Académique Documents
Professionnel Documents
Culture Documents
Hillel Ephros, DMD, MDa,*, Robert Klein, DDSb, Anthony Sallustio, DDSc
KEYWORDS
Stability Retention Vestibuloplasty Dental prosthesis Skin graft Tuberosity Torus
KEY POINTS
The need for preprosthetic surgery may be caused by anatomic variations, gradual loss of support-
ing tissues, or a lack of foresight during earlier stages of treatment.
Functional, comfortable, and esthetically pleasing prostheses often require collaboration between
the surgeon and restoring dentist.
All denture bearing hard and soft tissues should be evaluated with great care before denture
construction.
Surgical improvement of existing anatomy should at least be considered in every patient for whom a
conventional prosthesis is planned.
Even the partially implant-borne prosthesis may benefit from preprosthetic surgery.
Preprosthetic surgery comprises a unique and for preprosthetic surgery, focusing on the core
evolving group of soft and hard tissue procedures. concepts and detailing selected procedures that
Although the focus of such procedures has shifted continue to be useful in the successful oral rehabil-
dramatically over the last 30 years, the funda- itation of partially and fully edentulous patients.
mental concepts remain unchanged. Prepros-
thetic surgery exists to serve the needs of GOALS
dentists who provide patients with replacements
for missing teeth and associated tissues. The pur- In the introductory paragraph of his 1972 article
pose is to facilitate the fabrication of prostheses or Objectives of Preprosthetic Surgery, Lawson
to improve the outcome of prosthodontic treat- asks: Why should it be assumed that a full den-
ment. The surgeons role is to produce an environ- ture is the one type of dental restoration for which
ment in which esthetics and function may be the mouth is already perfectly designed?1 In fact,
optimized by manipulating, augmenting, or replac- the quality of dentures and the patients experi-
ing soft and/or hard tissues. With the emergence ence can often be enhanced significantly by surgi-
of implants as predictable anchors for a wide vari- cal preparation. Oral and maxillofacial surgeons
ety of dental prostheses, many preprosthetic pro- must understand the criteria for successful pros-
cedures, particularly those that were developed to theses and let the needs of patients and the
prepare the jaws for dentures, have become less dentist/prosthodontist dictate the selection of
relevant and may be headed toward obsoles- applicable preprosthetic procedures. Lawsons
cence. They have been displaced by a newer set criteria include insertion, comfort, retention, stabil-
of surgical interventions designed to prepare sites ity, adequate occlusion, satisfactory appearance,
for implant placement. Dr Michael Block reviews and no damage to the oral tissues.
these procedures elsewhere in this issue. The dis- The surgical/prosthetic collaboration begins
oralmaxsurgery.theclinics.com
cussion that follows provides a historical reference with treatment planning based on diagnostics
that are adequate to ensure appropriate proce- Surgical procedures that address skeletal dis-
dure selection. These diagnostics should include crepancies, particularly anteroposterior and
a thorough clinical examination, mounted study vertical issues, may be indicated.
models, and a panoramic radiograph supple- Damage to the oral tissues must be minimized
mented by periapical films and other imaging as even with consistent denture use over long pe-
needed. Medical, surgical, anesthetic, and psy- riods of time. Maximal denture-bearing surface
chological risk assessment should all be done as area distributes the compressive load; high-
for any other elective surgery. In the realm of pre- quality, immobile soft tissue in that area handles
prosthetic surgery, communication between the that load most effectively. Removal of bony un-
surgeon and restoring dentist is crucial. For each dercuts may allow the masticatory load to be
of the criteria listed earlier, the team must deter- spread as widely as possible. Skin graft vestibu-
mine whether existing anatomy is satisfactory loplasty provides a larger surface area for den-
and, if not, what intervention might best serve ture contact and replaces moveable alveolar
the needs of the patients and the restoring dentist. mucosa with immobile, tough soft tissue that
Insertion requires adequate interarch space is capable of bearing the masticatory load.
