Preprosthetic 2

Bony enlarged maxillary tuberosity:

Tuberosity reduction
May be enlarged buccally, palatally or vertically.
Unilateral or bilateral.
Could be associated with pneumatized sinus.
Indication for removal:
1. If causes injury to the overlying soft tissue or coronoid process.
2. If interfere with Denture Fitness and retention.
3. Encroach inter-arch space and interfere with denture construction.
Technique:
Pre-operative radiograph is mandatory to look for sinus floor
approximation and
preventing Oro-antral Communication
1. L.A (infiltration buccally and palatally) or
Posterior superior alveolar and greater palatine nerve block
2. Crestal incision using B.P blade No 15 and incision is extended
posterior to
tuberosity using B.P blade No 12
3. Reflection buccally or palatally.
4. Bone removal by surgical burs or bone rongeur
5. Filing and irrigation.
6. Remove excess tissue.
7. Suturing by interrupted or continuous suturing
  Fibrous tissue enlarged maxillary tuberosity:
 Indications:
1. If causes soft tissue irritation.
2. Encroach inter-arch space and interfere with denture construction
 Technique:
1- Wedge shape incision with the blade 45 ( the upper border of the
tissue is larger then the lower ) to avoid redundancy of the tissue (
flappy tissue )
2- Removing of the tissue
3- Tailoring of the tissue & suturing
  Papillary hyperplasia :
 Soft tissue lesion characterized by formation of knots on the palate
 easily bleeding due to high vascularization of this area
 Complication : easily teared by denture , food accumulation
 Ttt : cauterization is preferred due to due to high vascularization ,
surgical removing by scalpel no 15 can be used

 Multiple gingival fibromatosis

 Can occur in upper or lower arch

 DD: bony lesion & can differentiate by clinical & radiographic
examination
 Clinical : palpation ( soft ) inspection ( yellow color ) , can’t depend
100% percent on clinical
 Radiographic : affecting periodontium of the tooth  radiolucency
& resorption of the tooth + mobility
 Ttt : excision of the lesion & extraction of the related tooth
  Surgical Correction of Flat Ridge
 Vestibuloplasty: Sulcus deepening ( insertion of the of the soft
tissue in deeper layer ) or relative ridge heightening. Bone height ≥
2cm
 Ridge augmentation: Absolute ridge heightening. Bone height <
2cm

 Vestibuloplasty :
 Submucosal Vestibuloplasty:
1- A midline incision is made vertically to subperiosteal
- Another incison in canine premolar area could be done
2- Sharp Dissection of the mucosa from the underlying
periosteum using a curved dissecting scissors
3- Prefabricated denture with the desired flange height is placed
over the ridge as a stent and held in position using
circumferential wiring for 1 week.
4- Adv : both labial & alveolar mucosa is covered so the healing
occur by 1ry heeling
5- Disadv. :
a- Blind technique
b- The scissor can’t reach the tuberosity area
c- Could injury infra-orbital & mental nerve
  Kazanjian Tech.:
1- 1-2 mm horizontal incision away from the deepest part of the
labial vestibule along the maxillary tuberosity right & left on
labial mucosa
2- Dissection of all mucosa till the crest of the ridge
3- Pulling the alveoler mucosa to the deepest part of labial
vestibule
4- Raw area at the inner aspect of labial mucosa ( healing with 2ry
intention and the patient suffer from pain )

