rgery in the eld

8, PhD, DrOdont?
University Hospital Glostrup, Glostrup, Denmark

~re~r~~the~i~ surgery is an aspect of dentistry that has a chose relati~eesbip to

~rosthQdQ~tics and oral and maxillofacial surgery. The main fanetians of prepros-
thetic surgery are elimination of pathology in the denture-bearing soft
tissues, and ridge improvement. Limited vestibuloplasty is still con
~r~d~ct~b~~ and cost-&ective procedure for patients who are well
ures. The excellent documentation of osseointegrated implants as
retentive devices for prostheses has reduced the need for major
~i~~e-irn~~~v~~~ surgery. Many clinical conditions, especially in the maxilla, cannot
be rn~~age~ solely with implants. The combination of preprosthetic surgery and
roblems that neither discipline can solve alone. (5 &H3$TKET

eing elderly (65 i- years) and having trouble with
ones teeth or dentures are problems with ramifications
that relate lessto teeth and have more to do with age-
related conditions. Such conditions may be reduced ap-
preciation ofquality of function, hesitation toward changes,
difficulty in ad~~~at~o~to new situations, and limited eco-
nomic potential. On top ofthese, preprosthetic surgery that
is needed by an elderly individual has to be explained so
that the patient is aware that a surgical operation in his or
her mouth will probably be helpful for future denture
wearing, and that a certain morbidity may be encountered.
Thesecircumstancesare obstaclesin preprosthetic surgery
for elderly patients. Absolute clarity in communication be-
tween doctor and patient is a prerequisite for a successful
outcome of surgery, yet is a processthat may be time-con-
SUXdKlg.
inciple, kdications for preprosthetic surgery in the
do not dii7er from those applicable to patients un-
der 65 yez~rsof age, but these indications have to be crit-
ically considered with respect to age-related factors, the
te of health, the patients potential for cooper-
ain indications for preprosthetic surgery are pathology
of the denture-bearing tissues and inadequate ridges. In
the past, a number of surgkal methods have emergedto
improve or restcce the anatomic preconditions for denture
wearing. Some operations yield spectacular results but
carry with them an unacceptablerate of surgicalcomplica-
tions. Others appear easy and even promising, but do not
furnish the patient with sufficient long-term improvement.
Presented at the Toronto Symposium an Prosthodontic Treat-
ment for the Geriatric Patient, Toronto, Ont., Canada, Decem-
ber 1993.
aConsultant, Department of Oral and Maxillofacial Surgery.
Copyright @ 1994 by The Editorial Council of THE JOURNAL OF
b3SIHETIC DENTISTRY
L .
3022s3913/34/$3.9~ i 0. 1Qi1157770
Particularly for elderly patients, snrgica.~:nak~& should
be limited and associatedwith 1~ mocSidity. Further-
more,asituation ~~o~~dbee~~is~~~~d ~~~~~~~c~~~e~~t~~~~
is no longer able to maintain optimal orei .bi~@.e~~
The overwhelming successof dentai implants k pros&-
odontic rehabilitation has dramatic&y ::educedthe need
for conventional prepsosthetic surgery as a solemeansLo
improve dentnre retention and stabiEt,y. Howe-re~,surgical
soft and hard tissueprocedures may be rqui-red fm ridge
improvement before the installation of ~rn~~~~~~Even in
countries with the most advancedtreatme;ltq zbemajoriky
of edentulous patients are pro@&$Iy &Ail treated v&h
removable dentures. Therefore preprosthetic swgery wi.li
comeinto play when pathology alTe&st& d~~~~~~~,.b~~~~~~~
tissues, and limited surgery for ridge i~~~~~~~e~~~~ may
still be helpful.
dicate the need for a surgical correction. Casesof tissue
hyperplasia may be monstrous and may dema:r,drecon-
struction titer excisioa. The avereg c&e, hwwver, dces
not present, problems and can eaail~ be managed on an
outpatient basiswith local an hesia. Six g-my is faditated
if the patient can be persuad to c3ope:.ateby not wuem-
ing the denture for a week or 2 before eur~ry, whereby by+
peremia and bleeding are reduced.
,~yperp!astEc candidiasis of p&ml mtbmsaia another
name for papillary hyperplasia of p&C~tPt z,,ric08a. This
condition may be the result of a rz.egle~:terf destt~~re-sore
mouth (stomatitis pro&etica). A proper ~~~~~~~~~ regimer:
consists of anlimyeotie therapy, surgery. and ~~~~~~~~~~~-
tic follow-up, and includes the cosreetisll 03:oral.and den-
ture hygiene habits. The surgica! co~~~~~~.~~~
may be exci-
sion of hyperplastic tissue after a~~~rn:~~co~,~~
tr&ment of
at least 1 months duration. After ct~mple.Leds~gery, the
surgeonshould provide the den&z ~3% a re%irieand lhe
prosthesisshould not be removed from ~!%emou% for the
THE JOURNAL OF PROSTHETIC DENTISTRY HILLERIJP

