Preprosthetic surgery in prostho new.....ppt

preprosthetic surgery

1. Pre-prosthetic Surgery

2. Prosthetics is the replacement of missing
teeth(lost or congenitally absent) and
contiguous oral and maxillofacial tissues,
with artificial substitute.
Preprosthetic surgery attempts to create
an oral environment that can properly
support a functional prosthetic appliances
and should be viewed as an essential
component of prosthetic reconstruction.

3. GOALS PREPROSTHETIC
SURGERY
Provide bony foundation for the
prosthesis.
Eliminate hard and soft tissue pathology.
Provide proper interarch relationships.
Eliminate bony and soft tissue undercuts
and protuberances.
Ensure adequate vestibular depth.
Plan for possible dental implants.

4. IDEAL CHARACTERISTICS OF
EDENTULOUS RIDGE
Adequate bony support
Bone covered by normal, attached soft
tissue
No bony or soft tissue protuberances or
undercuts
No sharp ridges
Adequate buccal and lingual sulci
No peripheral scar bands to prevent
seating as denture prosthesis

5. No muscle fibers or frena to mobilize the
prosthesis
No soft tissue folds, redundancies, or
hypertrophies on the ridges or in the sulci
No neoplastic lesions
A satisfactory maxillary and mandibular
alveolar ridge relationship

6. INDICATIONS FOR PRE-
PROSTHETIC SURGERY
SKELETAL CLASS III
due to severe
resorption of maxilla
and mandible.

7. Enlarged maxillary tuberosity resulting in decreased interocclusal
space and thus inadequate space to restore edentulous span

8. Decreased vestibular depth
Palatine Torus that
prevents fabrication of
Removal Partial
Denture

9. Low Frenum attachment
Tongue-tie

10. DENTURE INDUCED
GINGIVAL HYPERPLASIA
Deficient thickness of alveolar ridge that
prevents rehabilitation

11. PREPROSTHETIC SURGERY
Soft tissue surgery
-Frenectomy-labial and lingual
-Vestibuloplasty
-Denture induced fibrous hyperplasia removal

12. PREPROSTHETIC SURGERY
Hard tissue surgery
-Alveoloplasty-labial, primary, secondary
-Excision of tori& exostosis,tubercle
-Recontouringof alveolar ridges
-Overdenturesurgeries
-Mandibular& maxillary augmentation
-Reduction of genial tubercle & mylohyoidridge

13. FRENECTOMY
Frenal attachment is a thin band of fibrous
tissue and a few muscle fibers covered by
mucous membrane.
Types-Maxillary midline frenum(Labial
frenum
Lingual frenum
Maxillary and mandibular frena( in
premolar and molar area

14. FRENECTOMY
INDICATIONS:
-High frenumattachment leading to midline
diastema.
-Interfering with denture wearing

15. FRENECTOMY
INDICATIONS:
-Ankyloglossia

16. Labial frenectomy : (usually extends
from the upper lip to the crest of the
alveolar ridge and it can extend
toward palate to the incisive papilla) --
-
-Simple labial frenectomy (
Diamond excision )(in cases with lot
of tissue available)
-Z-plasty (in cases with broad
frenum & short vestibule)

17. LABIAL FRENECTOMY
Simple labial frenectomy
Steps
Infiltration L.A
Hold frenumwith
hemostat.
Surgical cross-diamond
excision with #15blade
Excise wedge
of tissue
Dissect fibers from
periosteum
Interrupted gut
suture placed

18. Simple labial frenectomy
in edentulous patient

19. Simple labial frenectomy
in denutlous patient

20. Z -Plasty
Used when frenum is broad and vestibule is
short
Used for eliminating the frenum as well as for
deepening the vestibule. Also lessons the
tension scar band

21. Z Plasty
• Make elliptical incision
• Excise fibrous tissue
• Make 2 oblique incisions
• Undermine pointed flaps
• Rotate points to close vertical
incision horizontally
Technique done to reduce loss
of vestibular depth sometimes
seen with linear incision

22. Z -Plasty

23. V -Y Plasty
–V-Y type of incision is used for lengthening
localized area.
–Broad frena in premolar-molar area can be
treated by taking SEMILUNAR incision at the
mucogingival junction and a supraperiosteal
dissection is done.
–Superior edge of incision is sutured at the
depth of the vestibule to the periosteum and
the rest of the raw area below is allowed to
heal by secondary epithelization.
–Use of prefabricated stent is necessary.

