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INTRODUCTION
Preprosthetic surgery is a surgical procedure designed
to facilitate fabrication of a prosthesis to improve the
prognosis of prosthodontic treatment. In 1967 the
principles of Preprosthetic reconstructive surgery were
first introduced by MacIntosh and Obwegeser.1,2
Every dental surgeon should have a thorough
knowledge of the conditions which favour success in
denture construction, for carefully planned and
executed surgery can prevent the occurrence of many
undesirable features and can eliminate others, either at
the time teeth are extracted or later.3,4
Patient Evaluation
Before any surgical or prosthetic treatment a thorough
evaluation outlining the problems to be solved and a
detailed treatment plan should be developed for each
patient.1
Initial preoperative examination:
Patient’s past medical history and current medical
status must be reviewed with particular attention to
allergies, drug idiosyncrasies, and medications.
Haemorrhages tendencies or systemic disorders which
would complicate anaesthetics procedures, increase
surgical risk etc.1
Secondary preoperative examination: patients
frequently have oral tissues which have been abused
and distorted by their existing malfitting prosthesis.1
Evaluation of supporting bony tissues: includes
visual inspection, palpation, radiographic examination
and cases evaluation of models. The remaining
mandibular ridge should be evaluated visually overall
ridge form and contour, gross ridge irregularities, tori
and buccal exostosis Cephalometric radiographics
may also be helpful in evaluating the cross sectional
configuration of the anterior mandibular ridge area and
ridge relationship.1
Surgical procedures for removable prosthesis:
A. Bony recontouring procedures
Simple Alveoloplasty Associated With Removal of
Multiple Teeth
Alveoplasty is contouring of the alveolar ridge to
remove any irregularities and undercuts. The goals
are to provide a stable base for the prosthesis and
REVIEW ARTICLE
Preprosthetic surgery: A review of literature
Prachi Madan Rohilla1, Manish Kumar2, Ulfat Majeed2, Akanksha Singh2
ABSTRACT
Following the loss of natural teeth after extraction, the bone begins to resorb. The results of this resorption are
accelerated by wearing dentures and tend to affect the mandible more severely than the maxilla. Preprosthetic
surgical treatment must begin with a thorough history and physical examination of the patient. One component that
can profoundly affect treatment success is the condition of the denture-bearing tissues. In preprosthetic surgery
every effort should be made to ensure that both the hard and soft tissues are developed in a form that will enhance
the patient’s ability to wear a denture.
Keywords: Alveoloplasty, Ridge augmentation, Osteopromotion, Vestibuloplasty, Sinus lift.
1. Senior lecturer.
2. Post Graduate Student. Department of
Prosthodontics and Crown & Bridge
*Correspondence Author:
Dr. Manish Kumar (P.G. Student) Kothiwal Dental
College and Research Centre, Mora Mustaqeem
Moradabad.
Email: [email protected]
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preserve as much alveolar bone as possible. Always
be conservative when removing the bone.1
Fig.1: Simple Alveoloplasty
Intraseptal Alveoloplasty- An alternative to the
removal of alveolar ridge irregularities by simple
alveoloplasty technique is the use of an intraseptal
alveoloplasty, or dean’s technique, involving
removal of intraseptal bone and the repositioning of
the labial cortical bone, rather than removal of
excessive or irregular areas of the labial cortex.2
Fig. 2: Intraseptal Alveoloplasty
Maxillary Tuberosity Reduction:
The maxillary tuberosities are found to be abnormally
large in a considerable number of edentulous patients
and in the vast majority of cases this enlargement is
due to an excess of white fibrous tissue.5
Fig 3: Maxillary Tuberosity Reduction
Buccal Exostosis and Excessive Undercuts:
Exostosis generally require removal, small undercut
areas are often best treated by being filled with either
autogenous or allogenic bone material. such situation
might occur in the anterior maxilla or mandible, where
removal of the bony buccal protuberance results in
narrow crest in the alveolar ridge area and a less
desirable area of support for the denture ,as well as an
area that may resorb more.
Fig 4: Removal of Buccal Exostosis
Lateral Palatal Exostosis:
The lateral aspect of the palatal vault may be
somewhat irregular because of the presence of lateral
palatal exostosis. This presents problems in denture
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construction because of the undercut created by the
Exostosis and the narrowing of the palatal vault.
