Prepro Surgery

Preprosthetic Surgery
Dr. Mohamed Adel

Lecturer of OMFS – Nahda University
Definition:
• It is a branch of oral surgery dealing with surgical correction
of oral cavity soft and hard tissues before construction of
the dental prosthesis, so that the restoration rests on sound,
firm base without any complications.
Objectives of Preprosthetic Surgery:
• Improvement of masticatory function.
• Reconstruction of acceptable facial and dental esthetics.
• Creation of broad ridge form for denture and implant.
• Adequate fixed soft tissue over denture bearing area.
• Adequate vestibular depth.
• Proper inter arch relationship.
• Protection of neurovascular bundle.
Patient evaluation before corrective surgery
• It is mandatory prior to any surgical procedure to obtain:
1. Proper case history, intraoral & extraoral examination to report ridge form,
irregularities, levels of muscle attachment & presence or absence of flappy
tissues… etc.
2. Radiographic examination: Panoramic radiograph provides information
about pathological lesions, impacted teeth or remaining roots.
3. Patient expectation from treatment.
4. Patient adaptability to the new prosthesis.
5. Psychological response of the patient to the new situation.
Important Considerations
• Alveolar bone is the part of bone which

ends at apices of teeth while basal
bone is the bone below the apices of
teeth.
Important Considerations
• In presence of teeth, the periodontal ligament fibers convert compressive stresses

of mastication into tensile stresses which result in bone formation.
• When teeth are lost; bone resorption occurs in response to compressive stresses
due to absence of periodontal ligament.
Classification of Residual Alveolar Ridge
❑ Cawood & Howell, 1988 classification of residual ridge:
 Class I → dentate.
 Class II → post-extraction.
 Class III → convex ridge form, with adequate height & width.
 Class IV → knife-edge form with adequate height but
inadequate width.
 Class V → flat-ridge form with loss of alveolar process.
 Class VI → loss of basal bone that may be extensive but follows
no predictable pattern.
❑ Modifications include sub-classifications in II and VI:

 Class II → no defect, buccal wall defect, or multiwall defect.
 Class VI → marginal resection defect or continuity defect.

Treatment Planning of Preprosthetic Surgery
Initial Preparation
At time of tooth Extraction
Raising The Standards of Teeth Extraction

❑ Proper case history: to take precautions in cases that may
end up with delayed wound healing & improper ridge.
❑ Preoperative radiographs to assess for preexisting lesions

& remaining roots.
❑ Extraction procedures should be very merciful to hard & soft tissues furthermore, extraction
movements & forces should be controlled.
❑ Careful inspection of the extracted tooth/root as well as the
extraction sockets to assess for any fractured root fragments,
residual lesions or sharp projecting interradicular bone.
❑ Management of gingival inflammations before extraction (if present),

to Reduce possibility of developing hyperplastic tissues or delayed
healing.
Initial Preparation
At time of tooth Extraction
Alveoloplasty
Alveoloplasty
Definition:
Surgical contouring of the alveolar process, It is performed to:
a) Facilitate removal of teeth.
b) Correct irregularities of the alveolar ridge.
c) Remove undercuts or sharp edges.
Alveoloplasty
Types:
1) Simple Alveoloplasty:
a) Associated with single tooth extraction.
b) Associated with multiple teeth extraction.
c) In edentulous case.
2) Alveoloplasty associated with maxillary prognathism:
a) Dean’s Alveoloplasty.
b) Obwegesser’s Modification.
Simple Alveoloplasty
A) Associated with single tooth extraction
Aim:
In single isolated molar, surrounding bone undergoes sclerosis due to
high load.
Therefore, surgical contouring after extraction is done, otherwise
irregularities of ridge occur.
A) Associated with single tooth extraction
Steps of Surgery:
1) Anesthesia.
2) Incision around tooth to be extracted.
3) Extraction.
4) Reflection of buccal and lingual tissue.
5) Trimming of sharp bone by side cutting bone rongeur.
6) File is used to smoothen the bone in one direction.
7) Irrigation with saline.
8) Suturing to approximate tissue.
B) Associated with multiple teeth extraction
Aim:
In cases of multiple teeth extraction, the resulting alveolus may have
labial undercuts and multiple crestal irregularities that may prevent
construction of a proper prosthesis.
Therefore, surgical contouring after extraction has to be performed.
1) Anesthesia (Infiltration anesthesia).
2) Gingival incision around necks of the teeth to be extracted, the incision should extend
1 cm. distal on each side of the area of surgery.
3) 2 small oblique incisions just beyond the bone to be contoured, not to the mucobuccal
fold, not to obliterate the mucobuccal fold and could cause loss of the vestibular depth
when healing (fibrosis) occurs.
4) Reflect mucoperiosteal flap using mucoperiosteal elevator, to a
point just beyond the bone to be removed.
5) Start extraction of teeth.
6) Use side cutting rongeur to remove sharp edges and undercuts.
7) Use end cutting rongeur to remove projecting interdental bones.
8) Smooth the sharp edges of bone with round bur &/or bone file,
in one direction to avoid clogging cutting edges of the file.
9) Irrigation with normal saline.
10)Inspection of surgical field for any bony spicules, R.R., foreign body, filling material,
calculus.
11)Soft tissue flap is held over the alveolar bone and palpate by index finger for any
sharp edges, (if there is sharp bone edge, remove it).
12)Trimming of excessive soft tissue if necessary,
to avoid folding (over lapping) of the soft tissue
over the alveolar crest.
13)Flap is then approximated and sutured with
either interrupted sutures or continuous
sutures.
C) In Edentulous Case
Aim:
To correct irregularities of edentulous ridge prior to denture construction.
C) In Edentulous Case
1) Anesthesia.
2) Incision is done on the crest of the ridge.
3) Reflection of buccal &/or lingual tissues, as necessary.
4) Use side cutting rongeur or round surgical bur to remove
sharp edges and undercuts
5) Smoothening with bone file in one direction as needed.
6) Trimming of excessive soft tissue if necessary
7) Suturing with either interrupted or continuous sutures.
Alveoloplasty Associated with Maxillary Prognathism
A) Dean’s Interseptal Alveoloplasty

