Pre-prosthetic surgery Ali AL-Hiyali BDS,MSc OMFS UK AL-Mustansyria uni/college of dentistry BDS 4, 2015-2016

Intended Tutorial outcomes At the end of this tutorial you should be able to: Define the pre-prosthetic surgery process Understand the principles of and indications for preprosthetic surgery Explain the principal advantages and disadvantages of preprosthetic procedures Know the types of available surgical procedures

Definition 1st grafting procedure to restore intraoral defect was in 19th century “Preprosthetic surgery involves operations aiming to eliminate certain lesions or abnormalities of the hard and soft tissue of the jaws, so that the subsequent placement of prosthetic appliances is successful.”

Objectives Restore function (mastication, speech and swallowing Preserve or maintain jaw structures Improve patient’s quality of life Improve facial aesthetics

Treatment planning History Clinical examination Patients age , general health , concerns and expectations Clinical examination Intra and extra oral assessment of hard and soft tissue Asses the bone (height , width , shape , undercuts)

Treatment planning Special investigations Assess the soft (lesions, attached mucosa, flabby tissue ,fraenum attachment) Special investigations Radiographs , articulated study casts Any pathological lesions should be investigated (biopsy)

Types of intraoral abnormalities or lesions Hard tissue abnormalities or lesions Soft tissue abnormalities or lesions

Preprosthetic surgery procedures Therefor, the procedures will be Hard tissue correction procedures Soft tissue correction procedures Endo-osseous implant surgery

Soft tissue procedure s Excision of hyperplastic tissue Fraenectomy Reduction of fibrinous max. tuberosity Vestibuloplasty

Excision of hyperplastic tissue Chronic irritation = hyperplastic oral mucosa Ill -fitted dentures clasp Sharp cusps from acrylic teeth Poorly designed RPD

Elevate and undermine the periosteum Management of hyperplastic tissue Remove the source of irritation Follow up Healed, No treatment If residual tissue remain Surgical procedures Elevate and undermine the periosteum (edentulous ridge) Elliptical incision (cheek, buccal sulcus) Incision closure Primary closure (suturing) Mucosal grafting Excision of hyperplastic tissue

Fraenectomy Denture’s flange could traumatize: Prominent fraenum Muscle’s attachment Supra periosteal plane (all procedures) Surgical procedures : Diamond shaped Z- plasty Vestibulo plasty V-Y advancement flap Fraenectomy

1.Diamond shaped flap (commonly used) Easy to perform LA must not be injected directly into the fraenum ????? Lips must be reflected

1.Diamond shaped flap (commonly used) 2nd healing

Tongue tie (ankyloglossia) treatment Speech difficulties

2. Z- plasty Less scar formation Indicated Wide crestal part To increase the alveolar height

2. Z- plasty

3.Vestibuloplasty Broad fraenum Make horizontal cut Supra periosteal level Leave to heal by 2nd epithelialization

Reduction of fibrinous max. tuberosity Soft tissue bulkiness : Reduce the inter maxillary space Interfere with the accuracy of impressions (if flabby) Pneumatisation of maxillary air sinus

Surgical procedure 2 elliptical incisions Wedge shaped resection Remove the fibrinous tissue Submucosal undermining Suturing

What if antral communication happened ? Its ok if no signs of infection seen Just irrigate copiously Suture

Hard Tissue procedures Dentoalveolar proceures Alveoplasty Excision of intraoral tori Restoring of deficient denture bearing area

Dentoalveolar proceures Preserve alveolar bone and oral mucosa during teeth extraction Periotomes instrument : breaks the PDL fibres down (fig (1))

Dentoalveolar proceures If alveolar bone is Displaced :Reposition it by finger pressure (reduction) Loose : remove small fragment to prevent delayed healing Or left in situ if it large and have an intact periosteum

The procedure performed to recontour an uneven alveolar ridge Alveoplasty The procedure performed to recontour an uneven alveolar ridge Classified into two groups Primary (at time of extraction ) Secondary (after healing of alveolar ridge )

Bony protuberance or undercuts seen after tooth extraction Alveoplasty Secondary alveoplasty Bony protuberance or undercuts seen after tooth extraction Interfere with placement and stability of dentures Procedure : incision, bone reduction ,suturing

Secondary alveoplasty

Alveoplasty

Excision of intraoral tori Tori are a developmental bony exostosis Present typically one hard palate (midline) or mandible (lingual and bilateral) If any doubt about origin of this bony enlargement , refer

Excision of intraoral tori Dentures causes mucosal ulceration if seated over Tori Therefore , tori should be removed to avoid this

Excision of intraoral tori STOP!!

Excision of intraoral tori Before commencing the surgery you must have a plan Radiographs must be taken Oro-nasal fistula Perform surgery under LA , Sedation or General Anastheis (GA) Gagging reflex : GA or sedation

Excision of intraoral tori Mand.Tori Torus palatinus

Excision of intraoral tori

Excision of intraoral tori

Restoring of deficient denture bearing area Bone grafting??? It’s a procedure used to augment or restore a resorbed, deficient or lost bone with a natural or artificial bone substitute Type of bone grafting materials Autograft : taking bone from the same subject (patient) Allograft : taking bone from different subject but same species (human to human) Xinograft : use of artificial materials or different species( Bovine bone, Hydroxy appetite crystals … )

Restoring of deficient denture bearing area Bone grafting alone is not sufficient Efficiency increased if used with endosseous implants

Major Preprosthetic surgery Orthognathic surgery SK CL II : deep bite and retruded mandible SK CL III : maxillary hypoplasia Reconstructive surgery

References Jonathan Pedlar, John W.Frame,Oral and maxillofacial surgery An objective based text book, second edition ,chapter 11