Mylohyoid Ridge Reduction:
For most parts of the denture border, the limits of the
functional anatomy are determined by muscles in
activity; this activity may be favourable or
unfavourable depending on the direction of the muscle
fibres relative to the denture base.6
Genial tubercle reduction:
As the mandible begins to undergo resorption, the area
of attachment of the genioglossus muscle in the
anterior portion of the mandible may become
increasingly prominent. In some cases the tubercle
may actually function as shelf against which the
denture can be constructed, but it usually requires
reduction to construct the prosthesis properly. 1,2,3,4
Tori Removal:
After teeth are lost, tori may complicate or even
preclude denture fabrication. Large, lobulated tori
with undercuts must be treated, whereas the restoring
dentist may deem smaller, smooth, broad-based tori
insignificant.7
Fig 5; a, b : Surgical Process of Palatal Torus
removal
Fig 5; c : Surgical Process of Palatal Torus removal
B. Mandibular Augmentation
Superior Border Augmentation- Superior border
augmentation with a bone graft is occasionally
indicated when severe resorption of the mandible
results in inadequate height and contour potential risk
of fracture or when the treatment plan calls for
placement of implants in areas of insufficient bone
height or width.8,9( .
Fig.6: Superior Border Augmentation
Inferior Border Augmentation- Sanders and Cox
reported the first clinical use of an inferior border
technique for augmentation of the atrophic mandible.
This technique is rarely used for augmentation of
Mandibular bulk with inferior grafting using iliac crest
bone grafts and is secured with rigid fixation.10.
Fig 7: Inferior Border Augmentation
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Hydroxyapatite Augmentation of the Mandible:
Hydroxyapatite has revived interest in augmentation
of resorbed alveolar ridges. Because bony
augmentation of alveolar ridges often undergoes
resorption in a short period of time, nonresorbable
hydroxyapatite holds the promise of avoiding a
recurrence resorption. 10
Guided Bone Regeneration (Osteopromotion):
A membrane [nonresorbable or resorbable] is used to
cover an area where bone graft healing or bone
regeneration is desired. The concept of guided
regeneration is based on the ability to exclude
undesirable cell types, such as epithelial cells or
fibroblast from the area where bone healing is taking
place.11
Visor Osteotomy:
The goal of visor osteotomy is to increase the height
of Mandibular ridge for denture support. It 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
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.
Corticocancellous bone grafts particles with
hydroxyapatite granules are placed in the gap between
the superior and inferior anterior segments. Rest of the
graft material can be molded on the buccal aspect of
the posterior segments.12
Fig 8: Modified Visor Osteotomy
C. Maxillary Augmentation
In certain cases, a severe increase in interarch space,
loss of palatal vault, interference from the zygomatic
buttress area, and absence of posterior tuberosity
notching may prevent construction of proper denture.
Onlay Bone Grafting:
It is indicated primarily when severe resorption of the
maxillary alveolus is seen that results in the absence of
clinical alveolar ridge and loss of adequate palatal
vault form13.
Interpositional Bone Grafts:
Interpositional bone grafting in the maxilla is indicated
in the bone-deficient maxilla, where the palatal vault
is found to be adequately formed but ridge height is
insufficient.
Maxillary Hydroxyapatite Augmentation HA is
readily available, eliminates the need for donor-site
surgery and is easily placed in an outpatient setting.
HA can be used to contour and eliminate minor ridge
irregularities and undercut areas in the maxilla.14
D. Alveolar distraction osteogenesis
This process is based on the concept of bone
distraction along a vector that is transverse to the long
axis of the bone, which results in bone formation. A
primary advantage of distraction osteogenesis is that
there is no need for additional surgery at the donor site.
Another benefit is the coordinated lengthening of the
bone and associated soft tissues.13,14
E. Correction of Abnormal Ridge Relationship
In totally edentulous patients, the interarch space and
the anteroposterior and transverse relationships of the
maxilla and mandible must be evaluated with the
patient‘s jaw at proper occlusal vertical dimension. In
the diagnostic phase may require the construction of
bite rims with proper lip support.4
Soft tissue abnormalities and their surgical
management:
a. Soft tissue surgery for ridge extension of the
mandible
As alveolar ridge resorption takes place, the
attachment of mucosa near the denture –bearing area
exerts a greater influence on the retention and stability
of dentures. Soft tissue surgery performed to improve
denture stability may be carried out alone or may be
done after bony augmentation.15,16,
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1. Transpositional flap vestibuloplasty [lip
switch]:
A lingually based flap vestibuloplasty was first
described by Kazanjian. These techniques provide
adequate results in many cases and generally do
not require hospitalization.
