Preprosthetic Surgery

Preprosthetic surgery is concerned with the surgical modification of the alveolar process and its
surrounding structures to enable the fabrication of a well-fitting, comfortable and aesthetic
dental prosthesis.

Goals of Preprosthetic Surgery

● To provide adequate height, length, breadth, width and shape of residual tissue with
which the ridge can support and retain the denture and withstand masticatory stress.
● To help proper speech and deglutition.
● Satisfy the aesthetic concerns of the patient.
● Remove all the hard and soft tissue protuberances and undercuts.
● Provide adequate vestibular depth.
● Provide appropriate frenal attachment.
● Achieve proper jaw relationship in anteroposterior, transverse and vertical dimension
● Relocate the mental nerve and establish correct vestibular depth.
● Reduce the pain and discomfort produced by the denture pressure on a narrow alveolar
ridge and unsupported alveolus due to the presence of superficial mental nerve or an
impacted or buried tooth or root which was asymptomatic prior to denture placement.

Indications
● Complete or partial edentulism secondary to early tooth loss.
● Naturally occurring reduction of the residual bony ridge.
● Pain due to: Mucositis, Neuropathy, Local recurrent ulceration of unsupported crestal
soft tissues and thin atrophic mucosa, Temporomandibular joint pain, Dental roots or
unerupted teeth.
● Dysfunction of mastication, speech or deglutition.
● Disproportionate growth of the jaws or facial skeleton producing mechanically impossible
conditions for mastication and denture retention.
● Craniofacial deformity which results from abnormal growth patterns of the skull base and
facial skeleton.
● Oligodontia, anodontia: a naturally occurring failure of tooth development.
● Enhanced gag reflex: patients have an excessive sensitivity of the soft palate which if
contacted produces ‘retching’.

Contraindications
● General contraindications to surgery-medically compromised state.
● Generalised bone disorders such as osteoporosis, hyperparathyroidism etc.
● Patient on bisphosphonate therapy-at risk of osteochemonecrosis.
● Patient with history of head and neck irradiation recently.
Preprosthetic Surgery Techniques:
1. Hard Tissue
2. Soft Tissue

1. Hard Tissue
A. Alveolar ridge preservation
B. Alveolar ridge augmentation
a. Mandible
❏ Superior border augmentation
❏ Inferior border augmentation
❏ Visor Osteotomy
❏ Interposition bone grafting
❏ Alveolar distraction osteogenesis
b. Maxilla
❏ Onlay bone graft
❏ Interpositional bone graft
❏ Sinus lift
❏ Alveolar distraction osteogenesis
C. Alveolar ridge correction
❏ Primary alveoloplasty
❏ Secondary alveoloplasty
❏ Excision of tori
❏ Mylohyoid ridge reduction
❏ Genial tubercle reduction
❏ Maxillary tuberosity reduction
❏ Tuberoplasty
D. Orthognathic Surgery
❏ Segmental surgery
❏ Total jaw surgery
2. Soft Tissue
A. Frenectomy
B. Vestibuloplasty or ridge extension procedure
C. Redundant tissue extends
D. Mental nerve repositioning