Aim:
This technique is done immediately after extraction of teeth in maxillary
anterior region to reduce gross labial prominence.

1) After extraction of teeth, exposure of the crest of the alveolar ridge by reflection of the
mucoperiosteum is done.
2) A rongeur can be used to remove the interseptal portion of the alveolar bone.

3) After adequate bone removal has been accomplished, digital
pressure should be sufficient to fracture the labial cortical plate
of the alveolar ridge inward to approximate the palatal plate
area more closely.

4) Occasionally, small vertical cuts at either end of the labial cortical plate facilitate repositioning of
the fractured segment. This is done by using a burr or osteotome inserted through the distal
extraction area, the labial cortex is scored without perforation of the labial mucosa.
B) Obwegesser Modification of Dean’s Interseptal Alveoloplasty

❑ This is a modification of the last technique in
which both the labial and palatal cortices are
repositioned.
❑ This is done when the anterior overjet is too
gross that cannot be reduced by labial plate
repositioning alone.
❑ Procedure is same as dean’s alveoloplasty but
the only addition is that, here palatal plate is
fractured too at its base and repositioned with
labial plate in palatal direction.
Initial Preparation
At time of 1 st Denture Insertion
Hard Tissue Procedures

Hard Tissue Procedures
1) Torus Palatinus.
2) Torus Mandibularis.
3) Lingual Balcony (Mylohyoid Ridge).
4) Genial Tubercles.
5) Bony Exostosis.
6) Sharp Knife Edge Ridge.
7) Bony Enlarged Maxillary Tuberosity.
8) Pneumatization of Maxillary Sinus
1) Torus Palatinus
 Congenital osseous non neoplastic outgrowth in the midline
of the palate, could have different shapes (oval, flat, spindle).
 It may be single or lobulated (lobules may coalesce with
each other forming large single mass in the midline of the
palate).
 It is covered with very thin palatal mucoperiosteum, firmly

adherent to bone.
 It increases in size in the 1st 3 decades of life then stabilized.
 Present in 20 - 25% of the patients.
1) Torus Palatinus
Indications for Removal:

1) If it acts as a fulcrum leading to rocking and instability of the denture.
2) Also, severe pain & ulceration of the palatal mucosa under the denture may occur.
3) An extremely large torus, filling the palatal vault with deep bony undercuts & food
lodgement under the folds and projection of the torus.
4) Interference with the function; speech &/or deglutition.
5) Psychological consideration; malignancy/ cancerphobia.

1) Torus Palatinus
Technique for Removal:

1) Anesthesia:
 Nerve Block Anesthesia:
 Greater palatine nerve block in both sides.
 Nasopalatine nerve block.

 Also, field block anesthesia around the torus can be done.
1) Torus Palatinus

2) Flap:
 A straight incision is carried from the posterior to the
anterior end of the torus, at either end of this incision

a V shape releasing incisions are done, so that the
incision is given a double Y shape in the midline.
1) Torus Palatinus

3) Reflection of the Flap:
 Reflection of the flap is done carefully to avoid
tearing or laceration of the palatal mucosa.

 After reflection, the flap can be held back with
sutures or with broad periosteal elevator held by
assistant.
1) Torus Palatinus

4) Removal of the torus:
 Large bony mass is removed in small parts by using round surgical bur to make
several holes in the mass which are then connected by fissure bur (using saline
coolant).
 Then remove each piece with uni-beveled chisel.
1) Torus Palatinus

 Round surgical bur is used to shave and trim the remnants of bone under saline
coolant.
 Return the flap to its position and trim excess tissue by scissor if needed to avoid
overlapping (folding) of the tissues & then suturing is done with interrupted sutures.
1) Torus Palatinus

 Prefabricated acrylic resin plate is used to prevent
postoperative hematoma by the effect of gravity which will
affect healing.
 Postoperative antibiotics & analgesics.
 Postoperative instructions.
1) Torus Palatinus
Possible Complications:
1) Fracture of the palatal bone.
2) Injury to floor of the nose.
3) Bleeding from nose.
4) Ulceration and sloughing of the palate.
5) Hematoma.
6) Nasopalatine nerve & vessels injury.
7) Greater palatine nerve & vessels injury.
2) Torus Mandibularis
 It is congenital exostosis situated on the lingual surface of the mandible in the canine-
premolar region.
 It is usually bilateral.
 It may be single, multiple, or lobulated (lobules may coalesce together forming single large
mass).
Indications for Removal:

1) Instability of the denture.
2) Irritation, pain, and ulceration of soft tissue covering from insertion and removal of
denture.
3) Cannot extend the lingual flange into lingual sulcus.