and a clear path free of bony protuberances,
sharp undercuts, and bulbous soft tissue BONY RECONTOURING PROCEDURES
prominences. Applicable procedures may Preoperative Planning
include alveoloplasty, tuberosity reduction,
torus, and exostosis removal. As with any other surgical procedure, planning be-
Comfort is related to the seating of a pros- gins with a thorough history and physical examina-
thesis on good-quality soft tissue overlying tion. An understanding of patients surgical and
smooth bone. Examples of procedures that prosthetic expectations must be clear and a deter-
may enhance comfort are alveoloplasty, mination made as to whether these goals can be
lingual balcony reduction, removal of redun- achieved.1 Special emphasis is placed on systemic
dant soft tissue, frenectomy, and skin graft conditions that may directly affect bone healing.
vestibuloplasty. The clinical examination focuses on bony projec-
Retention is resistance to vertical displace- tions and undercuts, large palatal and mandibular
ment and is optimized by an intimate relation- tori, and other gross ridge abnormalities. The inter-
ship between the prosthesis and the arch relationship should be evaluated in 3 dimen-
underlying soft tissue. The surface area of sions. Radiographs are reviewed for bony
contact should be maximized and sealed pathology, impacted teeth, retained root tips, de-
peripherally. Procedures designed to address gree of maxillary sinus pneumatization, and the po-
retention include frenectomies and various sition of the inferior alveolar canal and mental
vestibuloplasties.2 foramina.3 This section focuses on bony reduction
Stability is resistance to lateral displacement and recontouring procedures.
from functional horizontal and rotational
stresses. It depends on adequate ridge height Alveoloplasty
as well as the quantity and quality of soft tis- Alveolar bone irregularities may be found at the
sue in the denture-bearing area. In general, time of tooth extraction or after healing and re-
severely resorbed maxillae and mandibles modeling has occurred. The goal for alveoloplasty
are poor candidates for bony augmentation is to achieve optimal tissue support for the
when implants are not part of the restorative planned prosthesis, while preserving as much
plan. When bone is adequate, procedures bone and soft tissue as possible.4
such as lingual balcony reductions, removal
of redundant soft tissue, and skin graft vesti- 1. An incision along the crest of the alveolus, or a
buloplasty may enhance stability.1,2 sulcular incision before tooth extractions, is
Adequate occlusion requires a reasonable created with adequate extension to allow
skeletal relationship between the jaws. For proper visualization of the area of interest.
patients with severe skeletal class II or III rela- Generally, extension approximately 1 cm
tionships, orthognathic surgery may be indi- mesial and distal to the site is adequate.
cated as a preprosthetic procedure. 2. A full-thickness envelope flap is then elevated.
Satisfactory appearance is at or near the top Vertical releasing incisions may be necessary
of the list of patient expectations and can for exposure; however, this may lead to a
only be achieved when the restoring dentist greater amount of patient discomfort postoper-
is able to set teeth properly in the context of atively. Extensive flap reflection may lead to de-
the facial skeleton and overlying soft tissues. vitalization of bone and should be avoided.
Preprosthetic Surgery 461
3. The degree of bony abnormality will dictate the Maxillary Tuberosity Reduction
most effective method for alveoloplasty. Smaller
The intermaxillary space necessary for proper
irregularities at an extraction site may only
prosthesis fabrication may be decreased because
require digital compression of the socket walls.
of vertical excess of the maxillary tuberosity.
A rongeur, bone file, handpiece with bur, or a
Generally, the intermaxillary distance should be
mallet and osteotome are all viable options for
at least 1 cm when patients are placed into the
bony recontouring (Fig. 1). Irrigation with normal
correct or planned vertical dimension of occlu-
saline during the procedure is critical to maintain
sion.4 A dental mirror passing freely between the
bony temperature less than 47 C.6
tuberosity and retromolar tissue suggests
4. The site is inspected carefully and irrigated
adequate vertical clearance. The mirror can then
copiously with normal saline. Undetected resid-
be placed on the lateral aspect of the tuberosity,
ual free bony fragments may lead to delayed
and patients are instructed to open and close. If
postoperative healing or possibly infection.
