IJPCDR

10.5005/jp-journals-00000-0000
REVIEW ARTICLE

Preprosthetic Surgery - An Overview

Saptarshi Banerjee1, Subhadeep Mukherjee2, Dhruba Chatterjee3, Saikat Deb4, Sahana N. Swamy5, Atreyee Mukherjee6

ABSTRACT the maximum level of comfort. A denture sits on the bone

The preparation of your mouth before the placement of a den-
ridge, so it is very important that the bone is the proper
ture (or prosthesis) is referred to as preprosthetic surgery. The shape and size.[1] One of several procedures might need to
aim of preprosthetic surgery is to prepare the soft and hard be performed to prepare your mouth for a denture includ-
tissues of the jaws for a comfortable prosthesis that will restore ing bone smoothing and reshaping, removal of excess
oral function, esthetics, and facial form. It helps to restore the bone, and/or removal of excess gum tissue.[2] In the aver-
function of the jaws (mastication of food, speech, and swallow- age person, satisfactory dentures can be constructed with-
ing), preserve or improve jaw structure, improve the patient’s out many difficulties a few weeks or months after being
sense of well-being, and improve facial esthetics. One of sev-
rendered fully edentulous and such dentures usually ren-
eral procedures might be performed to prepare the mouth for
der several years of trouble-free service.[3,4] The alveolar
a denture, which includes bone smoothening and reshaping,
removal of excess bone, and removal of excess gum tissue. process initially develops as the teeth calcify and erupt, a
This paper reviews these major procedures briefly outlining phenomenon that takes place with both the primary and
the surgical procedure, and discusses the indications and permanent dentitions. This process stimulates the alveolar
techniques of these procedures. process to grow and leads to the shape of the fully grown
Keywords: Esthetics, preprosthetic, prosthesis. jaws of the adult.[5] This growth is a result of the remodel-
ing of bone and, as in the whole skeleton, is brought about
How to cite this article: Banerjee S, Mukherjee S, Chatterjee D, by the processes of resorption and deposition. As soon as
Deb S, Swamy SN, Mukherjee A. Preprosthetic Surgery - An
the physiological function of the teeth is lost, there is no
Overview. Int J Prev Clin Dent Res 2018;5(1):S149-152.
longer a functional stimulation of the alveolar process, and
Source of support: Nil the resorption process becomes dominant.[6]
Conflicts of interest: None Differences in the shape of the upper and lower alve-
olar ridges result in: [7]
1. A reduction in the height of the residual ridges.
INTRODUCTION
2. An increase in interarch distance.
The preparation of your mouth before the placement of a 3. A prognathic mandible in prole.
denture (or prosthesis) is referred to as preprosthetic sur- 4. In the horizontal plane, the maxillary arch becomes
gery. Some patients require minor oral surgical procedures narrower and the mandibular arch wider as resorp-
before receiving a partial or complete denture, to ensure tion progresses.

1,3,5,6
TYPES OF PREPROSTHETIC SURGERY[8]
Consultant, 2Senior Lecturer, 4Reader
1
Department of Prosthodontist and Implantologist, Smiley • Respective
Dental Care, Srirampur Hooghly, West Bengal, India • Recontouring
2 • Augmentation.
Department of Oral and Maxillofacial Surgery, Awadh Dental
College and Hospital, Jamshedpur, Jharkhand, India
Involved Areas
3
Oral and Maxillofacial Surgeon, Kolkata, West Bengal, India
4 • Osseous tissues
Department of Prosthodontics Crown Bridge and Implantology,
Awadh Dental College and Hospital, Jamshedpur, Jharkhand,
• Soft tissues.
India
5
Category of Patient
Dental Surgeon, GDMO, Chanchol Super Specialty Hospital,
Malda, West Bengal, India • Completely edentulous patient
6
Dental Surgeon, Prefer Dental Clinic, Kolkata, West Bengal, • Partially edentulous patient.
India
Alteration of Alveolar Bone
Corresponding Author: Dr. Saptarshi Banerjee, Consultant,
Department of Prosthodontist and Implantologist, Smiley • Removing of undesirable features/contours
Dental Care, 29/4 Barabagan Lane, Srirampur Hooghly –
• Osseous plasty/shaping/recontouring
712 203, West Bengal, India. e-mail: [email protected]
• Bone reductions
International Journal of Preventive and Clinical Dental Research, January-March(Suppl) 2018;5(1):S149-152 149
Banerjee, et al.