1) Anesthesia:
 Inferior alveolar & lingual nerve block.
2) Flap:
 Incision is made on crest of ridge (in bilateral cases
incision extends from the 1st molar area on one side to
that on the other side to provide good vision & access).

3) Reflection of the flap:
 Reflection of the flap is done lingually only to
expose torus.
 Flap should be reflected to 1 cm. below torus.

4) Bone Removal of Torus:
 Make a groove in the superior aspect
with small round bur and complete the
cut with uni-beveled chisel, placed in
the groove.
 Care must be exercised to avoid injury
of lingual nerve & vessels which are
present on a groove on the lingual
plate of bone at the region of 3rd molar.

 Bone is smoothed with a large rose head bur or
bone file.
 Irrigation.
 Return the flap into its position, excess soft
tissue is trimmed with scissor.

 Close the flap with interrupted or continuous
sutures.
 Postoperative instructions.
3) Lingual Balcony
 It is accentuated, prominent internal oblique ridge.
 It results from excessive resorption of the alveolar ridges (old extraction).
 Problems:
 Severe pain when denture presses on it.
 Lingual flange cannot extend deeper into the sulcus, so affecting denture stability.
3) Lingual Balcony

1) Anesthesia: Inferior alveolar & lingual nerve block.
2) Incision is made on crest of ridge; reflection of the flap is done lingually.
3) Strip the mylohyoid muscle from its attachment to allow it to reattach at lower level
(lobules of fat will appear in the wound as soon as the muscle is detached).
4) A rongeur or a burr can be used to remove bone & a bone file for smoothening.
4) Genial Tubercles
 As the mandible begins to undergo resorption, the area of the
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 a shelf
against which the denture can be constructed, but it usually
requires reduction to construct the prosthesis properly
4) Genial Tubercles

1) Anesthesia.
2) Incision on the crest of the ridge; reflection of Lingual and labial tissues as needed.
3) Detach genioglossus muscle to allow it to reattach at a lower level.
4) Remove bone with a burr or a rongeur followed by a bone file for smoothening as usual.
5) Bony Exostosis
 Buccal and palatal bony exostosis are bony spicules present on the buccal or palatal sides
which represent difficulties in denture wearing.
 They are removed easily with rongeur or surgical bur after reflecting a suitable flap.
5) Bony Exostosis
Removal of buccal exostosis Removal of palatal exostosis

6) Sharp Knife Edge Ridge
 The ridge is narrow and overlying mucosa may be very thin.
 It causes severe pain under the denture.
6) Sharp Knife Edge Ridge

1) Anesthesia.
2) Incision is done on crest of ridge.
3) Minimal reflection of mucosa labially & lingually.
4) Trim sharp edges of bone with rongeur, and then
do filling & Irrigation.
5) The use of a rongeur or file for recontouring is
preferred to rotary instruments to prevent over-
reduction.
6) Excess soft tissue is trimmed, & suturing is done.
7) Bony Enlarged Maxillary Tuberosity
 Horizontal or vertical excess of the maxillary
tuberosity area may be a result of excess bone, an
increase in the thickness of soft tissue overlying the
bone, or both.
 Indications for Surgical Recontouring:
 To remove bony ridge irregularities.
 To create adequate inter-arch space, which allows
proper construction of prosthetic appliances in the
posterior areas.
 A Careful Diagnosis here is Important:
 A preoperative radiograph or is useful to determine the extent of bone enlargement and
locate the floor of the maxillary sinus (pneumatization of the sinus may add difficulties to
the surgery).
 Selective probing with a local anaesthetic needle is useful to determine whether the
extent of soft tissue may contribute to this excess.

1) Anesthesia.
2) Incision on the crest of the ridge; reflection of buccal
& lingual tissues.
3) Reduction of bone (avoid endangering the hamular
notch which may affect the posterior palatal seal of
the upper denture).
4) Smoothening with bone file in one direction.
5) Irrigation with normal saline.
6) Trimming of excess soft tissue, suturing with
interrupted or continuous sutures.
8) Enlarged Tuberosity with Sinus Pneumatization
 In such cases; to avoid gross sinus perforation with the risk of oroantral communication the
surgery to reduce the tuberosity should be preceded by a sinus floor lift and augmentation
4-6 months earlier.
Discussed Later in Details ….

Initial Preparation
Soft Tissue Procedures

1) Labial frenectomy
2) Lingual frenotomy.
3) Fibrous Enlarged Maxillary Tuberosity.
1) Labial Frenum (Frenectomy)
 Mucosal fold in the labial surface of the ridge, attaching the
upper lip to labial surface of ridge.
 Congenital anomalies.
 It restricts movement of the upper lip.