24. V -Y Plasty

25. V -Y Plasty

26. LINGUAL FRENOTOMY
Lingual frenum is attached to the crest of alveolar
ridge and it connects to the tongue below the tip of the
tongue in edentulous patient.
In dentulous patient it is attached to the lingual gingiva,
behind mandibular incisors.
Condition is know as tongue tie or ankyloglossia
Aims
-To correct speech
-Prior to denture construction
-To improve tongue mobility

27. Tongue-tie is a condition caused by a
short lingual frenum that prevents the
tongue from protruding.
A grooved probe is used to retract the tongue and tense
the frenum. The picture on the right shows the site and
horizontal direction of the frenum incision.
Preoperative
The horizontally incised frenum is now pulled vertically,
allowing the release of the tongue.The incision is
sutured vertically with absorbable stitches.
Postoperative

28. LINGUAL FRENOTOMY

29. LINGUAL FRENOTOMY
COMPLICATIONS
Intraoperative
-Injury to superior lingual vessels
-Injury to Wharton's duct/papilla
-Postoperative
-Hematoma in the floor of mouth
-Pain, restricted tongue movements
-Partial dysphagia

30. VESTIBULOPLASTY
Purpose: to deepen the vestibule for denture
retention
Key is to have a prosthesis to insert at the time
of surgery to maintain vestibular depth

31. VESTIBULOPLASTY ( Deepening of
vestibule without any addition of bone)
Mucosal advancement labial
vestibuloplasty(Submucosal
vestibuloplasty)
Secondary epithelization labial
vestibuloplasty
–Kazanjian’s technique
–Clark's technique
Grafting lingual vestibuloplasty
–Mucosal graft
–Skin graft

32. MUCOSAL ADVANCEMENT
VESTIBULOPLASTY
–Useful for maxillary and mandibular labial, buccal
vestibules.
–Indicated, when the dentures are unstable, due to
shallow vestibular depth and/ or high muscle
attachments, but good underlying bone height and
contour available.
–The mouth mirror test is used to determine the
adequacy of mucosa vestibule.
A mouth mirror is placed in the vestibule and
elevated against the desired vestibular depth. If mobile
tissue is present and no abnormal shortening of the lips
occurs, then adequate mucosa exists to perform
submucosal vestibuloplasty.

33. MUCOSAL ADVANCEMENT
VESTIBULOPLASTY

34. SECONDARY EPITHELIZATION
VESTIBULOPLASTY
This procedure is indicated when there is sufficient bone
present but the mucosa is either insufficient or poor in
quality
e.g.cases of inflammatory hyperplasia, ulceration or scar
tissue formation.
TECHNIQUES
Kazanjian’s technique
Clark's technique

35. Kazanjian Technique
In this procedure, a mucosal flap is raised
and transferred to line the osseous side of
the deepened vestibule.
The mucosa is left raw to heal
secondarily.

36. Kazanjian Technique

38. KAZANJIAN’S TECHNIQUE

39. Disadvantages of Kazanjian
This technique leaves a raw surface on
the labial side of the sulcus to heal by
secondary epitheliazition.
This soft tissue tends to contract as it
heals.
This could lead to further loss of sulcus
depth.

40. Lipswitch Procedure/ Modified
Kazanjian Technique
•Also known as transpositional
vestibuloplasty
•There should be adequate vestibular
depth on the lingual aspect of the
mandible and inadequate labial
vestibular depth.

41. Lip Switch Procedure/ Modified
Kazanjian’s Technique

42. Clark's technique
Clark’s technique is the reverse technique of
the Kazanjian`s technique. It is based on the
following principles:
Raw surface on connective tissue contracts,
whereas when covered with epithelium the
contraction is minimum.
Raw surface on bone does not undergo
contracture.
For repositioning and fixation, epithelial flap
must be undermined adequately.
Soft tissues which are repositioned tend to
return to their normal position, therefore over
correction is necessary.

43. CLARK’S TECHNIQUE

44. GRAFTING VESTIBULOPLASTY
Grafting vestibuloplasty is used,
–When the available bone is inadequate to compensate
for relapse of the vestibuloplasty.
–When bone has being previously placed in the
surgical site.
–When there is large surgical defect.
Graft used
mucosal graft (palatal and buccal mucosa)
skin graft
Advantages
Relapse cause due to contraction of wound is reduced.
Patient discomfort is reduced to to early covering of
surgical defect
Healing is fast
Disadvantages
Depending upon the graft secondary healing take place
Replace of vestibule after surgery.

45. GRAFTING VESTIBULOPLASTY -
OBWEGESER`S TECHNIQUE
It is very similar to Clark's technique,
except the area of the alveolar bone with
its periosteal attachment is covered with a
spilt-thickness graft
Graft is held in position by sutures or stent
constructed preoperatively.
Instead of skin mucosal graft has also
been tried.

