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Preprosthetic Surgery. Part 1. Epidemiology of Aging. By 2030, one in five Americans will be elderly Considered on of the fastest growing age groups in the United States. Edentulous US population 10% entire US population 35% of the 65 and older population. Objective.

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epidemiology of aging
Epidemiology of Aging
  • By 2030, one in five Americans will be elderly
  • Considered on of the fastest growing age

groups in the United States.

  • Edentulous US population
    • 10% entire US population
    • 35% of the 65 and older population
objective
Objective
  • To create supporting oral structures for placement of partial or complete dentures
introduction
Introduction
  • Tooth loss
  • No stimulus
  • Resorption
  • Patterns of resorption may vary
  • >mandible than in maxilla (decreased surface area less favorable distribution of the occlusal forces)
pattern of alveolar bone loss
Pattern of alveolar bone loss
  • General Systemic factors
    • Nutritional
    • Bone disease
    • Endocrine dysfunction
  • Local factors
    • Alveloplasty technique
    • Localized trauma
resorption patterns
Resorption patterns
  • Facial Structure
    • Volume of bone
    • Low mandibular plane
    • Acute gonial angle –Generate higher bite force
characteristics of best denture support
Characteristics of best denture support
  • Absence of any Pathologic conditions
  • Proper interarch jaw relationship
  • Appropriate size alveolar arches
  • No soft or bony protruberences or undercuts
  • Adequate palatal vault
  • Proper posterior tuberosity notching
  • Adequate attached keratinized mucosa for the denture bearing area
  • Adequate vestibular depth
  • Protection of vital anatomic structures
  • Adequate bony support and soft tissue covering for implant placement
ideal support mandible
Ideal support mandible

Broad Alveolar ridge

Adequate FOM

Deep Vestibular depth

Mylohyoid muscle

ideal vs atrophic mandible
Ideal vs atrophic(mandible)
  • Lack of
    • FOM
    • Vestibular depth
    • Resorption
patient evaluation and treatment planning
Patient evaluation and treatment planning
  • History , physical examination, patients expectations
  • Final outcome of the prosthesis vs. patient expectations
  • Thorough Intraoral and extra oral evaluation
evaluation of supporting bone
Evaluation of Supporting Bone
  • Visual
  • Palpation
  • Radiographic examination
evaluation of supporting soft tissue
Evaluation of Supporting Soft tissue
  • Quality
    • Amount of keratinized soft tissue over the denture overlying areas Vs poorly keratinized tissue
    • Hypermobile keratinized tissue
  • Vestibule
    • Ulcerations
    • Scarring
    • Inflammed areas
  • Frenal attachments
    • Type
evaluation of supporting soft tissue1
Evaluation of Supporting Soft tissue
  • Tissue should be
    • Supple
    • Without irregularities

Mylohyoid Muscle

    • level of attachment in relation to the crest of the alveolar ridge
    • Genioglossus attachment
treatment planning
Treatment Planning
  • Think of long term consequences
  • Do not burn the bridges behind you
  • Outcomes /responsibility
recontouring of alveolar ridges
Recontouring of Alveolar Ridges
  • Simple Alveloplasty associated with Removal of Multiple teeth
  • Interseptal alveloplasty (Dean’s Technique)
  • Maxillary tuberosity reduction (hard Tissue)
  • Buccal Exostosis and Excessive undercuts
  • Lateral Palatal Exostosis
  • Mylohyoid ridge reduction
  • Genial Tubercle reduction
simple alveloplasty associated with removal of multiple teeth
Simple Alveloplasty associated with Removal of Multiple teeth
  • Simplest Alveloplasty- Compression of alveolar socket
  • Simple Alveloplasty- Immediate/Delayed
slide20

Alveoloplasty

Anesthesia

(local infiltration)

Incision &

Mucoperiosteal flap reflection

(scalpel & periosteal elevator)

  • Take home points
  • exposure & visualization
  • blood supply
  • rest on intact bone
  • full-thinckness
  • avoid injury to vital structures
slide21

Bone removal

(bur/chisel&mallet / rongeur)

unibevel

side-cutting

Bone smoothening

  • Take home points
  • side-cutting for rongeur
  • unibevel chisel
  • preserve bone AMAP
  • “pull” for smoothening

(bone file)

slide22

(Interrupted/continuous/continuous locking)

Suturing

Post-op care

  • Mouth rinses
  • Suture removing
  • (1w post-op)
  • Prosthetic restoration
  • (2w post-op)
simple alveloplasty
Immediate/Delayed