 It may extend to incisive papilla, causing diastema between 1│1.
 If patient is edentulous, it prevents proper seating of denture and
decreases its stability.
 Indication for removal of labial frenum (Frenectomy):
 Treatment of central diastema between 1│1.
  Stability of denture is edentulous patient.
Technique for Labial Frenectomy:

1) Anesthesia (Infiltration anesthesia).
2) Upper lip is stretched upward and outward on labial plate of bone.
3) Frenum should be properly stretched.

4) Two mosquito forceps (Hemostats) are used to clamp the frenum.
5) One forceps parallel to inner surface of the lip reaching mucolabial
fold.
6) Another forceps parallel to labial surface of the alveolar ridge
reaching the mucolabial fold, to be perpendicular on the 1st forceps.
7) The tips of the two beaks should now meet & labial frenum is held
between them.
8) Use Bard parker blade No. 11 to cut along the outside of the
hemostats to free the lip from the frenum and frenum from the labial
alveolar mucosa covering alveolar ridge.

9) Pear shaped wound in lip and over
labial bone will result.
10) The margins of the wound are now
undermined by blunt scissors.
11) Then suturing of the wound margins
without tension is done.
12) Removal of tissue in areas adjacent to
attached mucosa sometimes prevents
complete primary closure at the most
inferior aspect of wound margin.
The Z - Plasty Technique:

 It is more difficult to perform but useful when
the frenum is broad and the vestibule is
short.
 Two releasing incisions are made creating a
Z shape; the two flaps are eventually
undermined and rotated to close the initial
vertical incision horizontally.
Localized Vestibuloplasty Technique:

 Wide-based frenum attachments may be treated with this technique:
1) Wide V-type of incision made at the most inferior portion of frenal attachments in the
area of the alveolar ridge
2) A supraperiosteal dissection is made to expose the underlying periosteum.
Localized Vestibuloplasty Technique:

3) Superior repositioning of the mucosa is done.
4) The wound margin is then sutured to the
underlying periosteum at the depth of the
vestibule.
5) Healing proceeds by secondary epithelialization.
6) A preexisting denture or stent may be used for
patient comfort in the initial postoperative period.
2) Lingual Frenum “Tongue Tie” (Frenotomy)
 Tongue tie is a congenital anomaly where lingual frenum is short and thick.
 Problems:
 It restricts the movement of the tongue.
 Patient is unable to clean away food from oral cavity.
 Patient develops speech difficulty.
 In infants it interferes with sucking.
 In edentulous patients it prevents proper seating of the denture (as the lingual frenum
has its origin near or at the crest of ridge) → poor retention and instability of the denture
occurs.
Correction of tongue tie (lingual frenotomy):

1) Anesthesia: Bilateral lingual nerve block.
2) Tongue is stretched upward and outward by tongue
forceps or by suture passed through the midline of the
tongue ¼ inch from the tip of tongue.
3) A hemostat is used to compress the frenum area for 2 to
3 minutes to allow for improved hemostasis.

4) Incision is made at the superior portion of frenal
attachment through the serrations created by the
hemostat to the inferior surface of the tongue.
5) The incision is continued until the tongue is freed
and its tip can touch the palatal surfaces of the
upper anterior teeth with the mouth opened.

6) The incision will produce Rhomboidal wound in the undersurface of the tongue and in
the floor of the mouth.
7) Edges of the mucosa at the incision lines on each side of the wound are undermined
with blunt scissor.
8) The wound is closed without tension with interrupted sutures.
3) Fibrous Enlarged Maxillary Tuberosity
 Enlarged fibrosed maxillary tuberosity affects the intermaxillary space.
 In some patients, this overgrowth of tissue is related to periodontal disease around maxillary
molars, or overgrowth of tissue distal to over erupted upper third molar.
Reduction of Fibrous Enlarged Maxillary Tuberosity:

1) Infiltration anesthesia.
2) An elliptical V-shaped incision is made on the alveolar ridge extending from unaffected
normal tissue till the end of the maxillary tuberosity.
3) This incision should be carried deep down to bone.

4) The elliptical mass of tissue is grasped with an Allis forceps.
5) The mass of tissue is then dissected by periosteal elevator, lifted and discarded.
6) The Buccal and palatal edges of the wound are undermined.

7) Roundation of bone of alveolar ridge by round surgical bur if needed.
8) Suturing of the wound with interrupted suture.
Initial Preparation
Mixed (Hard & Soft) Tissue Procedures

Mixed (Hard & Soft) Tissue Procedures
❑ Bony & Fibrous Enlarged Tuberosity:
➢ As Mentioned before; careful clinical & radiographic examination is important in enlarged

tuberosity cases to determine exactly the enlarged component(s) and the approximation
of the maxillary sinus. Management then proceeds accordingly.
Secondary Preparation
After Long Period of Denture
Wearing

1) Flabby Ridge.
2) Denture Fissuratum.
1) Flabby Ridge:
 Hyperplastic Ridge with lack of bony support.
 It results from irritated soft tissue covering edentulous
ridge due to excessive occlusal trauma which causes
bone resorption and the space formerly occupied by
alveolar bone is filled with fibrous tissues.
 Surgical correction aims to remove excess soft tissue

covering the ridge to avoid pain on biting & decreased
denture stability.
1) Flabby Ridge:
Surgical Correction of Flabby Ridge:

