A 62 year old male presents for a new upper partial. He had his posterior teeth removed 22 years ago.

The soft tissue in the tuberosity area is hyperplastic and touches the lower ridge when the patient closes.

Using diagrams, describe a surgical procedure for tuberosity reduction.

A 54 year old female presents for the fabrication of new complete dentures. She has been edentulous for 30 years. She is currently wearing her original set of immediate dentures which fit poorly. There is a I cm high by 1 cm wide by 5 cm long grooved soft tissue mass in the labial vestibule. The denture fits into the groove. On radiograph, the mandible is approx. 15 mm high in the anterior. Note a 3 item differential diagnosis for the soft tissue mass. 3 ___________________ ________________ ________________ What factors may have contributed to the bone loss? 3 ___________________ ________________ ________________ What treatment will the soft tissue mass require? 2 ___________________ ________________ How will you address rehabilitation of the ridge? 3 ___________________ ________________ ________________

Preprosthetic Surgery
The Dentition Function Curve 120 100

Function (%age)

80 60 40 20 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 Age Dentate Partially dentate Edentulous

Preprosthetic Surgery

Objectives:
1. To understand the anatomy and physiology of the edentulous milieu including alveolar atrophy and its associated pathoses 2. To diagnose conditions that can be improved by preprosthetic surgical procedures 3. To treatment plan, design and execute preprosthetic surgical procedures

The Dentition Function Curve

120 100

The Dentition Function Curve

Function (%age)

80 60 40 20 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 Age Dentate Partially dentate Edentulous

A model for understanding dental function over time

The challenge of edentulism

Factors that impact on fit: anatomy

1. 2. 3. 4. Bone quantity Bone contour Muscle attachments Gingiva vs. mucosa

Factors that impact on fit: anatomy

1. Bone quantity

Factors that impact on fit: anatomy

2. Bone contour 3. Muscle attachements 4. Gingiva vs. mucosa

Factors that impact on fit: physiology

1. Gingiva vs. mucosa 2. Lip / tongue habits 3. Salivary function 4. TMJ / muscle function

Factors that impact on fit: physiology

1. Gingiva vs. mucosa

Factors that impact on fit: physiology

2. Lip / tongue habits

Factors that impact on fit: physiology

3. Salivary function 4. TMJ/ muscle function
Parotid

Submandibular

Factors that impact on fit: pathoses

1. Hard tissue 2. Soft tissue

Factors that impact on fit: pathoses

1. Hard tissue a. Dental caries b. Periodontal disease c. Infection d. Cysts and tumours

Factors that impact on fit: pathoses

1. Hard tissue a. Dental caries b. Periodontal disease c. Infection d. Cysts and tumours

Factors that impact on fit: pathoses

1. Soft tissue a. Ulceration b. Hyperplasia c. Dysplasia d. Carcinoma

Factors that impact on fit: atrophy

1. Atrophy a. Decreasing bone b. Increasing soft tissue
1

2 4

Factors that impact on fit: atrophy

1. Atrophy a. Decreasing bone b. Increasing soft tissue

Factors that impact on fit: atrophy

1. Atrophy a. Decreasing bone b. Increasing soft tissue

Factors that impact on fit: atrophy

1. Atrophy: accelerated by inflammation a. Infection b. Poorly fitting dentures friction c. Habits clenching / bruxism

Factors that impact on fit: atrophy

1. Atrophy: end result loss of support & retention
The Dentition Function Curve 120 100

Function (%age)

80 60 40 20 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 Age Edentulous

Preprosthetic Surgery
An attempt to reverse the trend
Function (%age)
The Dentition Function Curve 120 100 80 60 40 20 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 Age Edentulous

Preprosthetic Surgery
Procedures designed to optimize the retention, support, stability and comfort of prostheses by the selective modification of soft and hard tissues

Preprosthetic Surgery
Indications: compromized retention, support, stability or comfort of prostheses due to suboptimal hard or soft tissue anatomy or pathoses

Preprosthetic Surgery
Procedures span a spectrum from very simple to quite complex: a. extractions and alveolar osteotomy b. removal of pathoses c. gingivoplasty and frenectomy d. tuberosity reduction e. alveoplasty and torus removal f. vestibuloplasty with soft tissue graft g. bone grafting??? h. orthognathic surgery

Preprosthetic Surgery
a. Extractions for caries, periodontal disease, infection, etc.