the mirror intrudes on the mandibles path during
5. The mucoperiosteal flap is reapproximated and
function, horizontal reduction of the tuberosity
the site palpated to ensure removal of all irreg-
may be required. A determination as to the extent
ularities. Excess soft tissue should also be
of soft tissue and bony contribution to the problem
removed at this time. The flap is then closed
is made radiographically. A panoramic view is rec-
with a running resorbable suture, as fewer
ommended to ensure an adequate assessment of
knots may be more comfortable and hygienic
the relationship between the maxillary sinus and
for patients.7
residual alveolus, particularly if bony reduction is
Historically, intraseptal alveoloplasty offers an contemplated.
alternative technique to remove large bony under-
1. Local anesthetic with epinephrine is adminis-
cuts while maintaining vertical ridge height (Fig. 2).
tered, and a crestal linear or elliptical incision is
However, this method should be used judiciously
made from the posterior tuberosity to a point
while maintaining adequate ridge width to accom-
anterior to the site of interest (Fig. 3). When an
modate possible future implant placement.7
Fig. 1. Alveoloplasty techniques using hand and rotary instruments. (A) Flap elevation, alveoloplasty using ron-
geurs. (B) Alveoloplasty using rotary instrumentation. (C) Final contouring and smoothing using a bone file.
(From Peterson LJ, Ellis E, Hupp JR, et al, with six contributors, editors. Contemporary oral and maxillofacial sur-
gery. St Louis (MO): C.V. Mosby; 1988; with permission.)
462 Ephros et al
Fig. 2. Intraseptal bone is removed and digital pressure applied to collapse ridge and eliminate undercuts. (A)
Alveolar bone after extractions. (B) Intraseptal bone removed to depth of socket with rotary instrumentation.
(C) Intraseptal bone removed with a rongeur. (D) Finger pressure applied to in-fracture labial plate of bone
and eliminate undercuts. (E) Cross-sectional view of pre-extraction alveolus. (F) Cross-sectional view after alveo-
loplasty. (From Peterson LJ, Ellis E, Hupp JR, et al, with six contributors, editors. Contemporary oral and maxillo-
facial surgery. St Louis (MO): C.V. Mosby; 1988; with permission.)
Fig. 3. Incisions for tuberosity reduction: (A) Single crestal incision (red dashed line) used when minimal reduc-
tion is planned. (B) Elliptical incision with anterior release. (From Peterson LJ, Ellis E, Hupp JR, et al, with six con-
tributors, editors. Contemporary oral and maxillofacial surgery. St Louis (MO): C.V. Mosby; 1988; with permission.)
Preprosthetic Surgery 463
elliptical design is selected, the width of the el- unlimited keratinized, attached tissue. The site
lipse is estimated by the magnitude of antici- is then closed with a running resorbable suture
pated tissue removal. The buccal side of the (see Fig. 4D).
ellipse is placed first, well within the zone of
attached tissue. When minimal reduction is antic- In the case of solely soft tissue tuberosity reduc-
ipated, a single crestal incision may be used. tion, excess tissue can be removed by simple wedge
2. Before flap elevation, excess fibrous tissue is resection. Tension free closure is then achieved by
removed by undermining the mucosa with a undermining the buccal and palatal flaps subperios-
beveled incision and excising a wedge on the teally. Additional submucosal tissue can be under-
palatal side of the wound and, if indicated, on mined and removed to aid in closure (Fig. 5).
the buccal side as well (Fig. 4A).
3. A buccal release at the anterior end of the inci- Torus Removal
sion provides significantly enhanced access The cause of maxillary and mandibular tori is un-
and visibility, particularly when horizontal as clear.8 In dentate individuals, removal is often un-
well as vertical bony reduction is planned. The necessary unless normal speech, mastication, or
mucoperiosteal flap is then elevated in both general patient comfort is affected. However, after
buccal and palatal directions allowing access teeth are lost, tori may complicate or even pre-
to the bony tuberosity (see Fig. 4B). clude denture fabrication. Large, lobulated tori
4. Depending on the circumstances and operator with undercuts must be treated, whereas the
preference, bone can be removed with hand restoring dentist may deem smaller, smooth,
and/or rotary instruments (see Fig. 4C). The broad-based tori insignificant.