1) Anesthesia.
2) Grasp the flabby ridge with several Allis forceps at its crest
and hold it up.
3) Cut a V-shaped elliptic incision down to the bone through the
flabby tissue (Buccal & lingual incision meet on crest of
ridge).
4) The tissue is then removed.
5) Wound edges are undermined.
6) Suturing wound edges.
2) Denture Fissuratum:
 Several false unstable wide ridges composed of granulation tissue in the mucobuccal
fold resulting from wearing of ill fitted denture.
 Removed surgically as in flabby ridge.
Surgical Correction of Denture Fissuratum:

1) In case of Small, well-localized area of fibrous hyperplasia:
➢ This area can be removed with simple Excision as in flabby ridge.
➢ Primary closure of wound margins can proceed as usual.
Surgical Correction of Denture Fissuratum:

2) In case of Large area of inflammatory fibrous hyperplasia:
➢ Removal and primary closure would result in elimination of the labial vestibule.
➢ So, After supraperiosteal removal of excess tissue, the mucosal edge is sutured to the
periosteum at the depth of the vestibule which leaves area of exposed periosteum that
heals by secondary epithelialization.
Wearing
Hard Tissue Procedures (Flat Ridge)

1) Ridge Augmentation.
I. Mandibular Ridge Augmentation.
II. Maxillary Ridge Augmentation.
1) Vestibuloplasty.
2) Inferior Alveolar & Mental Nerve Procedures.

1) Ridge Augmentation:
Mandibular Ridge Augmentation
1) Superior Border (Onlay) Augmentation:
 Performed when there is adequate inter arch space to accommodate the graft.
 Autogenous bone grafts are obtained from ribs or iliac crest.
 Grafts are then horseshoe shaped & fixed to the superior border of the mandible using
circumferential wiring, trans-osseous wiring, screws, plates or Implants.
1) Superior Border (Onlay) Augmentation:
 Disadvantages:
1. Donor site morbidity.
2. Second surgical site necessary.
3. Continued resorption of the grafted sites.
4. Soft tissue dehiscence or limitation.

5. Soft tissue preparation (Vestibuloplasty) should be considered one month before
surgery.
2) Inferior Border Augmentation:
 Performed when there is no adequate inter arch space to accommodate the graft.
 Inferior border augmentation has been demonstrated using autogenous rib or composite
cadaveric mandibles combined with autogenous cancellous bone.
 Steps of Surgery:
1. Submandibular Incisions are placed from one mandibular angle to the other.
2. The inferior border is exposed in a subperiosteal dissection.
3. Cadaveric mandible is adjusted creating a scalloped tray to incorporate the
autogenous bone obtained from the ileum.
4. Once the atrophic mandible fits securely inside the cadaveric specimen, bur holes are
drilled throughout the specimen to facilitate vascularization & the entire specimen is
fixed rigidly to the native mandible using screw fixation.
5. After graft maturation (4-6 months), vestibuloplasty is then performed.
 Advantages:
a) Increased stabilization of the mandible.
b) No change in vertical dimension.
c) No direct masticatory forces.
 Disadvantages:
a) Extraoral scar.
b) Sensory or motor nerve deficiencies.
c) Facial Disfigurement.
3) Hydroxyl apatite bone augmentation:
 Hydroxyl apatite granules or blocks can be used to  the height of the ridge as follows:
1. A vertical midline incision is made.
2. A small mucoperiosteal elevator is used through the incision to produce a tunnel
beneath the periosteum.
3. H.A. is injected through the incision (a special syringe is inserted to the depth of the
tunnel & withdrawn while injecting the hydroxyl apatite granules).
4. Molding by digital pressure is performed to obtain a uniform ridge shape.

