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Preprosthetic Surgery

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.
Besides, general factors include the presence of nutritional abnormalities and systemic bone
disease such as osteoporosis, endocrine dysfunction may affect bone metabolism.
Preprosthetic surgical treatment must begin with a thorough history and physical examination
of the patient. Sometimes there are contraindications to surgery because the patient suffers
from serious general disease. Specific attention should also be given to laboratory tests which
could inform us as to a degree of bone resorption. Of course an extremely important aspect of
the history taking is to obtain a clear idea of the patient’s chief complaint and expectations
from surgical and prosthetic treatment.
Esthetic and functional goals are very important for the patients. Information on success or
failure with previous prosthetic appliances may be helpful.
Examination includes visual inspection, palpation and radiographic examination. An intraoral
and extraoral examination of the patient should include:
• An assessment of the existing tooth relationships, if any,
• The amount and contour of the remaining bone,
• The quality of soft tissue overlying the primary denture-bearing area,
• The vestibular depth,
• The location of muscle attachments,
• The jaw relationships,
• And the presence of soft tissue or bony pathologic conditions;
Panoramic radiograph provides an excellent overview assessment of underlying bony
structure, impacted teeth, remaining roots, the size and pneumatization of the maxillary sinus
and pathological lesions.
Surgical treatment includes:
• Recontouring of alveolar ridges (Alveoplasty, Maxillary tuberosity reduction,
Exostosis, Removal of palatal torus)
• Removal of soft tissue abnormalities (Maxillary tuberosity reduction, Unsupported
hypermobile tissue, Inflammatory fibrous hyperplasia = epulis fissuratum)
• Labial frenectomy
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• Lingual frenectomy
• Augmentation /Bone grafts, Sinus lift/
• Vestibuloplasty
• Vestibule and floor-of-mouth extension procedures

Alveoplasty
Sometimes removal of multiple teeth require recontouring of alveolar ridge. It could be done
during extraction or after, if indicated.
Maxillary tuberosity reduction
Recontouring of the maxillary tuberosity area may require the removal of soft tissue and bone
to form adequate interarch space, which will enable proper construction of prosthetic
appliances in the posterior areas. Access to the tuberosity for bone removal is accomplished
by making a crestal incision. Avoid perforation of the floor of the maxillary sinus during bone
reduction. The soft tissue is excised in an elliptic fashion.
Removal of palatal torus
Large palatal torus may cause problems when the maxillary denture is present. A linear
incision in the midline of the torus with oblique vertical incisions are performed. Avoid
perforation of the floor of the nose during bone removal by a bur or osteotome and mallet.
Exostosis
Exostosis results in undercuts and imbalance of a prothesis and should be removed from
denture-bearing area prior to making denture.
Epulis fissuratum /Inflammatory fibrous hyperplasia/
It results from ill-fitting dentures. Excision of the hyperplastic tissue is the treatment of
choice. There are different techniques of the hyperplastic tissue removal:
• Electrosurgical techniques
• Laser techniques
• Excision by scalper
Excision of epulis fissuratum frequently results in total elimination of the vestibule. To
prevent this situation prior to surgical operation make new denture or place surgical cement
postoperativly to prevent constriction of the scar.
Labial frenectomy
Strong and wrong labial frenulum attachment cases diastema, crowded teeth and sometimes
problem with denture stabilization. There are different methods of labial frenuloplasty
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/Dieffenbach, Schuchardt, Mathis/. The most popular are Dieffenbach V-plasty and
Schuchardt Z-plasty.
During labial frenectomy removal of frenulum is performed. After the procedure denuded
periosteum is present. The wound can be closed by suturing or by cementing. Frenectomy is
more common in the frenulum of lower lip, frenuloplasty is more common in the frenulum of
upper lip.
Linqual frenectomy
Wrong linqual frenulum attachment causes problem during neonate sucking and in the future
leads to slurred speech. Besides, these can impair periodontal tissue and cause problem with
denture stabilization. During this procedure transverse cutting of the frenulum is performed.
Wound suturing is done along tongue base and on the mouth floor.
Vestibuloplasty
Vestibuloplasty should be performed in case of shallow vestibule to widen denture-bearing
area. There are different techniques of vestibuloplasty. Most of them provide access from
buccal aspect of the mandible.
Kazanjian vestibuloplasty
A mucosal flap pedicled from the alveolar ridge is elevated from the underlying tissue and
sutured to the depth of the vestibule. The inner portion of the lip is allowed to heal by
secondary epithelialization.
Clark vestibuloplasty
Clark’s vestibuloplasty technique uses mucosa pedicled from the lip. Horizontal incision is
performed from canine to canine between immobile gingiva and mobile gingiva. After
supraperiosteal dissection the mucosa is sutured at the depth of the vestibule. The denuded
periosteum heals by secondary epithelialization. It is possible to use tissue graft on exposed
periosteum. The healing process is more rapid in this situation.
Corn vestibuloplasty
This vestibuloplasty is similar to Clark’s vestibuloplasty.
Difference:
Horizontal incision is through soft tissue /mucosa and periosteum/ so the mucoperiosteal flap
is dissected and the bone is exposed.
Disadvantages:
More painful procedure;
The healing process is longer;
Obwegeser vestibuloplasty
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Vestibuloplasty described by Obwegeser is the method in which labial extension procedure

and Trauner’s procedure provide maximal vestibular extension to both the buccal and linqual
aspects of the mandible.
Trauner operation:
• The attachment of the mylohyoid and genioglossal muscles in the floor of the
mandible to the denture-bearing area /the alveolar process/ present similar problems
on the lingual aspect of the mandible
• Trauner described detaching the mylohyoid muscles from the mylohyoid ridge area
and repositioning them inferiorly, effectively deepening the floor of the mouth and
relieving the influence of the mylohyoid muscle on the denture.