Preprosthetic Surgery
a. Extractionsflap, bone removal, section

Preprosthetic Surgery
a. Extractionsflap, bone removal, section

Preprosthetic Surgery
a. Extractions and alveolar osteotomy removal of proclined incisors and osteotomy of labial plate of bone

Preprosthetic Surgery
a. Extractions & and alveolar osteotomy removal of proclined incisors and osteotomy of labial plate of bone

Preprosthetic Surgery
a. Extractions and alveolar osteotomy removal of proclined incisors and osteotomy of labial plate of bone

Preprosthetic Surgery
b. Removal of pathosescystic, traumatic, hyper-plastic, dysplastic, etc.

Preprosthetic Surgery
c. Gingivoplasty or frenectomy for flabby ridge tissue or high frena that interfere with support or retention

Gingivoplasty

Preprosthetic Surgery
c. Frenectomy

Preprosthetic Surgery
d. Tuberosity reduction

Canoe shaped wedge

Undermine

Close

Preprosthetic Surgery
d. Tuberosity reduction

2 3

Preprosthetic Surgery
e. Alveoplasty or torus reduction to alleviate pain from point loading or allow for path of insertion

Preprosthetic Surgery
e. Alveoplasty: flaprecontourclose
5 1

3 2

Preprosthetic Surgery
e. Alveoplasty: flaprecontourclose

Preprosthetic Surgery
e. Torus reduction: flaprecontourclose

4 2

Preprosthetic Surgery
f. Vestibuloplasty: ridge extension move muscle attachment and retain with soft tissue graft

Preprosthetic Surgery
f. Vestibuloplasty: ridge extension move muscle attachment and retain with soft tissue graft

Preprosthetic Surgery
f. Vestibuloplasty: move muscle attachment and retain with soft tissue graft

5
1

4 2

Preprosthetic Surgery
f. Vestibuloplasty: Mandibular palatal graft vestibuloplasty
6 months PO 6 months PO

Pre-op

12 months PO 12 months PO

Preprosthetic Surgery
f. Vestibuloplasty: Maxillary palatal graft vestibuloplasty 6 months post-op

Preprosthetic Surgery
f. Vestibuloplasty: Mandibular split thickness skin graft vestibuloplasty

12 months PO

Preprosthetic Surgery
f. Bone grafting: replacement of bone loss to alveolar atrophy benefit ???

Preprosthetic Surgery
f. Bone grafting: process graft donor site

f. Bone grafting: process graft site

Preprosthetic Surgery
f. Bone grafting: replacement of bone loss to alveolar atrophy benefit ??? typically ALL of the newly grafted bone is gone within 5 years unless supported by implants

=
Details to follow

A 62 year old male presents for a new upper partial. He had his posterior teeth removed 22 years ago. The soft tissue in the tuberosity area is hyperplastic and touches the lower ridge when the patient closes.

Using diagrams, describe a surgical procedure for tuberosity reduction.

Canoe shaped wedge

Close

Undermine

A 54 year old female presents for the fabrication of new complete dentures. She has been edentulous for 30 years. She is currently wearing her original set of immediate dentures which fit poorly. There is a I cm high by 1 cm wide by 5 cm long grooved soft tissue mass in the labial vestibule. The denture fits into the groove. On radiograph, the mandible is approx. 15 mm high in the anterior. Note a 3 item differential diagnosis for the soft tissue mass. 3 ___________________ ________________ ________________ What factors may have contributed to the bone loss? 3 ___________________ ________________ ________________ What treatment will the soft tissue mass require? 2 ___________________ ________________ How will you address rehabilitation of the ridge? 3 ___________________ ________________ ________________

Preprosthetic Surgery

Objectives:
1. To understand the anatomy and physiology of the edentulous milieu including alveolar atrophy and its associated pathoses 2. To diagnose conditions that can be improved by preprosthetic surgical procedures 3. To treatment plan, design and execute preprosthetic surgical procedures

Preprosthetic Surgery
The Dentition Function Curve 120 100

Function (%age)

80 60 40 20 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 Age Dentate Partially dentate Edentulous