• Bone repositioning either side of the midline, which gives attachment to the
• Bone grafting. genial muscles. The two genial tubercles located superi-
orly are more prominent than the inferior ones due to the
Soft Tissue Modifications gross resorption of the mandibular ridge.[19] This may
elevate the ridge lingually, giving a shelf-like appear-
• Soft tissue plasty/recontouring
ance and making the anterior lingual seal impossible.
• Soft tissue reductions
Genial tubercles are exposed by blunt dissection. Using
• Soft tissue excisions
bur, chisel, or rongeurs, the tubercle is removed, and the
• Soft tissue repositioning
rough bony margins are smoothened using file.[4]
• Soft tissue grafting.
VESTIBULOPLASTY
OBJECTIVE OF PREPROSTHETIC SURGERY[9]
Vestibuloplasty should be performed in case of the
Correcting conditions that preclude optimal prosthetic
shallow vestibule to widen denture-bearing area. There
function
vestibuloplasty should be performed in case of the shal-
• Hyperplastic replacement of resorbed ridges
low vestibule to widen denture-bearing area. There are
• Unfavorably located frenular attachments
different techniques of vestibuloplasty. Most of them
• Bony prominences undercut.
provide access from the buccal aspect of the mandible.[4]
ALVEOLOPLASTY
KAZANJIAN VESTIBULOPLASTY
An alveoloplasty (also referred to as alveoplasty) is a sur-
A mucosal flap pedicled from the alveolar ridge is ele-
gical procedure used to smooth and reshape a patient’s
vated from the underlying tissue and sutured to the
jawbone in areas where teeth have been extracted or
depth of the vestibule. The inner portion of the lip is
otherwise lost.
allowed to heal by secondary epithelialization.[4]
The purpose of this procedure can be two-fold:
• When performed before (partial or complete) den- CLARK VESTIBULOPLASTY
ture construction, it is used to optimize the shape
of the patient’s jawbone (ridge) so to avoid compli- Clark’s vestibuloplasty technique uses mucosa pedi-
cations with appliance insertion, comfort, stability, cled from the lip. Horizontal incision is performed from
and/or retention. canine to canine between immobile gingiva and mobile
• When performed in association with tooth gingiva.[4] After supraperiosteal dissection, the mucosa
extractions, it also establishes a jawbone shape that is sutured at the depth of the vestibule. The denuded
helps to facilitate the healing process that follows. periosteum heals by secondary epithelialization. It is
possible to use tissue graft on exposed periosteum. The
• An alveoplasty also aims to facilitate the healing
healing process is more rapid in this situation.[3]
procedure as well as the successful placement of a
future prosthetic restoration.
CORN VESTIBULOPLASTY
Faster healing is important for certain people, such
as cancer patients. They may need to have decayed teeth This vestibuloplasty is similar to Clark’s vestibuloplasty.
extracted before they receive radiation therapy to the Difference: Horizontal incision is through soft tissue/
head or neck. Radiation can “dry up” the salivary glands mucosa and periosteum/to the mucoperiosteal flap
and reduce blood flow to the jaw, increasing the risk of is dissected, and the bone is exposed. Disadvantages:
further decay and infection of the jaw bones (osteoradio- More painful procedure; the healing process is longer.[3]
necrosis). Once the teeth are removed, radiation therapy
cannot begin until the sockets are healed.[10-17] OBWEGESER VESTIBULOPLASTY
Vestibuloplasty described by Obwegeser is the method
REDUCTION OF GENIAL TUBERCLE in which labial extension procedure and Trauner’s pro-
The genial tubercles are extremely prominent as a result cedure provide a maximal vestibular extension to both
of advanced ridge reduction in the anterior part of the the buccal and lingual aspects of the mandible.[3]
body of the mandible. If the activity of the genioglossus
muscle has a tendency to displace the lower denture, the MAXILLARY TUBEROSITY REDUCTION: (SOFT
TISSUE)
genial tubercle is removed and the genioglossus muscle
detached.[18] Genial tubercles are the bony projections The primary objective of soft tissue maxillary tuberos-
located on the lingual aspect of the mandible, two on ity reduction is to provide adequate interarch space for
International Journal of Preventive and Clinical Dental Research, January-March(Suppl) 2018;5(1):S149-152150
 IJPCDR

