Chronicles of Dental Research, June2019, Vol 8, Issue 1 Chronicles of

Dental Research

REVIEW ARTICLE
Preprosthetic surgery: A review of literature
Prachi Madan Rohilla1, Manish Kumar2, Ulfat Majeed2, Akanksha Singh2

ABSTRACT
Following the loss of natural teeth after extraction, the bone begins to resorb. The results of this resorption are
accelerated by wearing dentures and tend to affect the mandible more severely than the maxilla. Preprosthetic
surgical treatment must begin with a thorough history and physical examination of the patient. One component that
can profoundly affect treatment success is the condition of the denture-bearing tissues. In preprosthetic surgery
every effort should be made to ensure that both the hard and soft tissues are developed in a form that will enhance
the patient’s ability to wear a denture.
Keywords: Alveoloplasty, Ridge augmentation, Osteopromotion, Vestibuloplasty, Sinus lift.

INTRODUCTION Initial preoperative examination:

Preprosthetic surgery is a surgical procedure designed Patient’s past medical history and current medical
to facilitate fabrication of a prosthesis to improve the status must be reviewed with particular attention to
prognosis of prosthodontic treatment. In 1967 the allergies, drug idiosyncrasies, and medications.
principles of Preprosthetic reconstructive surgery were Haemorrhages tendencies or systemic disorders which
first introduced by MacIntosh and Obwegeser.1,2 would complicate anaesthetics procedures, increase
Every dental surgeon should have a thorough surgical risk etc.1
knowledge of the conditions which favour success in
denture construction, for carefully planned and Secondary preoperative examination: patients
executed surgery can prevent the occurrence of many frequently have oral tissues which have been abused
undesirable features and can eliminate others, either at and distorted by their existing malfitting prosthesis. 1
the time teeth are extracted or later.3,4
Evaluation of supporting bony tissues: includes
1. Senior lecturer. visual inspection, palpation, radiographic examination
2. Post Graduate Student. Department of and cases evaluation of models. The remaining
Prosthodontics and Crown & Bridge mandibular ridge should be evaluated visually overall
ridge form and contour, gross ridge irregularities, tori
*Correspondence Author:
and buccal exostosis Cephalometric radiographics
Dr. Manish Kumar (P.G. Student) Kothiwal Dental may also be helpful in evaluating the cross sectional
College and Research Centre, Mora Mustaqeem configuration of the anterior mandibular ridge area and
Moradabad. ridge relationship.1

Email: dr.manishk8@gmail.com Surgical procedures for removable prosthesis:

A. Bony recontouring procedures
Simple Alveoloplasty Associated With Removal of
Patient Evaluation Multiple Teeth
Before any surgical or prosthetic treatment a thorough
evaluation outlining the problems to be solved and a
detailed treatment plan should be developed for each Alveoplasty is contouring of the alveolar ridge to
patient.1 remove any irregularities and undercuts. The goals
are to provide a stable base for the prosthesis and

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preserve as much alveolar bone as possible. Always

be conservative when removing the bone.1

Fig 3: Maxillary Tuberosity Reduction

Buccal Exostosis and Excessive Undercuts:

Fig.1: Simple Alveoloplasty Exostosis generally require removal, small undercut
areas are often best treated by being filled with either
Intraseptal Alveoloplasty- An alternative to the autogenous or allogenic bone material. such situation
removal of alveolar ridge irregularities by simple might occur in the anterior maxilla or mandible, where
alveoloplasty technique is the use of an intraseptal removal of the bony buccal protuberance results in
alveoloplasty, or dean’s technique, involving narrow crest in the alveolar ridge area and a less
removal of intraseptal bone and the repositioning of desirable area of support for the denture ,as well as an
the labial cortical bone, rather than removal of area that may resorb more.
excessive or irregular areas of the labial cortex.2

Fig. 2: Intraseptal Alveoloplasty

Maxillary Tuberosity Reduction:

The maxillary tuberosities are found to be abnormally
large in a considerable number of edentulous patients
and in the vast majority of cases this enlargement is Fig 4: Removal of Buccal Exostosis
due to an excess of white fibrous tissue.5
Lateral Palatal Exostosis:
The lateral aspect of the palatal vault may be
somewhat irregular because of the presence of lateral
palatal exostosis. This presents problems in denture

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construction because of the undercut created by the

Exostosis and the narrowing of the palatal vault.

