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

2. 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

3. 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.”

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

5. 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)

6. 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)

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

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

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

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

13. 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

14. 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

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

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

17. Tongue tie (ankyloglossia) treatment Speech difficulties

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

19. 2. Z- plasty

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

21. 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

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

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

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

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

26. 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

27. 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 )

28. 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

29. Secondary alveoplasty

30. Alveoplasty

31. 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

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

33. Excision of intraoral tori
STOP!!

34. 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

35. Excision of intraoral tori
Mand.Tori
Torus palatinus

36. Excision of intraoral tori

37. Excision of intraoral tori

38. 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 … )

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

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

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