Technique

Mucoperiosteal flap

Crest of Alveolar ridge

Envelop flap

Visualization

Access

Simple Alveloplasty
slide25
Assess the irregularity

Recontour

Rongeur/bone file

Bone bur/Handpiece

Ensure all Irregularities are removed

Irrigation with copious saline

Suture

Interrupted

Continuous

slide27
Soft tissue redundancy created with reduction of the bony irregularities often shrinks and readapts over the alveolus
    • Allows preservation of attached gingiva
interseptal alveloplasty
Dean’s technique

Indications

Regular ridge

Adequate height

Undercut to depth of labial vestibule

Advantages

Reduced prominence without height loss

Reduced bone resorption

Muscle attachment to the area is undisturbed

Interseptal alveloplasty
technique
Small rongeur’s

Remove the interseptal bone

Technique
maxillary tuberosity reduction
Maxillary Tuberosity reduction
  • Indications:
    • Horizontal/vertical excess
    • Create adequate interarch space
    • Contour overlying soft tissue
technique1
Crestal incision

Reflect mucoperiosteal flap

Side cutting rongeurs

Avoid floor of the maxillary sinus

Debridment

Suture

Technique
excessive undercuts
Excessive Undercuts
  • Excessive bony protuberances >Maxilla
  • Technique: (large protuberances)
    • Crestal incision
    • Extend 1-1.5 cms beyond area requiring contouring
    • Flap
small undercuts
Small Undercuts
  • Common location :
    • Anterior maxilla or Mandible
  • Fill with autogenous or allogenic bone
technique4
Expose undercut with vertical incision

Subperiosteal tunnel

(periosteal elevator)

Technique
slide39
Autogenous/allogenous material

Cover with resorbable membrane

Impressions-3-4 weeks

lateral palatal exostoses
Palatal vault irregular

Crestal incision

(Extend slightly beyond the area of exostoses)

Reflection of mucoperiosteal flap

Careful about the greater palatine vessels

No surgical splint required

Lateral Palatal Exostoses
mylohyoid ridge reduction
Mylohyoid Ridge reduction
  • Commonly responsible for dislodging of denture
  • Sharp ridge-Painful
  • Extreme resorption of ext. oblique ridge and mylohyoid ridge may form the most prominent areas of mandible
  • Technique
  • Immediate placement of denture-facilitates inferior relocation of muscular attachment
tori removal
Tori Removal
  • Palatal Tori Removal
  • Mandibular Tori removal
maxillary tori
Maxillary Tori
  • Bony exostosis in the area of the palate
  • Origin-Unclear
  • 20% female population
  • > females than in males
  • Various shapes
  • Few problems with dentate jaws
  • Interferes with fabrication of prosthesis
technique5
Linear midline incision

Oblique vertical releasing incisions

Mucosa is THIN

Flap reflection may be challenging

A full palatal flap may sometimes be helpful

Technique
slide46

Incision

Flap reflection

Segmenting w/ fissure bur

slide47

smoothing

Remove bone stripes

technique6
Technique
  • Small pedunculated tori removed using an osteotome and mallet
  • Smoothen area, ensure all undercuts are removed
  • Re-inspect, tension free closure
  • Prevent hematoma formation
    • Pressure dressing
    • Temporary denture
    • Prefabricated splint
complications
Fracture or perforation of floor of nose

Flap necrosis

Ulceration

Hematoma formation

Complications
mandibular tori
Lingual side of mandible

>premolar area

Origin- uncertain

Mandibular Tori
slide52

Removal of mandibular tori

  • Location
  • Anesthsia
  • Incision
slide53

Lingual mucoperiosteal flap reflection

  • Leave a band of tissue attached to the midline between the anterior extent of the incision
  • Advantages
    • Eliminate potential hematoma formation
    • Maintains depth of lingual vestibule
slide54
Small pedunculated tori

Osteotome/mallet

Use bur to define the trough

Post operative complications

Edema

Hematoma

Injury to anatomic structures

Misadventure with bur

soft tissue abnormalities continued next class
Soft Tissue Abnormalities…Continued Next class
  • Maxillary Tuberosity reduction (soft Tissue)
  • Mandibular retromolar pad reduction
  • Unsupported Hypermobile tissue
  • Lateral Soft tissue excess
  • Inflammatory fibrous hyperplasia
  • Labial frenectomy
  • Lingual frenectomy