Mylohyoid Ridge Reduction:

For most parts of the denture border, the limits of the
functional anatomy are determined by muscles in
activity; this activity may be favourable or
unfavourable depending on the direction of the muscle
fibres relative to the denture base.6
Fig 5; c : Surgical Process of Palatal Torus removal
Genial tubercle reduction:
As the mandible begins to undergo resorption, the area B. Mandibular Augmentation
of attachment of the genioglossus muscle in the Superior Border Augmentation- Superior border
anterior portion of the mandible may become augmentation with a bone graft is occasionally
increasingly prominent. In some cases the tubercle indicated when severe resorption of the mandible
may actually function as shelf against which the results in inadequate height and contour potential risk
denture can be constructed, but it usually requires of fracture or when the treatment plan calls for
reduction to construct the prosthesis properly. 1,2,3,4 placement of implants in areas of insufficient bone
height or width.8,9( .
Tori Removal:
After teeth are lost, tori may complicate or even
preclude denture fabrication. Large, lobulated tori
with undercuts must be treated, whereas the restoring
dentist may deem smaller, smooth, broad-based tori
insignificant.7

Fig.6: Superior Border Augmentation

Inferior Border Augmentation- Sanders and Cox

reported the first clinical use of an inferior border
technique for augmentation of the atrophic mandible.
This technique is rarely used for augmentation of
Mandibular bulk with inferior grafting using iliac crest
bone grafts and is secured with rigid fixation.10.

Fig 7: Inferior Border Augmentation

Fig 5; a, b : Surgical Process of Palatal Torus
removal

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Hydroxyapatite Augmentation of the Mandible: C. Maxillary Augmentation

Hydroxyapatite has revived interest in augmentation In certain cases, a severe increase in interarch space,
of resorbed alveolar ridges. Because bony loss of palatal vault, interference from the zygomatic
augmentation of alveolar ridges often undergoes buttress area, and absence of posterior tuberosity
resorption in a short period of time, nonresorbable notching may prevent construction of proper denture.
hydroxyapatite holds the promise of avoiding a Onlay Bone Grafting:
recurrence resorption. 10 It is indicated primarily when severe resorption of the
maxillary alveolus is seen that results in the absence of
Guided Bone Regeneration (Osteopromotion): clinical alveolar ridge and loss of adequate palatal
A membrane [nonresorbable or resorbable] is used to vault form13.
cover an area where bone graft healing or bone Interpositional Bone Grafts:
regeneration is desired. The concept of guided Interpositional bone grafting in the maxilla is indicated
regeneration is based on the ability to exclude in the bone-deficient maxilla, where the palatal vault
undesirable cell types, such as epithelial cells or is found to be adequately formed but ridge height is
fibroblast from the area where bone healing is taking insufficient.
place.11 Maxillary Hydroxyapatite Augmentation HA is
readily available, eliminates the need for donor-site
Visor Osteotomy: surgery and is easily placed in an outpatient setting.
The goal of visor osteotomy is to increase the height HA can be used to contour and eliminate minor ridge
of Mandibular ridge for denture support. It consists of irregularities and undercut areas in the maxilla.14
central splitting of the mandible in buccolingual D. Alveolar distraction osteogenesis
dimension and the superior positioning of the lingual This process is based on the concept of bone
section of the mandible, which is wired in position. distraction along a vector that is transverse to the long
Cancellous bone graft material is placed at the outer axis of the bone, which results in bone formation. A
cortex over the superior labial junction for improving primary advantage of distraction osteogenesis is that
contour. there is no need for additional surgery at the donor site.
Another benefit is the coordinated lengthening of the
Modified Visor Osteotomy: bone and associated soft tissues.13,14
Consists of splitting of mandible buccolingually by E. Correction of Abnormal Ridge Relationship
vertical osteotomy only in the posterior regions and a In totally edentulous patients, the interarch space and
horizontal osteotomy in the anterior region. the anteroposterior and transverse relationships of the
Corticocancellous bone grafts particles with maxilla and mandible must be evaluated with the
hydroxyapatite granules are placed in the gap between patient‘s jaw at proper occlusal vertical dimension. In
the superior and inferior anterior segments. Rest of the the diagnostic phase may require the construction of
graft material can be molded on the buccal aspect of bite rims with proper lip support.4
the posterior segments.12
Soft tissue abnormalities and their surgical
management:
a. Soft tissue surgery for ridge extension of the
mandible
As alveolar ridge resorption takes place, the
attachment of mucosa near the denture –bearing area
exerts a greater influence on the retention and stability
of dentures. Soft tissue surgery performed to improve
denture stability may be carried out alone or may be
Fig 8: Modified Visor Osteotomy done after bony augmentation. 15,16,