2. Vestibule and floor of mouth extension
procedure:
This combination procedure effectively
eliminates the dislodging forces of the mucosa
and muscle attachments and provides a broad base
of fixed keratinized tissue on the primary denture
–bearing area.
b. Soft Tissue Surgery for Maxillary Ridge
Extension
The Submucosal vestibuloplasty as described by
Obwegeser may be the procedure of choice for
correction of soft tissue attachment on or near the crest
of the alveolar ridge on the maxilla. This technique is
particularly useful when maxillary alveolar ridge
resorption has occurred but the residual bony maxilla
is adequate for proper denture support.
Maxillary Vestibuloplasty with Tissue Grafting:
When sufficient labiovestibular mucosa exists and lip
shortening would result from the submucosal
vestibuloplasty technique, other vestibular extension
techniques must be used a modification of Clark‘s
vestibuloplasty technique using mucosa pedicled from
the upper lip and sutured at the depth of the maxillary
vestibule after a supraperiosteal dissection can be
used.17,18
Surgical procedure in fixed denture prosthesis
1. Gingivectomy and Gingivoplasty
Gingivectomy means excision of the gingiva.
Gingivoplasty is a reshaping of the gingiva to create
physiologic gingival contours with the sole purpose of
recontouring the gingiva in the absence of pockets.19
Techniques to increase attached gingiva:
To simplify and better understand the techniques, the
following classifications are presented:
A. Gingival Augmentation Apical to
Recession
Root resection:
A procedure where one or two roots of a
multirooted tooth are amputated, leaving the
crown to be supported by the remaining root
or roots.
Hemisection:
The most common root resection involves
the distobuccal root of the maxillary first
molar.
B. Gingival Augmentation Coronal to
Recession (Root Coverage) :
Understanding the different stages and
condition of gingival recession is necessary
for predictable root coverage.19
Immediate Ridge Augmentation:
Performed at the time of tooth extraction
Onlay graft- It is of value and predictable in small
areas.
Pouch technique- Garber and Rosenberg (1981) -
Used for soft tissue ridge augmentation .Usually for
Class I type of defects.
Roll technique:
Used for soft tissue ridge augmentation, Class I
defects.
Ridge augmentation: improved technique.
Techniques to remove frenum Frenectomy:
Frenectomy is complete removal of the frenum,
including its attachment to underlying bone, and may
be required in the correction of an abnormal diastema
between maxillary central incisors. Frenotomy is
incision of the frenum.19
1. Conventional technique
A narrow elliptical incision around the frenal area
down to the periosteum is completed. The fibrous
frenum is then sharply dissected from the underlying
periosteum and soft tissue, and the margins of the
wound are gently undermined and reapproximated
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2. Z-plasty:
After excision of the fibrous tissue, two oblique
incisions are made in a z fashion, one at each end of
the previous area of excision. The two pointed flaps
are then gently undermined and rotated to close the
initial vertical incision horizontally. The two small
oblique extensions also require closure.
Fig 9 : Z-plasty technique
Sinus lift and bone augmentation procedures for
implant placement, 20, 21, 22
Subantral Option 1: Conventional implant
placement sufficient bone available for implant
placement:
In case of abundant bone (Division A) use implant of
Height > 12 mm and 4 mm diameter. In Division B
bone, osteoplasty or augmentation is done to increase
the width to Division A. Augmentation for width is
accomplished by bone spreading and autogenous
Onlay.
Subantral Option 2: Sinus lift and simultaneous
implant placement:
Vertical bone present is 10 – 12 mm. Antral floor is
elevated by 0-2 mm
Subantral Option 3: Sinus graft with delayed
endosteal implant placement -Atleast 5 mm of
vertical bone is present between antral floor and crest
of residual ridge.
Subantral Option 4: Sinus graft and extended delay
of endosteal implant placement
Height of bone is < 5 mm between residual crest and
sinus floor.
CONCLUSION
Preprosthetic surgical approach, however, calls for the
utmost of surgical and prosthetic preplanning and
cooperation, as well as meticulous attention to detail
in all phases of treatment. When the principles of case
selection and treatment outlined previously are
followed, excellent results and patient satisfaction can
be expected
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