47. Split-thickness Skin Graft
Advantage of Split-thickness Skin Graft
Hyperkeratosis (similar to callus on hand) whereas
mucosa will ulcerate
Patients usually more comfortable with skin graft
Greater amount of tissue available
PROCEDURE
Operating room
Position-Supine
Nasal Intubation
Patient Preparation –Donor and Recipient Sites
Local Anesthetic –Lidocaine with Epinephrine for
Hemostasis

48. Vestibuloplasty: Mandibular split thickness
skin graft vestibuloplasty
12 months PO

49. Vestibuloplasty: ridge extension …move
muscle attachment and retain with
soft tissue graft

50. 1
4
5
3
2
Vestibuloplasty: move muscle attachment
and retain with soft tissue graft

51. Pre-op
6 months PO
12 months PO
Vestibuloplasty: Mandibular.. palatal graft
vestibuloplasty
6 months PO
12 months PO

52. Vestibuloplasty: Maxillary palatal graft
vestibuloplasty 6 months post-op

53. Steps of Removal of Extensive
Denture-Induced Fibrous Hyperplasia
Pre-op
post-op

54. Fibrous HyperplasticRetromolarTuberosity
Radiographic assessment
Pre-op
Post-op

55. Pre-op
Post-op
Sequence Of Operative Procedure

56. Other soft tissue procdureare done for:-
Gingival Fibromatosis
Papillary Hyperplasia of the Palate

57. PREPROSTHETIC SURGERY
Hard tissue surgery
-ALVEOLECTOMY
-ALVEOLOPLASTY
-TORI REMOVAL
-OVERDENTURE SURGERY
-MANDIBULAR AUGMENTATION
-MAXILLARY AUGMENTATION

58. Alveolectomy
Surgical removal or trimming of alveolar
process is called alveolectomy
Judicious trimming (with rongeur or round
bur) and filing (with bone file) of sharp
margins at interdental, interseptal or
labiobuccal alveolar crest after extraction

59. Definition:-Alveoloplasty is the surgical
procedure performed to smooth or re-contour
the alveolar bone, aiming to facilitate the
healing procedure as well as the successful
placement of a future prosthetic restoration.
ALVEOLOPLASTY

60. Types
Simple Alveoloplasty
InterseptalAlveoloplasty
1. Deans alveoloplasty
2. Obswegersalveoloplasty
Post extraction alveoloplasty

61. SIMPLE ALVEOLOPLASTY

62. DEAN’S
INTRASEPTAL
ALVEOLOPLASTY

63. INDICATIONS
Used in maxilla( mainly in the anterior
region)
Used to reduce gross maxillary overjet
Used to reduce buccal undercut or labial
prominance

64. ADVANTAGES
Reduce the volume of cancellous bone,
maintaining stress bearing cortical bone
intact
Does not require raising of mucoperiosteal
flap
Can be carried out immediately after
extraction
Alveolar ridge height can be maintained

65. Immediate denture can be planned
The labial prominence of the alveolar ridge can
be reduced without significantly reducing the
height of the ridge in this area.
The periosteal attachment to the underlying
bone can also be maintained, thereby reducing
postoperative bone resorption and remodeling.

66. DISADVANTAGES
The decrease in ridge thickness that
obviously occurs with this procedure.
If the ridge form remaining after this type
of alveoloplastyis excessively thin, it may
preclude placement of implants in the
future.

68. OBWEGESER ’S MODIFICATION
FOR INTRASEPTAL
ALVEOLOPLASTY
Used in cases with gross maxillary overjet
where only labial cortex compression is
not sufficient for reduction of overjet

69. Technique
Cutting of interseptal bone
Widen the socket at the base by inverted
cone or vulcanite bur
Make horizontal cut with disc or bur at the
base of extraction socket in labial and
palatal cortices
Vertical cuts are made distal to canine
socket with straight fissure bur bilaterally
in both cortices

70. Compress both labial and palatal cortices
with digital pressure
Take sutures
Use clear acrylic denture if immediate
denture is planned for easy check for
pressure point

71. TORI REMOVAL
Exostoses
Exostoses are classified into three types:
(1) torus palatinus,
(2) torus mandibularis,
(3)multiple exostoses.

72. TORUS PALATINUS
“Y”INCISION
SMOOTHING OF
BONE SURFACE
SUTURE PLACEMENT
EXPOSURE OF BONE
SECTION OF TORUS

73. MANDIBULAR AND MAXILLARY
RIDGE AUGMENTATION

74. INTRODUCTION
It is the procedure by which the
augmentation of the bone is achieved in
horizontal as well as vertical direction
using autogenous or homogenous bone or
alloplastic materials.