Hard Tissue Procedures

Alveolar Ridge Augmentation
Goals of ridge augmentation
 ● Restoration of the optimum ridge height and width, vestibular depth, ridge form and
optimum denture bearing area.
● To increase retention and stability of the denture.
● To attain a proper interarch relationship.
● To protect and prevent injury to anatomic vital structures such as neurovascular bundle,
maxillary sinus, mental nerve.
Criteria for Ridge Augmentation
● Gross atrophy of the jaws with the risk of mandibular fracture
● Atrophy of the jaws with knife-edge ridge causing prosthetic difficulties.
● Insufficient alveolar dimension for implant placement.
Mandibular Augmentation Procedures
1. Superior border augmentation
This procedure is indicated when mental foramen is situated in the superior border. In this
procedure, autogenous bone graft is used. The rib graft with or without addition of rhBMP-2 in
absorbable collagen sponge can be fixed to the superior border of the mandible.
2. Inferior border augmentation
It is indicated in case of severely atrophic edentulous mandible or for prevention of pathological
fracture of atrophic edentulous mandible.
3. Visor osteotomy
This technique is designed wherein the muscle insertion to the mandible and nutrient supply are
maintained. The mandible is divided buccolingually by a vertical osteotomy from external
oblique ridge of one side of the mandible to the other side.
4. Interposition bone grafting
This procedure is known as sandwich grafting and is similar to visor osteotomy. Here the vertical
osteotomy cut is made only in the posterior region to divide the segments buccolingually. A
horizontal osteotomy is performed in the anterior mandible to divide the anterior segment
superiorly and inferiorly and bone grafting is done into the osteotomized gap and the two
osteotomized segments are fixed with wires.
Maxillary Augmentation Procedures
1. Onlay grafting
It is done when there is adequate bone height but inadequate bone width.
2. Sinus lift
Due to excessive pneumatization of the maxillary antrum and atrophy of the maxillary ridge,
floor of the sinus almost comes to lie to very close to the maxillary alveolar crest. Maxillary sinus
lift procedure is carried out to lift the floor of the sinus lining by placing a graft in between the
maxillary sinus lining and the floor of the maxillary antrum in the posterior aspect.
The various materials used for this surgical procedure are:
● Iliac crest cancellous graft
● Rib graft
● Hydroxyapatite
Maxillary and Mandibular Augmentation
Alveolar ridge distraction
It refers to alveolar reconstruction by means of bone transport technique whereby the transport
segment would be moved using a special device called distractor.
Alveolar ridge augmentation can be divided into two categories:
● Vertical augmentation, in which the transport alveolar segment is translated vertically
and the height of the alveolar ridge is increased.
● In horizontal augmentation, the transport alveolar segment is translated horizontally,
thereby increasing the alveolar ridge width.

Alveolar Ridge Correction

1. Alveoloplasty
Goals of alveoloplasty:
● To provide optimum ridge contour quickly.
● The alveolar ridges should be left as broad as possible for maximum distribution of the
masticatory load.
● The ridge need not be perfectly smooth but sharp irregularities should be removed and
the edges should be rounded.
● The mucosa covering the ridge should have uniform thickness, density and
compressibility for even transmission of the masticatory forces to the underlying bone.
● In younger patients, less amount of bone should be removed as the process of
resorption extends for longer number of years than the older patients.

a. Primary Alveoloplasty
It is the term used to describe the trimming and removal of the labiobuccal alveolar bone along
with some interdental and interradicular bone and is carried out at the time of extraction of teeth.
Indications:
● Patients with prominent and dense alveolar bone undergoing extraction.
● Done as a procedure prior to the construction of an immediate denture.
Technique:
● The crevicular incision is placed along the free gingival margin and a full thickness
mucoperiosteal flap or a triangular flap is elevated which extends up to one tooth
distance on either side of the sockets.
● A sharp cutting rongeur forcep is held with one beak beneath the bony rim of the socket
and the other on the crest of the ridge.
● Small pieces of required amount of bone are removed and then finally, bone file is used
to smoothen the bone.
● The mucous membrane is then held with sutures over the interradicular bony septa.
● If any excess flap is present, it is trimmed away and the edges are approximated.

❖ Dean’s Intraseptal Primary Alveoloplasty

This procedure helps in eliminating anterior maxillary undercuts and reducing the large anterior
maxilla by removing the interseptal bone between the teeth. This procedure involves
preparation of six anterior teeth and sometimes the premolars are included. The advantage of
this technique is that since it retains much of the compact labial cortical bone, it reduces the
resorption of the bone postoperatively. According to Dean the most posterior teeth should be
removed first to preserve the integrity of labial cortical plate and avoid any disturbance to its
blood supply. Dean’s intraseptal alveoloplasty is based on the following biological principles:
● The prominence of the labial and buccal alveolar margin is reduced to facilitate the
reception of dentures
● The muscle attachments are undisturbed
● The periosteum remains intact
● The cortical plate preserved as a viable onlay bone graft with an intact blood supply
● Because the cortical bone is spared, postoperative resorption is minimized
Indications:
● To decrease gross maxillary overjet
● Adequate bone height
● Multiple extractions
Technique
● Incision is made along the gingival margin with epithelial attachment and interdental
papilla attached to the respective teeth.
● An envelope flap is raised as conservative as possible.
● Now the teeth are extracted starting from the canine to the incisors.
● After extraction of teeth, the interradicular bony septa should be removed with a rongeur
forcep or rotatory drill introduced into the socket to separate the labial and palatal cortical
plate.
● A V-shaped excision of the bone is done in the labial cortical plate distal and posterior to
the canine eminence as close to the alveolus as possible.
● Thus three sides of the labial cortex become free and the labial cortex becomes a freely
movable osteoperiosteal graft attached to only the mucoperiosteum from which it
receives its blood supply.
● Now finger pressure is applied to the labial cortical plate which is collapsed towards the
socket. Sutures are places to stabilize the tissues.