site should be smoothed with a bone file, in-
spected for residual bony fragments, and irri- Maxillary (palatal) torus removal
gated copiously with normal saline. Before surgery, potential complications should be
5. Any excess soft tissue can be excised from the discussed with patients, including wound
palatal aspect as this side of the wound has dehiscence, prolonged pain, and oral-nasal
Fig. 4. (A) Beveled incision to eliminate bulky tissue while preserving mucosa. (B) Elevation of buccal and palatal
mucoperiosteal flaps. (C) Removal of excess bone from the tuberosity. (D) Closure with interlocking continuous
suture technique. (Courtesy of [A] Alan Samit, DDS, West Orange, NJ; and From [B, C] Peterson LJ, Ellis E,
Hupp JR, et al, with six contributors, editors. Contemporary oral and maxillofacial surgery. St Louis (MO): C.V.
Mosby; 1988; with permission.)
464 Ephros et al
Fig. 5. Soft tissue tuberosity reduction. (A) Maxillary tuberosity with excess soft tissue. (B) Removal of tissue be-
tween buccal and palatal arms of the incision. (C) Flap edges after undermining and removing excess tissue. (D)
Primary closure after any necessary mucosal trimming. (From Fonseca RJ, Davis WH. Reconstructive preprosthetic
oral and maxillofacial surgery. St Louis (MO): W.B. Saunders; 1986; with permission.)
communication caused by thin overlying palatal 2. Depending on the size of the torus and the nature
bone following torus removal. A maxillary impres- of its attachment to the underlying bone, removal
sion is taken and study model poured. The torus may be accomplished with rongeurs, a rotary in-
is then removed from the cast until flush with the strument with an acrylic bur, or a mallet and os-
surrounding palate, and a splint is formed with re- teotome. It is recommended that large tori be
lief provided in the area of the torus. The splint may sectioned with a fissure bur and then removed
be made from acrylic or thermoplastic (suck down) with the mallet and osteotome. Final contouring
material. Soft tissue liner may be used when the is done with an egg-shaped bur and/or bone file.
splint is placed postoperatively to aid in patient 3. The site is irrigated copiously with normal sa-
comfort and prevent hematoma formation. line. Excess soft tissue may be trimmed, and
the flaps are reapproximated with interrupted
1. Local anesthesia with epinephrine is adminis- resorbable sutures.
tered, and a midline incision is made with poste- 4. The stent is relined with tissue conditioner and
rior and/or anterior releases (Y shape incision at inserted.
each end [Fig. 6]). Great care is taken to elevate
full-thickness mucoperiosteal flaps without
Removal of Mandibular Tori
tearing the thin overlying mucosa. A modified
palatal flap has been described to avoid incision 1. Local anesthesia is achieved with inferior alve-
lines over possible palatal perforations.9 olar and lingual blocks. Infiltration at the site
Fig. 6. Palatal torus removal. (A) Palatal torus. (B) Incision design. (C) Exposure of the palatal torus with retraction
sutures. (From Peterson LJ, Ellis E, Hupp JR, et al, with six contributors, editors. Contemporary oral and maxillo-
facial surgery. St Louis (MO): C.V. Mosby; 1988; with permission.)
Preprosthetic Surgery 465
may aid in hemostasis as well as facilitate for smoothing on the lingual surface of the
dissection. mandible and their use is recommended.
2. Incision over the crest of the ridge, or along the 5. The site is irrigated copiously with normal sa-
lingual sulcus of teeth when present, is made line; the tissue is adapted and palpated for ir-
with extension to ensure adequate visualization regularities, and closure is achieved with a
of the tori to be removed. Vertical incisions may running resorbable suture.
interfere with the blood supply to the thin over- 6. Some sources advise placement of a gauze
lying mucosa covering the tori and should be pack under the tongue in the floor of the mouth
avoided4 (Fig. 7). for approximately 6 to 12 hours to prevent he-
3. Elevation of the delicate lingual mucoperiosteal matoma formation.6
flap requires great care. A periosteal elevator or
Seldin retractor is placed beneath the torus to
SOFT TISSUE PROCEDURES
protect the floor of the mouth during removal.