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1. Transpositional flap vestibuloplasty [lip A. Gingival Augmentation Apical to

switch]: Recession
A lingually based flap vestibuloplasty was first Root resection:
described by Kazanjian. These techniques provide A procedure where one or two roots of a
adequate results in many cases and generally do multirooted tooth are amputated, leaving the
not require hospitalization. crown to be supported by the remaining root
or roots.
2. Vestibule and floor of mouth extension Hemisection:
procedure: The most common root resection involves
This combination procedure effectively the distobuccal root of the maxillary first
eliminates the dislodging forces of the mucosa molar.
and muscle attachments and provides a broad base B. Gingival Augmentation Coronal to
of fixed keratinized tissue on the primary denture Recession (Root Coverage) :
–bearing area. Understanding the different stages and
condition of gingival recession is necessary
b. Soft Tissue Surgery for Maxillary Ridge
for predictable root coverage.19
Extension
The Submucosal vestibuloplasty as described by
Immediate Ridge Augmentation:
Obwegeser may be the procedure of choice for
Performed at the time of tooth extraction
correction of soft tissue attachment on or near the crest
Onlay graft- It is of value and predictable in small
of the alveolar ridge on the maxilla. This technique is
areas.
particularly useful when maxillary alveolar ridge
Pouch technique- Garber and Rosenberg (1981) -
resorption has occurred but the residual bony maxilla
Used for soft tissue ridge augmentation .Usually for
is adequate for proper denture support.
Class I type of defects.

Maxillary Vestibuloplasty with Tissue Grafting:

When sufficient labiovestibular mucosa exists and lip Roll technique:
shortening would result from the submucosal Used for soft tissue ridge augmentation, Class I
vestibuloplasty technique, other vestibular extension defects.
techniques must be used a modification of Clark‘s
vestibuloplasty technique using mucosa pedicled from Ridge augmentation: improved technique.
the upper lip and sutured at the depth of the maxillary
vestibule after a supraperiosteal dissection can be Techniques to remove frenum Frenectomy:
used.17,18 Frenectomy is complete removal of the frenum,
including its attachment to underlying bone, and may
Surgical procedure in fixed denture prosthesis be required in the correction of an abnormal diastema
between maxillary central incisors. Frenotomy is
1. Gingivectomy and Gingivoplasty incision of the frenum.19
Gingivectomy means excision of the gingiva.
1. Conventional technique
Gingivoplasty is a reshaping of the gingiva to create
A narrow elliptical incision around the frenal area
physiologic gingival contours with the sole purpose of
down to the periosteum is completed. The fibrous
recontouring the gingiva in the absence of pockets.19
frenum is then sharply dissected from the underlying
periosteum and soft tissue, and the margins of the
Techniques to increase attached gingiva:
wound are gently undermined and reapproximated
To simplify and better understand the techniques, the
following classifications are presented:

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2. Z-plasty: Subantral Option 3: Sinus graft with delayed

endosteal implant placement -Atleast 5 mm of
vertical bone is present between antral floor and crest
After excision of the fibrous tissue, two oblique
of residual ridge.
incisions are made in a z fashion, one at each end of
the previous area of excision. The two pointed flaps
are then gently undermined and rotated to close the Subantral Option 4: Sinus graft and extended delay
initial vertical incision horizontally. The two small of endosteal implant placement
oblique extensions also require closure. Height of bone is < 5 mm between residual crest and
sinus floor.

CONCLUSION
Preprosthetic surgical approach, however, calls for the
utmost of surgical and prosthetic preplanning and
cooperation, as well as meticulous attention to detail
in all phases of treatment. When the principles of case
selection and treatment outlined previously are
followed, excellent results and patient satisfaction can
be expected

Fig 9 : Z-plasty technique REFERENCES

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