5. Temporary splint is used to keep H.A. in place above the crest of ridge.
3) Hydroxyl apatite bone augmentation:
4) Guided Bone Regeneration:
 It implies the use of membranes for space provision over a vertical or horizontal bounded
defect, promoting the ingrowth of osteogenic cells while preventing migration of
undesired cells from the overlying soft tissue.
 The space is maintained by various particulate graft materials and the use of resorbable,
non-resorbable as well as titanium-reinforced membranes.
 Failures are mainly related to premature membrane exposure that may lead to infection
and eventually partial or total loss of regenerated bone.
A) Membrane and “filler material” such as allogeneic bone are used to augment the ridge.
B) Same as in (A), except that an implant is placed simultaneously.
C) The membrane is supported by “tenting” screws that preserve the space beneath to allow bone fill.
5) Pedicled & Interpositional graft osteotomies:
 Success of these procedures is based on the maintenance of the lingual periosteum.
 The lingual periosteum maintains ridge form and its presence results in minimal
resorption of the transpositioned basilar bone.
 Visor Osteotomy:
▪ The body of the mandible is split or sectioned into labial &
lingual segments.
▪ The lingual segment is superiorly repositioned & fixed in the
new position to the labial segment with screws.
▪ Unfortunately, labial bone grafting of the superiorly
repositioned lingual segment was necessary to reproduce
alveolar dimensions that were compatible with prosthesis use.
 Sandwich Osteotomy:
▪ It is a horizontal osteotomy with interpositional grafts to
augment mandibular height, with repositioning of the inferior
alveolar neurovascular bundle.
▪ Unfortunately, neurosensory complications and collapse of the
lingual segment became significant disadvantages to this
technique.
6) Ridge Split Osteoplasty:
 Used to gain width for the alveolar
ridge→ expanding the knife edge
ridge in a B-L direction.
 It is easier in the maxilla.
 Requires a minimum of 4 mm wide
alveolar crest.
7) Alveolar Distraction Osteogenesis:
 Distraction osteogenesis (DO) is a biologic process of new bone formation between
surfaces of bone segments which are gradually separated by traction forces.
 Intraoral Distraction devices consisting mainly of two bone plates and a distractor.
 Procedure:
▪ A vestibular incision is done to expose the bone at the level of the planned osteotomy.
▪ During flap reflection, the soft tissue on crestal and lingual aspect should remain intact
to maintain the viability of the osteotomy segment.
▪ A saw is used to make osteotomies to mobilize the deficient alveolar ridge, two vertical
osteotomies are done connected by a horizontal osteotomy.
 Procedure:
▪ Mobilization of bone segment is done with an osteotome.
▪ DD is placed & activated everyday till desired height of the
alveolus is achieved.
▪ Latency: 5–7 days. Distraction rate: 1 mm/day.
Consolidation period: 3–4 months
 Advantages:
▪ No donor site morbidity.
▪ Shorter time of treatment in comparison with bone augmentation procedures.
▪ The quality of the bone grown in response to distraction is ideal for implant placement.
▪ Horizontal distraction of the alveolus to increase width can also be done successfully.
1) Ridge Augmentation:
Maxillary Ridge Augmentation
1) Onlay Augmentation:
 When clinical loss of the alveolar ridge and palatal vault occur
(Cawood and Howell Class V), vertical onlay augmentation of
the maxilla is indicated.
 Initial attempts the use of autogenous rib grafts; however,
currently corticocancellous blocks of iliac crest are the source of
choice.
 In a similar approach to that described for the mandible, the
crest of the alveolus is exposed, and grafts are secured with 1.5
to 2.0 mm screws.
2) Interpositional bone Grafting (le fort I osteotomy):
 Interpositional grafts are indicated when adequate palatal vault height exists in the face
of severe alveolar atrophy (Cawood and Howell Class VI) posteriorly.
 The procedure involves down fracturing of the maxilla (le fort I) with rigid fixation &
placing interpositional graft using autogenous iliac crest.
 Implants can be placed simultaneously.
 It provides a typical vertical gain of about 4 to 5 mm.
 A relapse of 1 to 2 mm has been demonstrated.

3) Hydroxyl Apatite Augmentation:
 Hydroxyl apatite granules or blocks can be used to  the
height of the ridge as follows:
1. A vertical midline incision is made.
2. A tunnel is made through the incision beneath the
periosteum.
3. Inject H.A granules.
4. Molding by digital pressure.

5. Temporary splint is used.
 The use of membranes for space provision over a vertical or horizontal bounded defect.
 As previously described for mandibular defects.
 Expanding the knife-edged alveolus in a
buccolingual direction.
 Adequate dimensions, however, should
exist that allow for a midcrestal osteotomy
to separate the buccal and lingual cortices
(4 mm crestal width).
 Procedure:
1. A mucoperiosteal flap is raised at the edentulous site.
2. A sagittal osteotomy of the edentulous ridge is initiated at the centre of the ridge
using a small crosscut fissure bur or better a piezoelectric saw.
3. Two buccal cortical vertical osteotomies are made at the start & the end of the
edentulous space & connected to the sagittal one.
4. Mobilization of labial segment can be done carefully with an osteotome.