Frenectomy
4. Depending on the size of the torus and the na-
ture of its attachment to the underlying bone, Many maxillary dentures are fabricated working
removal may be accomplished with rongeurs, around a pronounced labial frenum (Fig. 9A).
a rotary instrument with an acrylic bur, or a The result is a deeply notched prosthesis, irrita-
mallet and osteotome. A trough to guide proper tion of the mucosa, and the loss of surface area
osteotome cleavage can be created initially that might otherwise contribute to retention and
with a bur paralleling the lingual cortex to avoid stability. A variety of frenectomy techniques are
unfavorable fractures. Final contouring is done used; but if the moveable tissue interposed be-
with an egg-shaped bur or bone file. Specially tween mucosa and periosteum is not addressed,
designed bur guards are available that help the frenectomy is incomplete as a preprosthetic
protect the lingual soft tissues by exposing procedure.
only the surface of the bur in contact with the The maxillary labial frenectomy for denture
bone (Fig. 8). S-shaped bone files are designed patients should be a limited submucosal
Fig. 7. Mandibular torus removal. (A) Infiltration of local anesthesia at site to facilitate elevation of thin mucosa
overlying a mandibular torus. (B) Incision placed over the alveolar crest. (C) Flap elevation to ensure adequate access
and allow retractor placement to protect the floor of the mouth. (From Peterson LJ, Ellis E, Hupp JR, et al, with six
contributors, editors. Contemporary oral and maxillofacial surgery. St Louis (MO): C.V. Mosby; 1988; with permission.)
466 Ephros et al
Fig. 8. (A, B) Bur guard designed to protect lingual tissues during mandibular torus removal.
Fig. 9. (A) Hyperplastic maxillary labial frenum. (B) Incision at base of frenum with Dean scissors. (C) Submucosal
and supraperiosteal dissection. (D) Cross-sectional view of submucosal and supraperiosteal tunnels. (E) Completed
frenectomy with the new vestibular height established by periosteal tacking suture. (Courtesy of [D] Alan Samit,
DDS, West Orange, NJ.)
Preprosthetic Surgery 467
Fig. 10. (A) Split-thickness skin graft harvest using a dermatome. (B) Placement of a semiporous membrane over
the donor site.
Fig. 11. (A) Labial incision: note preservation of crestal attached gingiva. (B) Labial dissection: note development
of extensive periosteal bed free of moveable tissue.
Preprosthetic Surgery 469
Fig. 13. (A) Lingual dissection accomplished by the gentle use of a gloved finger. (B) Suture placed through the
mucosal edge of the lingual flap. The awl will be introduced through a submandibular cutaneous puncture.
470 Ephros et al
Fig. 14. (A) Both ends of the suture are fed through the eye of the awl. (B) The awl is withdrawn and carefully
brought around the inferior border of the mandible without exiting the skin. (C) The awl is passed into the labio-
buccal vestibule. This technique is done for each of the 4 sutures, right and left, anterior and posterior to the
mental nerve. (D) One end of the suture is removed from the eye of the awl, and the awl is then passed through
the mucosa near the edge of the labio-buccal flap. (E) The suture is now ready to be tied down lowering the floor
of the mouth and securing the labio-buccal mucosa at its new vestibular depth. (From [E] Fonseca RJ, Davis WH.
Reconstructive preprosthetic oral and maxillofacial surgery. St Louis (MO): W.B. Saunders; 1986; with permission.)
formation unlikely and allows the graft to Sloughing of outer layers of the graft is expected
remain well adapted during the critical early at week one; but by week 4 the graft is well adapt-
stages of healing. ed, and impressions may be taken by the restoring
dentist to begin the restorative phase of treatment
Donor site management and oral wound care (Fig. 16).