b. Secondary Alveoloplasty
When bone corrective surgery is done on the edentulous ridge for irregularity after the initiation
of extraction socket healing, it is termed as secondary alveoloplasty. A sharp knife-edge like
edentulous ridge causes great denture irritation. They are usually found in the anterior part of
the mandible. Localized tenderness over such ridge on palpation or on wearing denture is
common. The ridge may also show an irregular pattern known as feather edged ridge.
Technique:
● Incision should be made on the crest of the alveolar ridge.
● Usually an envelope flap would suffice, but releasing incision can be made on the labial
or buccal side to provide a broad base to the flap.
 ● Bony contouring is accomplished with bone files, rongeurs or burs.
● The ridge is made free of sharp irregularities and is not aimed at perfectly smooth ridge
requiring bone removal. Digital palpation can be used to determine the uniformity of the
ridge.
● Once satisfying results are obtained, the region is irrigated copiously with saline to
remove debris, small avascular bone pieces at the risk of necrosis and the flaps closed.

2. Tori Removal
Tori are small developmental anomalies that occur in constant sites on the jaw bones.

a. Maxillary torus or torus palatinus

A torus palatinus is an exostosis found along the suture line of the hard palate. Not all the tori
require to be removed as all of them do not cause prosthetic difficulty. Sometimes the bony
exostoses may be present on the buccal buttressing bone.
Indications for removal of maxillary tori:
● Smooth maxillary torus can be ignored but when it is extensively irregular, large and
extends beyond the junction of the hard palate and soft palate and interferes with the
postdam seal of the denture, it should be removed.
● Sometimes the torus may be subjected to constant trauma during mastication.
● When it interferes with normal speech.
● When the patient fears of malignancy.

b. Mandibular tori or torus mandibularis

It is an exostoses located on the lingual aspect of the mandible in the region of the premolar
above the mylohyoid line. They may be unilateral or bilateral.
Indications for removal
● It is removed if lower denture is to be constructed.
● It should be removed if there is chronic irritation.
● Very rarely, it is removed if the patient fears malignancy.

3. Mylohyoid Ridge Reduction

Mandibular lingual shelf area contains mylohyoid ridge and houses the third molar tooth. This
area is used extensively by the prosthodontists to extend the lingual flanges of the mandibular
denture to gain stability and retention.
This shelf, along with the mylohyoid muscle insertion, becomes more prominent and superficial
in due course of time due to atrophy of the mandible. A sharp lingual shelf interferes with the
denture construction and insertion and the mylohyoid muscle attachment here dislodges the
denture.
Therefore, this shelf needs to be reduced and the mylohyoid muscle attachment should be
released.

4. Genial Tubercle Reduction

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 due to the gross resorption of
the mandibular ridge. This may elevate the ridge lingually giving a shelf-like appearance and
making the anterior lingual seal impossible. This is also a frequent site of ulceration when a low
denture is used.
Technique
● An incision is placed in the midline in an anteroposterior direction and the tubercles are
exposed by blunt dissection.
● The muscle is secured using catgut before separating the tubercle.
● Using bur, chisel or rongeurs, the tubercle is removed and the rough bony margins are
smoothened using file.
● The wound is closed using suture.