5. Implants can be placed simultaneously.
6. Bone graft can be placed in the resulting defect & a membrane is used to cover it.
 As previously described for mandibular defects.
7) Maxillary Sinus Lift:
 The maxillary sub antral augmentation procedure is a well-established technique for
increasing bone volume in the deficient posterior maxilla.
 Indications:
▪ Grafting of the maxillary sinus was first used to increase the bulk of bone for later
maxillary tuberosity reduction.
▪ Grafting of the maxillary sinus now is mostly undertaken for patients with pneumatized
sinus & needed implant placement.
 Sinus Osteotome Technique (Closed Technique):
▪ This technique is indicated in residual alveolar bone height superior to 6 mm.
▪ Elevation of the sinus floor is carried out through a trans-alveolar approach using
osteotomes to press the bone.
▪ Once the first drilling is performed, osteotomes are introduced progressively thus
expanding the bone in a vertical and transversal direction until the pre-planned bed to
place the implant has been prepared.
 Sinus Osteotome Technique (Closed Technique):
▪ Condensing the alveolar bone transversally allows simultaneously for a better bone
density around the implant.
▪ In extreme cases, a small amount of grafting material can be introduced into the sinus
before implant placement.
 Maxillary Sinus Grafting (Open Technique):
▪ In case of poor residual bone with less vertical height
(less than 6 mm), a lateral approach to the sinus cavity is
indicated in order to place bone grafting material.
▪ Once the flap has been elevated, the lateral maxillary
bone wall is exposed.
▪ The osteotomy is outlined aiming to leave at least 3 mm
between the inferior margin of the window and the sinus
floor.
▪ The osteotomy is performed on the lateral maxillary wall
until the bluish lining of the sinus is visualized.
▪ Once osteotomy is completed, a green stick fracture of
the bone fragment covering the membrane is made.
▪ Careful dissection of the schneiderian mucosa from the
underlying bone walls will allow the membrane to be
reflected into the sinus cavity with the fragment of
osteotomized bone fragment attached.
▪ After this procedure (sinus lift) a new cavity will have
been created in the sinus floor region, allowing for
placement of the grafting material.
▪ Implant placement is carried out simultaneously in case
of having enough bone to provide primary stability.
▪ In case of atrophic bone, not allowing adequate fixation
for the implants, secondary placement of implants after
consolidation of the grafting material is done.
 Recent Advances:
▪ Piezo surgery is advocated for osteotomy & dissection of
membrane as it would not cut the schneiderian membrane.
▪ Recently antral balloon can be introduced into the osteotomy
hole and inflated to elevate the sinus membrane.
▪ The use of special kits with special types of burs that does
not injure the membrane.
8) Nasal Floor Elevation:
 The bone height in Atrophic premaxilla is limited by
the nasal cavity which hinders implant placement
because it may penetrate the nasal cavity.
 Nasal floor augmentation was described by Garg
in 1997 as a technique for implant placement in
cases of severe atrophy of the height of maxilla
with less than 10 mm of residual ridge height.
 It can elevate the nasal mucosa by 3-5 mm.
8) Nasal Floor Elevation:
 Advantages:
▪ No bone removal needed.
▪ Shortens time of treatment.
▪ High survival rate due to bicortical stabilization.
8) Tuberoplasty:
 Performed in case of deficient hamular notch, thus affecting
the posterior palatal seal of the upper denture.
 Incision is done on the crest of the ridge reaching the
pterygoid hamulus posteriorly.
 Posterior superior repositioning of the pterygoid plate is
done.
Wearing

1) Vestibuloplasty.

2) Vestibuloplasty (Ridge Extension):
 Deepening of the vestibule without any addition of the bone is
termed as “vestibuloplasty” or “sulcoplasty” or “sulcus deepening
procedure”.
 Vestibuloplasty is “uncovering the existing basal bone of the
jaws surgically & repositioning the overlying mucosa, muscle
attachments to a lower position in the mandible/ superior
position in the maxilla”.
2) Vestibuloplasty (Ridge Extension):
 However; to utilize this treatment option, sufficient amount of height of the alveolar bone
should be available. In extreme atrophy cases, where resorption of the basal bone has
taken place, this option is out of consideration.
Vestibuloplasty Procedures
Buccal Vestibuloplasty Lingual Vestibuloplasty
Secondary Epithelialization
Submucosal Vestibuloplasty Grafting Vestibuloplasty
Vestibuloplasty
Kazanjian’s V. Mucosal Graft V.
Lip Switch V. Skin Graft V.
Clark’s V.
Buccal Vestibuloplasty
1) Submucosal Vestibuloplasty:
 Indicated when the overlying mucosa is healthy (not scarred, hyperplasic nor fibrosed).
 A vertical midline incision is made in the labial vestibule.
 A supraperiosteal tunnel is made from (R) premolar to (L) premolar area.
 In maxilla, further separate incisions may be given in first molar region for further
advancement.
 The intervening submucosal tissue is then excised or repositioned superiorly.

 The new depth is maintained by placement of preformed dentures/stents, which can be
fixed to mandible with circummandibular wiring & to maxilla by per alveolar wiring.
1) Submucosal Vestibuloplasty:
Maxillary submucosal vestibuloplasty procedure
Mandibular submucosal vestibuloplasty procedure

2) Secondary Epithelialization Vestibuloplasty:
❑ Indicated when the overlying mucosa of the ridge is not healthy
(scarred mucosa).
A. Kazanjian’s Vestibuloplasty:
 An incision is made in the labial mucosa.
 A thin mucosal flap is dissected from the underlying tissue.
 A supraperiosteal dissection is performed on the anterior aspect
of the ridge.
 The labial mucosal flap is sutured to the depth of the vestibule.
 A raw soft tissue area is left to heal by 2ndry epithelialization.
B. Lip Switch Vestibuloplasty:
 An incision is made in the labial mucosa.
 A thin mucosal flap is dissected from the underlying tissue.

 A supraperiosteal dissection is performed on the anterior
aspect of the mandible.
 After elevation of the mucosal flap, the periosteum is incised
at the crest of the alveolar ridge.
B. Lip Switch Vestibuloplasty:
 A subperiosteal dissection is completed on the anterior
aspect of the mandible.
 The periosteum is then sutured to the anterior aspect of the

labial vestibule.
 The mucosal flap is sutured to the vestibular depth at the
area of the periosteal attachment.
C. Clark’s Vestibuloplasty:
 Horizontal incision is made at the level of the mucobuccal fold extending around arch
labially and buccally.
 Free the mucosal layer from labial & buccal aspect of the ridge.
 The freed mucosal layer is sutured to the periosteum at the new level.
 The exposed periosteum between the incision and suture line is covered by surgical
pack dressing or use splint for 1 week.
C. Clark’s Vestibuloplasty:
3) Tissue Graft Vestibuloplasty:
A. Mucosal Graft Vestibuloplasty:
 A mucosal graft is used to cover the denuded
periosteal area of the last technique.
 The mucosal graft should be free from lesions as

lichen planus or leukoplakia.
 Donor site may be cheek, palate or dorsum of the
tongue.
3) Tissue Graft Vestibuloplasty:
B. Skin Graft Vestibuloplasty:
 Graft is obtained from hairless area (inner thigh -
medial side of the forearm).
 Thin graft is preferable to a thick one.