 Clark’s technique
1- 1-2 mm horizontal incision from the crest of the ridge from
right to left tuberosity
2- Preform dissection to all labial & alveolar mucosa
3- Insert the labial mucosa at the deepest layer of the vestibule
4- The labial & buccul alveolar mucosa is bared ( raw area) so
healing with 2ry intention and the patient suffer from pain
  Khalil’s technique ( finstrating )
1- Stretching of the mucosa
2- Preform horizontal serration either in the labial or alveolar
mucosa
3- This will increase tissue elasticity so the tissue can be pulled
4- Take the advantage of both submucosal & Kazanjian Tech
So it :
1- Not blind technique
2- No incidence of nerve injury
3- 1ry healing

 all alveoplasty tech. except submucosal = supraperiosteal

 all bone augmentation tech. & submucosal = subperiosteal
 Ridge Augmentation:
 Indication :
1- Severe atrophy in ridge, remaining bone height is < 2cm
2- High muscle attachment that cannot be repositioned at lower
level
 Material used :
1- Onlay graft :
a- Autogenous = same patient
b- Homogenous = same species
c- Heterogeneous = another species ( animal bone )
d- Allo-plastic = synthetic material :
- Tri-calcium phosphate
- Hydroxy appetite
 Techniques :
1- Superior border grafting
2- Inferior border grafting
3- Destruction osteogenesis
4- Inter-positioning ( inter segment ) placement
 Mandible bone augmentation :
 Superior border grafting : ( along the crest of the ridge )
1- Indicated in adequate inter-arch space
2- Same incision as in submucosal Vestibuloplasty with
conservative incision on the crest of the bone without
involving of the labial or lingual mucosa to avoid escapement
of the graft ( guided graft regeneration could be done )
3- Insert the graft from pot. To ant.
4- Graft could be allo-plastic ( synthetic ) or Homogenous graft
5- Graft from -Rib or iliac crest ( ant aspect 40-50 mm , post.
aspect 80 – 120 mm )
6- Comes in block  remineralization to avoid rejection of the
graft from the body
7- Goals of success of graft :
1- Adequate fixation
2- Adequate coverage by soft tissue

 Guided graft technique : insertion of membrane before injection

of the graft to :
1- Avoid escapment of the graft
2- Avoid fibrous heeling between the graft & bone ( I need bone
healing )
  Inferior border grafting :
along the inferior border of the ridge
1- Indication ::
a- in limited inter-arch space
b- very thin ridge ( pencil like appearance )
c- adequate coverage of the graft can’t be applied
2- Using collar neck Incision ( incision extended extraorally
from the chin , hyoid bone & mastoid process , used in
resection cases of tumor especially the locally agresive &
malignant )
3- Insert the graft along the inner aspect of the jaw
4- Disadv: patient will suffer from double chin ( can be solved
by plastic surgery contouring )
 Inter positioning ( inter segment ) placement
1- Done by using “ visor osteotomy “
2- Osteotomy along the inner aspect of the mandible and elevating
the distal ( upper ) segment by insertion of cortico-cancellous
blocks between the proximal ( lower ) and the distal ( upper )
segment
3- Used to increase the height of the ridge
4- Ridge elevated ant. & post.
5- Adv. : eliminate the need of direct opposition of the mucosa
with the graft ( graft covered with bone adequately )
 Maxillary bone augmentation :
 Same as mandible in superior border but inferior border can’t
be applied
 Inter positioning ( inter segment ) placement
1- Insertion of the graft between the base of the skull and the
maxilla using “ lefort 1 technique “ ( this tech. is used in
orthognathtic surgery as gummy smile )
2- Osteotomy from ant. Nasal appratous  lateral nasal wall 
canine eminences  canine fossa  maxillary tuberosity
3- Separation & down fracture of the maxilla & insertion of
cortico-cancellous blocks from chin or iliac crest
4- Prevent resorption of the graft
 Destruction osteogenesis
1- Gradual traction of the bone
2- Adv: on cases of limited soft tissue or low elasticity
3- Can be tooth borne or bone borne ( bone borne gives more
controlled movement )
4- Destruction rate = dividing the treatment plan on each day
5- Destruction rhythm = dividing the destruction rate along the
day
6- Latency period : time between osteotomy and activation of the
destructor
7- Activation period : time between activation till reaching the
desired height , don’t remove the apllience as it work as fixation
device
8- Consultation period : time between reaching the desired height
until fixation and remodeling occur
9- Consultation period = every 1mm need 10 days of fixation
period