75. CLASSIFICATION
MANDIBULAR AUGMENTATON
–SUPERIOR BORDER AUGMENTATON
–INFERIOR BORDER AUGMENTATON
–INTERPOSITIONAL BONE GRAFTS
–VISOR OSTEOTOMY
–ONLAY GRAFTING
MAXILLARY AUGMENTATON
–ONLAY GRAFTING
–INTERPOSITIONAL GRAFTS
–SINUS LIFT PROCEDURES

76. Indications
Resorption of alveolar ridge at extreme
level

77. Aims
Restoration of optimum ridge height and
width, ridge form, vestibular depth and
optimum denture bearing area
Protection of neurovascular bundle
Establishment of proper inter arch
relationship
Improvement of retention and stability of
denture
Improve the patient’s comfort for wearing
the denture

78. Limitations
Physical condition of the patient
Healing capacity of the patient
Nutritional deficiencies
Availability of adequate soft tissue
coverage
Patient compliances of patient for major
surgeries

79. Materials used for augmentation
Autogeneous bone graft -iliac crest, rib
graft
Allogenic bone graft –freeze dried
cadaver bone
Alloplastic material –hydroxyapetite
Metal mesh with autogeneous cancellous
bone
Metal mesh with hydroxyapetite

80. Mandibular Augmentation
Superior border augmentation (Davis
1970)
Inferior border augmentation ( Marx and
Saunders 1986)

81. Superior border augmentation
Rib or Precarvedhydroxyapetiteblocks in
horseshoe-shape can be used
Diasadvantages:
1) Donor site morbidity
2) Second surgical site necessary
3) Continued resorptionof grafted site
4) Soft tissue dehisenceor limitation

83. Preoperative radiograph.
F, Postoperative
clinical photograph.
(Split-thickness skin-
grafting procedure has
been done after HA
augmentation to
improve vestibular
depth.)
G, Postoperative
radiograph
demonstrating
improvement in height
of alveolar ridge area.

84. Inferior Border Augmentation
Indicated in mandible where alveolar ridge
is less than 5-8 mm in height

85. ADVANTAGES
1.As there is no intraoral wound, patient
can wear old denture
2.11-17 mm of bone augmentation can be
achieved with only 5% of bone resorption
3.Increased bone height for implants
4.Adequate tissue coverage with extraoral
flap
5.Increased lower 1/3 facial height gives
better esthetic result

87. Interpositional bone graft(Sandwich
grafting)
Horizontal osteotomy is performed,
splitting of the residual maxilla or mandible
and bone is grafted into osteotomy gap
In mandible it is used for anterior part
Autogenous or allogenic or hydroxyapetite
can be used as graft
Prosthesis can be delivered after 3-5
months

88. Advantages:
Less resorption rate than onlay grafting
More predictable long term results
Decreased rate of nerve paraesthesia than
visor osteotomy
In conjunction osteointegrated implants
can be used

89. INTERPOSITIONAL BONE
GRAFTING

90. Onlay Grafting
When adequate height is present, but
width is inadequate
Advantages:
1) Both height and width of alveolar bone
is improved
2) Can be used in anterior and posterior
region

92. Iliac crest onlay bone reconstruction of maxilla. A, Diagram of atrophic maxilla. B,
Clini-cal photograph. C, Three segments of bone are secured in place. Small
defects are filled with cancel-lous bone. D, Clinical photograph

98. Visor Osteotomy
To increase height of the mandibular ridge
Central splitting of the mandible in
buccolingual dimension and superior
positioning of the lingual section
Wiring if lingual section and placement of
cancellous bone graft at outer cortex

99. VISOR OSTEOTOMY

100. Modified Visor Osteotomy
Splitting of mandible buccolingually by
vertical osteotomy only in posterior region
and horizontal osteotomy in the anterior
region
Both segments pushed superiorly and
wired
Placement of corticocancellous bone with
hydroxyapetite granules and moulding of
buccal surface by with rest of graft
material

101. MODIFIED VISOR OSTEOTOMY

102. Sinus Lift Procedure
Intra oral incision on the maxillary crest or
slightly palatal aspect with vertical
releasing incision from canine to tuberosity
Bony window lateral and posterior to
canine fossa by a trap door type
osteotomy
Inferior horizontal osteotomy cut 15-20
mm long ,3mm above sinus floor

103. Anterior vertical osteotomy cut is placed
perpendicular to horizontal cut and parallel
to lateral nasal wall , posterior vertical cut
placed at maxillary buttress
Vertical cuts are joioned superiorly
Expose schneiderian membrane
Put graft between sinus membrane and
floor

104. SINUS LIFT PROCEDURE
SINUS LIFT
PACKING WITH THE GRAFT

113. THANK
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