vertical scoring in the inner surface. The second rib is cut into small pieces to later pack against the solid rib. Fixation is done by means of transosseous wiring or circumferential wiring.[22,23]

Disadvantages1. Morbidity of the donor site2. Secondary surgical site3. Necessity of the patient to withdraw denture until the

surgical wound heals for a period of 6–8 months.[23]

Inferior Border Augmentation - Visor OsteotomyThis technique was first described by Sanders and Cox in the year 1986 for reconstruction of a resected mandible. This procedure is indicated to prevent and manage fractures of an atrophic mandible. Visor osteotomy was described by Harle to overcome the resorption of free onlay bone graft.[20-23] This technique is followed where the muscle insertion to the mandible and nutrient supply is maintained. In this procedure, the mandible is divided buccolingually by a vertical osteotomy from external oblique ridge of one side of the mandible to the other side. The osteotomized lingual segment is pushed superiorly and fixed with the buccal segment using stainless steel wire in the lower border of the lingual segment.[3,20-23]

REFERENCES1. Taylor RL. A chronological review of the changing

concepts related to modifications, treatment, preservation, and augmentation of the complete denture basal seat. Prosthodont Soc Bull 1986;16:17-39.

2. Hopkins R. A Colour Atlas of Preprosthetic oral Surgery. Vol. 2. London: Wolfe Medical Publications; 1987. p. 136-43.

3. Lytle RB. Complete denture construction based on a study of deformation of the underlying soft tissues. J Prosthet Dent 1959;9:539-51.

4. Mercier P, Lafontant R. Residual alveolar ridge atrophy: Classification and influence of facial morphology. J Prosthet Dent 1979;41:90-100.

5. Wowern N. Bone mineral contents of mandibles: Normal reference values–rate of age-related bone loss. Calcif Tissue Int 1988;43:193-8.

6. Bradley JC. A radiological investigation into the age changes of the inferior dental artery. Br J Oral Surg 1975;13:82-90.

7. Tideman H. A technique of vestibular plasty using a free mucosal graft from the cheek. Int J Oral Surg 1972;1:76-80.

8. Hark F. Visor osteotomy to increase the absolute height of the atrophied mandible. A preliminary report. J Maxillofac Surg 1975;3:257-60.

9. Davis WH, Delo RG, Ward WB, Terry B, Patakos B. Long-term ridge augmentation with rib graft. J Maxillofac Surg 1975;11:103-6.

10. Steinhauser E, Obwegeser H. Rebuilding the alveolar ridge with bone and cartilage autografts. Trans Congr Int Assoc Oral Surg 1967;24:203-8.

11. Gerry RG. Alveolar ridge reconstruction with osseous autograft: Report of a case. J Oral Surg 1956;114:74-8.

12. Liposky RB. Use of the mandibular staple bone plate with augmentation in bone grafts. J Oral Maxillofac Surg 1971;29:792-8.

13. Schnitman PA, Shulman LB. Recommendations of the consensus development conference on dental implants. J Am Dent Assoc 1979;98:373-7.

14. Adell R, Lekholm U, Rockler B, Brznemark PI. A 15 year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416.

15. Boyne P. The science of alveolar ridge augmentation. Compend Contin Educ Dent 1982;Suppl 2:S49.

16. Topazian RG, Hammer WB, Boucher LJ, Hulbert SF. Use of alloplastics for ridge augmentation. J Oral Surg 1971;29:792-8.

17. Stoelinga PJ, de Koomen HA, Tideman H, Huijberg TJ. A reappraisal of the interposed bone graft augmentation of the atrophic mandible. J Maxillofac Surg 1983;11:107-12.

18. Lekkas K. Absolute augmentation of the mandible. Int J Oral Surg 1977;6:147-52.

19. Hopkins R. A Colour Atlas of Preprosthetic Oral Surgery. Vol. 55. London: Wolfe Medical Publications; 1987. p. 136-43.

20. HIllerup S. Preprosthetic mandibular vestibuloplasty with split-skin graft: A two-year follow-up study. Int J Oral Maxillofac Surg 1987;16:270-8.

21. Bays RA. The pathophysiology and anatomy of edentulous bone loss. In: Fonseca R, Davis W, editors. Reconstruction Pre-prosthetic Oral and Maxillofacial Surgery. Vol. 34. St. Louis: Journal of Prosthetic Dentistry; 1999. p. 456-9.

22. Quayle AA. The atrophic mandible: aspects of technique in lower labial sulcoplasty. Br J Oral Surg 1979;16:169-78.

23. Tallgren A. The continuing reduction of residual alveolar ridges in complete denture wearers: Mixed longitudinal study covering 25 years. J Prosthet Dent 1972;27:120-32.

Source of support: Nil; Conflict of interest: None Declared

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