5. Maxillary Tuberosity Reduction

Enlarged maxillary tuberosity may be either fibrous or bony in nature. Unilateral hypertrophic
maxillary tuberosity is favourable for construction of denture if sufficient space exists between
the tuberosity and the ascending ramus of the mandible for the denture flange to fit in without
any difficulty during opening and closing of the mouth. However, bilateral hypertrophic tuberosity
needs reduction.
Technique
Crestal Approach
● An interarch space of at least 1 cm should exist between maxillary and mandibular
arches in the posterior region for proper construction of denture.
● Usually this is a combined procedure which requires removal of both soft and hard
tissue.
● A wedge-shaped or elliptical incision is made on the crest of the alveolar ridge to the
depth of the bone. This piece of the tissue is then removed.
● The buccal and palatal margins of the flap are then thinned by removing the submucosal
tissues beneath these flaps.
● A rongeur or a large oval bur is used to remove the bony undercut.
● The area is then smoothened with the help of bone files and irrigated with saline.
● Before closure, undermined buccal and palatal flaps may need to be trimmed for proper
approximation. The wound is closed primarily.
Lateral Approach
● When tuberosity is very narrow and overlying keratinised mucosa requires to be
preserved for vestibuloplasty in this region, a lateral rather than a crestal approach is
adapted.
● Any incision is made on the lateral side of the maxillary ridge inferior enough to pass
below the malar buttress.
● Two relaxing incisions are made on either side of the crestal incision anteriorly and
posteriorly and the flap is retracted and submucosal excision of the fibrotic tissue is
done.
 ● The sulcus is extended superiorly from the lateral incision to deepen the sulcus. The
palatally based flap is now advanced to cover the bone and line the newly created
sulcus and it is sutured here to the new periosteum.
● A maxillary denture splint is used to stabilize the tissue in the new position.

Soft Tissue Procedures

1. Frenectomy
A frenum is a fold of tissue or muscle connecting the lips, cheek or tongue to the jawbone. A
frenectomy is removal of one of these folds of tissues. Patients receiving denture may need a
frenectomy if the position of a frenum interferes with the proper fit of the denture thereby
frequently ulcerating and reducing the stability of the denture.
Labial Frenectomy
● Local infiltration anesthesia is used to anaesthetize the labial frenum at its origin and
insertion.
● Once anesthetized, upper lip is everted so that the frenum is kept taut.
● Using two hemostats, the fibres of the frenum are locked.
● The hemostats are kept in such a way that their tips touch each other so that the entire
fibrous tissue of the frenum which has to be removed lies within the hemostat.
● Using the No.11 BP blade the frenum is excised by cutting the outer surface of both the
hemostats so that the excised tissue comes out separately along with the hemostats.
● Now the lateral margins of the wound are undermined and the wound is sutured without
tension.
Lingual Frenectomy
● This procedure is performed when there is ankyloglossia or when there is high lingual
frenal attachment.
● A 3.0 silk suture is passed through the midline of the tongue around 2 cm from the lip.
● This is done to hold the tongue up so that the frenum becomes taut.
● Using sharp scissors, a cut is made 1-2 cm midway between the tip of the tongue and
the lingual surface of the mandible.
● Care should be taken to not injure the submandibular duct, papilla and the blood vessels
in the floor of the mouth.
● In certain cases the genioglossus muscle should also be dissected in addition to the
lingual frenum.
● The wound margins are undermined, approximated and closed without tension.

2. Vestibuloplasty
Vestibuloplasty is a surgical procedure wherein oral vestibule is deepened by changing the soft
tissue attachments. It can be done either on the labial or the lingual side.
Goals of the surgery
● To increase the size of the denture bearing area
● To increase the height of the residual alveolar ridge
Labiobuccal Vestibuloplasty of Maxilla
Different techniques for labial vestibuloplasty are
i. Mucosal advancement vestibuloplasty (submucosal vestibuloplasty)
ii. Pocket Inlay vestibuloplasty
iii. Grafting vestibuloplasty