 Graft should be immobilized with great care under
moderate pressure.
Lingual Vestibuloplasty
Floor of the Mouth Lowering:
 Inferior repositioning of the mucosal flap after the mucosal
incision and downward placement of genioglossus,
geniohyoid & mylohyoid muscle attachments.
 Fixation of mylohyoid & genioglossus muscles to the desired
vestibular depth on lingual side by sutures passed extraorally
over the skin at the inferior border of the mandible.
 Placement of skin graft and preform a denture/stent.
Wearing

1) Vestibuloplasty.

3) Inferior Alveolar & Mental Nerve Procedures
Repositioning of Inferior Alveolar Nerve:

 Repositioning of inferior alveolar nerve can be done by two techniques: (A) Lateralization
and (B) Transposition.
 A horizontal incision is made on the alveolar crest, with a vestibular releasing incision
anterior to mental foramen and a mucoperiosteal flap is raised.

A. Lateralization:
▪ Cortical bone window is prepared posterior to the mental foramen around
the inferior alveolar nerve, until nerve is fully freed from its intrabony
trajectory.
B. Transposition:
▪ A corticotomy is done around the mental foramen continuing with the
posterior window and the incisive nerve is transacted, such that the mental
foramen is repositioned more posteriorly.
▪ With this procedure, there is no interference with the incisive nerve with
nerve transposition.
A. Lateralization
B. Transposition

 The nerve fully lateralized and protected with periosteal elevator.
 The nerve is separated using a vessel loop, applying gentle traction
outwards as the implants are placed under direct visualization.
 A resorbable membrane is placed between the implants and the
nerve.
 Implant primary stability achieved as a result of fixation in the
mandibular basal layer.
Mental Foramen Surgical Relief:

 Bony margins of mental foramen are usually denser and more
resistant to resorption, which causes the margins of the foramen
to extend and have very sharp edges 2 to 3 mm higher than the
surrounding bone.
 Also, the pressure from the denture against the mental nerve will
cause pain.
 Hence, mental foramen surgical relief aims to smoothen the bony
margin of foramen and increase the foramen diameter on its
lower border, thereby relieving the nerve from excess pressure.
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Prepro Surgery

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Prepro Surgery

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Preprosthetic Surgery

Dr. Mohamed Adel

• Alveolar bone is the part of bone which

• In presence of teeth, the periodontal ligament fibers convert compressive stresses

❑ Modifications include sub-classifications in II and VI:

 Class VI → marginal resection defect or continuity defect.

Raising The Standards of Teeth Extraction

❑ Preoperative radiographs to assess for preexisting lesions

❑ Management of gingival inflammations before extraction (if present),

A) Dean’s Interseptal Alveoloplasty

A) Dean’s Interseptal Alveoloplasty

A) Dean’s Interseptal Alveoloplasty

A) Dean’s Interseptal Alveoloplasty

B) Obwegesser Modification of Dean’s Interseptal Alveoloplasty

Hard Tissue Procedures

 It is covered with very thin palatal mucoperiosteum, firmly

Indications for Removal:

5) Psychological consideration; malignancy/ cancerphobia.

Technique for Removal:

 Nasopalatine nerve block.

Technique for Removal:

anterior end of the torus, at either end of this incision

Technique for Removal:

tearing or laceration of the palatal mucosa.

Technique for Removal:

Technique for Removal:

Technique for Removal:

Indications for Removal:

Technique for Removal:

Technique for Removal:

Technique for Removal:

Technique for Removal:

Technique for Removal:

Technique for Removal:

Technique for Removal:

Removal of buccal exostosis Removal of palatal exostosis

Technique for Removal:

Technique for Removal:

Discussed Later in Details ….

Soft Tissue Procedures

 It restricts movement of the upper lip.

Technique for Labial Frenectomy:

Technique for Labial Frenectomy:

Technique for Labial Frenectomy:

The Z - Plasty Technique:

Localized Vestibuloplasty Technique:

Localized Vestibuloplasty Technique:

Correction of tongue tie (lingual frenotomy):

Correction of tongue tie (lingual frenotomy):

Correction of tongue tie (lingual frenotomy):

Reduction of Fibrous Enlarged Maxillary Tuberosity:

Reduction of Fibrous Enlarged Maxillary Tuberosity:

Reduction of Fibrous Enlarged Maxillary Tuberosity:

Mixed (Hard & Soft) Tissue Procedures

➢ As Mentioned before; careful clinical & radiographic examination is important in enlarged

Soft Tissue Procedures

 Surgical correction aims to remove excess soft tissue

Surgical Correction of Flabby Ridge:

Surgical Correction of Denture Fissuratum:

Surgical Correction of Denture Fissuratum:

Hard Tissue Procedures (Flat Ridge)

I. Mandibular Ridge Augmentation.

II. Maxillary Ridge Augmentation.