 Preprosthetic surgery

proper denture construction in the posterior area and a and are associated with bruxism. The size of the tori
firm mucosal base of consistent thickness over the alve- may fluctuate throughout life, and in some cases, the
olar ridge denture-bearing area.[3] Maxillary tuberosity tori can be large enough to touch each other in the mid-
reduction may require the removal of soft tissue and line of mouth. Consequently, it is believed that mandib-
bone to achieve the desired result. The amount of soft ular tori are the result of local stresses and not solely on
tissue available for reduction can often be determined by genetic influences.
evaluating a presurgical panoramic radiograph.[3] Local
anesthetic infiltration in the posterior maxillary area is INDICATION FOR REMOVAL OF MANDIBULAR
sufficient for a tuberosity reduction.[20] An initial elliptic TORI
incision is made over the tuberosity in the area requiring (1) Interfere with tongue positioning. (2) Speech inter-
reduction, and this section of tissue is removed. After ference. (3) Prosthodontic reconstruction. (4) Patient
tissue removal, the medial and lateral margins of the with poor oral hygiene around the lower posterior teeth.
excision must be thinned to remove excess soft tissue, (5) Traumatic ulceration from mastication.[22]
which allows further soft tissue reduction and provides
a tension-free soft tissue closure. This can be accom- FRENECTOMY
plished by digital pressure on the mucosal surface of
A frenectomy is the surgical alteration of a frenum
the adjacent tissue while sharply excising tissue tangen-
which is a fold of tissue which restricts movement. In the
tial to the mucosal surface. After the flaps are thinned,
mouth, this is generally a small portion of tissue related
digital pressure can be used to approximate the tissue
to the upper lip, the tongue, or the lower lip.[22] Usually,
to evaluate the vertical reduction that has been accom-
one end of the frenum is connected to a muscular part
plished.[21] If the adequate tissue has been removed, the
of the body such as the tongue or lip and the other to a
area is sutured with interrupted or continuous suturing
relatively static part such as the floor of the mouth in the
techniques. If too much tissue has been removed, no
case of the tongue or to the gums in the case of the upper
attempt should be made to close the wound primarily.
lip.[22] Too much restriction of movement of the tongue,
Sutures are removed in 5–7 days and impressions can
for example, is not necessarily a good thing since it can
generally be taken 3–4 weeks postoperatively.[21]
interfere with normal function and this is why a frenec-
tomy may be required.
MANDIBULAR TORI
Mandibular tori are bony exophytic growths that are RIDGE AUGMENTATION
present on the lingual aspect of the mandible, opposite Superior Border Augmentation
to the bicuspids. They present in early midlife and tend
to grow with age. Mandibular tori occur in 6–7% of the It was described by Davisin, 1970. This procedure is
population. The etiology of exostosis is multifactorial indicated when mental foramen is situated in the supe-
including genetic and functional influences.[21] rior border. In this procedure, autogenous bone graft is
used. The rib graft can be fixed to the superior border
TORI CAN BE CATEGORIZED BY THEIR of the mandible.[20-23] Two segments of the rib, about
APPEARANCE 15 cm long, are obtained from the 5th to 9th ribs. The rib
is contoured by vertical scoring in the inner surface. The
• Flat tori - arising as a broad base and a smooth sur-
second rib is cut into small pieces to later pack against
face, are located on the midline of the palate and
the solid rib. Fixation is done by means of transosseous
extend symmetrically to either side.
wiring or circumferential wiring.[22,23]
• Spindle tori - have a ridge located at their midline.
• Nodular tori - have multiple bony growths that each Disadvantages
has their own base.
• Lobular tori - have multiple bony growths with a • Morbidity of the donor site
common base. The torus may be bosselated or mul- • Secondary surgical site
tilobulated, but the exostosis is typically a single, • Necessity of the patient to withdraw denture until
broad-based, smooth-surfaced mass, perhaps with the surgical wound heals for a period of 6–8 months.
a central sharp, and pointed projection of bone pro-
Inferior Border Augmentation - Visor Osteotomy
ducing tenderness immediately beneath the surface
mucosa. This technique was first described by Sanders and Cox,
It is believed that mandibular tori are caused by sev- in 1986, for reconstruction of a resected mandible. This
eral factors. They are more common in early adult life procedure is indicated to prevent and manage fractures
International Journal of Preventive and Clinical Dental Research, January-March(Suppl) 2018;5(1):S149-152 151
Banerjee, et al.

of an atrophic mandible. Visor osteotomy was described 3:103-6.

by Harle to overcome the resorption of free onlay bone 10. Steinhäuser E, Obwegeser H. Rebuilding the alveolar ridge with
bone and cartilage autografts. Trans Int Conf Oral Surg 1967;
graft. This technique is followed where the muscle inser-
24:203-8.
tion to the mandible and nutrient supply is maintained.
11. Gerry RG. Alveolar ridge reconstruction with osseous auto-
In this procedure, the mandible is divided buccolin- graft: Report of case. J Oral Surg (Chic) 1956;14:74-8.
gually by a vertical osteotomy from external oblique 12. Liposky RB. Use of the mandibular staple bone plate with
ridge of one side of the mandible to the other side. The augmentation in bone grafts. J Oral Maxillofac Surg 1971;
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sensus development conference on dental implants. J Am
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Dent Assoc 1979;98:373-7.
14. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year
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International Journal of Preventive and Clinical Dental Research, January-March(Suppl) 2018;5(1):S149-152152