are performed as have been described for any
type of skin graft. The most critical instruction to
patients is to ensure that no alcohol comes into Other Skin Graft Procedures
contact with the graft for the first 10 to 14 days. Prosthodontic rehabilitation of patients with oral
Mouthwashes as well as alcoholic beverages will cancer is a major challenge. Denture-bearing tis-
interfere with graft healing. sues affected by surgery and/or radiation therapy
are not only changed morphologically but also
may acquire characteristics that impede or even
preclude denture construction. Implants may not
be an option for some who have undergone head
and neck cancer treatment. Although a complete
discussion of functional postablative reconstruc-
tion is well beyond the scope of this publication,
there is one relatively minor procedure used in
this population that may be appropriately included
on the preprosthetic menu. The pig-in-the-blanket
technique for enhancing tongue mobility is a sim-
Fig. 15. The rectangular graft is divided as shown to ple and efficacious method of managing patients
produce 2 segments. Each is placed into the recipient who have undergone wide local excision of lateral
bed, tacking the wider end at the midline and work- tongue/floor-of-the-mouth squamous cell carci-
ing posteriorly, right and left. noma. In these patients, there is often scarring
Preprosthetic Surgery 471
Fig. 16. (A) Preoperative view demonstrating shallow vestibules with superiorly positioned muscle attachments
and a minimal zone of crestal attached tissue. (B) Postoperative view with well-adapted skin graft, significant
labio-buccal vestibular depth, and floor of mouth lowered. (C) Postoperative view with well-adapted skin graft:
note skin pigmentation maintained at the recipient site. (D) Postoperative view with well-adapted skin graft, sig-
nificant labio-buccal vestibular depth, and floor of mouth lowered. (E) Postoperative view with well-adapted skin
graft, significant labio-buccal vestibular depth, and floor of mouth lowered. (F) Prosthesis demonstrating
maximal extension fabricated after skin graft vestibuloplasty.
produced that is lined by skin, and there is 3. Peterson LJ, Ellis E, Hupp JR, Tucker MR, With six
generally a significant improvement in tongue contributors, editors. Contemporary oral and maxil-
mobility. lofacial surgery. St Louis (MO): C. V. Mosby; 1988.
4. Fonseca RJ, Davis WH. Reconstructive prepros-
Care must be taken to ensure that graft healing thetic oral and maxillofacial surgery. St Louis (MO):
continues with appropriate instructions given to W. B. Saunders; 1986.
patients and dietary restrictions imposed for an 5. Obwegeser H. Die submukose vestibulumplastik.
additional 1 to 2 weeks. Dtsch Zahnarztl Z 1959;14:629, 749.
6. Eriksson RA, Albrektsson T. Temperature threshold
SUMMARY levels for heat-induced bone tissue injury. A vital micro-
scopic study in the rabbit. J Prosthet Dent 1983;50:101.
The delivery of a prosthesis that meets the Lawson 7. Miloro M, Ghali GE, Larson PE, et al, editors. Waite:
criteria often requires collaboration between the Petersons principles of oral and maxillofacial sur-
surgeon and the restoring dentist. Preprosthetic gery. 3rd edition. Shelton, CT: PMPH USA; 2011.
surgery should always be considered for patients 8. Garca-Garca AS, Martnez-Gonzalez JM, Gomez-
receiving conventional dentures as well as for Font R, et al. Current status of the torus palatinus
those who will have prostheses that are partially and torus mandibularis. Med Oral Patol Oral Cir Bu-
implant borne.16 Preoperatively this involves a cal 2010;15:E353.
careful and critical evaluation of the relevant anat- 9. Chacko JP, Joseph C. Modified palatal flap: a
omy and a shared vision of what is necessary to simpler approach for removal of palatal tori. J Oral
optimize the function and esthetics of the planned Maxillofac Surg 2010;68(4):9434.
prosthesis. Intraoperatively, each procedure 10. Kilner TP. The Thiersch graft: its preparation and
should be carried out with the intent of maximizing uses. Postgrad Med J 1934;10:17681.
the contours, quantity, and quality of denture- 11. Steinhauser EW. Vestibuloplasty skin grafts. J Oral
bearing tissues. Postoperatively, the surgeon en- Surg 1971;29:77785.
sures that healing is adequate before prosthesis 12. Leban SG. The use of a modified skin grafting tech-
fabrication begins. Once the prosthesis is deliv- nique for alveolar sulcus extension. J Oral Surg
ered, patients are followed as needed by the sur- 1977;35:5524.
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responsibility for periodic evaluation of the denture clinical update. Oral Surg Oral Med Oral Pathol
and its supporting tissues. The fit of the denture 1982;54:1417.
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clusion should direct forces appropriately to the following vestibuloplasty and lowering of the floor
supporting tissues. of the mouth. J Oral Maxillofac Surg 1983;41:2557.
15. Samit A, Kent K. Complications associated with skin
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