Mandibular Vestibuloplasty Techniques

Labial Approach
An incision is made deep in the sulcus and supraperiosteal dissection is carried out till the
predetermined depth. The raw surface heals by secondary epithelialization. The drawback of
this surgery is that in process of healing the sulcus tends to obliterate due to scar contracture,
techniques have been designed to reposition or ‘switch’ mucosa to cover the raw defect of the
deepened vestibule. They are:
● Kazanjian’s technique
● Godwin’s technique
● Lipswitch’s technique
● Clark’s technique
Kazanjian’s Technique
● An incision is made in the mucosa of the lip and a large flap of labial and vestibular
mucosa is retracted.
● The mentalis muscle is detached from the periosteum to required depth and the
vestibule is deepened via supraperiosteal dissection.
● A flap of the mucosa is turned downwards from the attachment of the alveolar ridge and
is placed directly against the periosteum to which it is sutured.
● A rubber catheter stent can be placed in the deepened sulcus and secured with
percutaneous sutures. It is removed after 7 days.
● The labial donor site is coated with tincture of benzoin compound and the surface heals
by granulation and secondary epithelialization. Contracture of the wound margins takes
place
Godwin’s Technique
● It is similar to the previous technique, but the vestibule is deepened by subperiosteal
stripping instead of supraperiosteal dissection.
● The periosteum and the connective tissue attached to it are pushed downwards and the
flap of labial and vestibular mucosa is placed against the bone and sutured to the
connective tissue beyond the deepened vestibule with the help of resorbable sutures.
● Now, a rubber catheter is placed in the deepened sulcus and secured by means of
percutaneous sutures. The catheter is left in place for 11 days.
● Meanwhile, raw tissue on the labial side is packed with zinc oxide-eugenol dressing,
which heals by secondary epithelialization and scar contracture.
Lipswitch Vestibuloplasty
● In this procedure, mucosal flap containing labial and vestibular mucosa is raised in a
similar way as in the previous two techniques, which have its free margin in the lip and
the base attached to the crest of the alveolar ridge.
 ● However, here the periosteum is incised high in alveolar ridge below the crest and it is
reflected from the bone. This flap consisting of periosteum, connective tissue and muscle
is turned outwardly ad sutured to the margins of the raw labial surface.
● Now the mucosal flap is turned downwards against the bare bone and sutured to the
periosteum deep in the vestibule.
Clark’s Technique
● This technique is the reverse of the Kazanjian’s technique. It is based on the following
principles.
● Raw surface on connective tissue contracts, whereas when covered with epithelium will
have minimum contracture.
● 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.
The flap is pedicled off from the lip, the raw surface on the bone is left exposed.
● An incision is made slightly labial to the crest of the alveolar ridge.
● The dissection is carried out supraperiosteally till the desired depth of the sulcus.
● The lip mucosa is undermined up to the vermillion border so that free edge of the
mucosal flap is secured to the periosteum deep in the sulcus.
● The raw surface on the bone heals by granulation tissue formation and epithelialization
without contracture. Initially, the depth of the sulcus is maintained for a long time.

Lingual Vestibuloplasty
It is used in patients with extensively resorbed mandible. Mylohyoid and genioglossus
muscles attached to the lingual aspect of the mandible interfere with the stability of the
prosthesis and try to dislodge them. The following methods are adapted for lingual
vestibuloplasty:
● Trauner’s technique
● Caldwell’s technique
Trauner’s Technique
● An incision is made in the floor of the mouth extending from the third molar of one side to
the third molar of the other side.
● The mucosa is reflected lingually and supra periosteal dissection is carried out, once
mylohyoid muscle is exposed a hemostat is passed through this muscle in the canine
region and the muscle fibres incised on the hemostat to avoid any injury to the
periosteum and the lingual nerve.
● Now the mucosa and the mylohyoid muscle are secured with percutaneous sutures to
the lower border of the mandible.
● On the lingual side of the mandible, a split thickness skin graft can be used on a stent to
cover the raw periosteal surface.
Caldwell’s Technique
● An incision is made in the crest of the posterior mandibular ridge extending from one
molar to the other molar region.
● Subperiosteal dissection is carried out and a full thickness mucoperiosteal flap is
elevated and reflected medially. The mylohyoid muscle is detached and mylohyoid ridge
is removed or reduced.
● The subperiosteal stripping is carried out till the desired depth and sometimes even to
the inferior border of the mandible. A rubber catheter is placed in the bottom of the
lingual sulcus and secured with percutaneous suture. It is left in place for 7-10 days.