Reduction of residual anterior

mandibular ridge
mm

-- Tallgren 1972

i- Carls. & Pers, IQ67

#- Tallgren et.al.1982

-@ Hedegaard 1962

_J

0 5 IO 15 20 25 30
years
After Atwood 1979

Fig. 1. Reduction of mandibular residual alveolar ridge.

next 24 hours for hemostasis.Prosthodontic follow-up is Ridge atrophy

essentialto prevent recurrence.
Denture irritation hyperplasia is a condition that
represents a hyperplastic healing responseto ulceration
that is causedby ill-fitting denture flanges.The pathologic
tissue alterations always respect the musclesunderlying
the tela submucosa, and simple excision with primary
wound closure is the treatment of choice. Extensive exci-
sionmay necessitatelater reconstructive surgery according
to need.
Flabby ridges have been characterized as unsupported
alveolar soft tissues.i The flabby ridges are often caused
by an unstable maxillary denture, usually an immediate
denture, that opposesan anterior natural dentition of the
mandible and results in the so-called combination syn-
drome. This condition acceleratesthe anterior residual
ridge reduction. Corrective surgery should be performed
before the quality of the soft tissueand the quantity of al-
veolar bone preclude further prosthodontic treatment.
Preferably, the insertion of implants should be considered
for anterior maxillary denture support.
Enlarged fibrous tuberosity is an idiopathic type of
fibrosisthat may invade and reduce the interalveolar space
to a degreewhere posterior extension of the denture is im-
possible.Several surgical methods have been describedto
reduce the redundant bulk of tissuein enlargedfibrous tu-
berosity.ra2
Lossof teeth leadsto atrophy, namely the resorption of
the part of the jaw from which the teeth were extracted.3-g
Atrophy is most likely related to the lack of functional
stimulation from teeth, adverse denture load, inflamma-
tion of the overlying denture-bearing soft tissues,and var-
iouscombinations of theseconditions. Atrophy leadsto re-
duction of the physical dimension of the residual ridge,
namely residual ridge reduction. The rate of mandibular
ridge reduction is initially high, about 12 mm per year dur-
ing the immediatepostextraction phase,and levelsoff to an
estimated 0.2 mm per year3,8>10(Fig. 1). The processis
chronic, progressive, irreversible, and cumulative.4 The
important factors in atrophy are anatomic, metabolic,
functional, and prosthetic in character, and their varying
influence may account for the individually differing reduc-
tion rates. The use of dentures undoubtedly adds to the
ridge resorption. It has beendocumentedthat the habit of
continuous denture wearing day and night leadsto signif-
icantly more ridge reduction than only diurnal use.7,8Cer-
tain types of facial morphology are associatedwith power-
ful or weak chewing musclesi and may predisposethe
individual to rapid or slowridge reduction.12The morpho-
logic changesfollow different patterns in the maxilla and
the mandible, and the mandibular ridge reduction rate is
approximately four times asgreat asthat of the maxilla. In
general, the changesof shapeof the residual ridge follow a

552 VOLUME 72 NUMBER 6

 a 2. Vestibular extension mean from tattooed measuring points in first molar, canine,
and midline regions in secondary epithelization vestibu~o~~asty in maxilla. ~e~rna~~~~, ex-
tension gain is 50 % of surgically created sulcus.

cba~~~~erist~~ pattern9 ~o~s$q~e~t to the ridge reduction
the mandible rotates craniaby, and the maxillomandibular
re~a~ionsb~~ is altere in all dimensions.r3 Residual ridge
rejection ~ve~t~a~~yjeo~~~i~es the conditions for denture
wearing by reducing the amount of bone, the denture-
bearing area, and the sulcus depth, and by altering the jaw
relations. ~~e-~e~~te~ meta olic bone lossl*~ l5 affects the
oes any other bones and may lead to pro-
gressive osteoporosis. In clinical treatment planning, prob-
lems related to bone quantity and bone quality are present.
The classification proposed by Lekholm and Zarb16 is use-
ful for clinica! judgments, because bone quantity as well as
bone quality is evaluated.
Tbe clinica ~r~b~a~ of ~~sn~~ient ridges in an elderly
patient may become so severe that even the best possible
~~os~bodo~t~~ treatment proves insufficient. This situation
enforces ~~~~s~o~~rn~ki~g in which several options are
weighed. The first question to be answered is: Will the pa-
tient carry on with complete dentures or overdentures, or
sbouid the patient opt for a I-nigh-tech solution with
irn~l~~ts and fixed ~es~o~at~o~s~
The patients e~~e~~ation of treatment outcome is a good
place to start. Is the elderly patient well adapted to the
concept of removable dentures as 5uch, and will a situation
wbere the denture retention and stability are comparable
to those of .Syears before be acceptable to him or her? If
such is the case, then a iimited vesti
~~~sidere~~? if the height of the residud ridge is suficient.
a su~ra~er~ostea~ dissection is carried o# to exten.d the
ridge, the flap is sutured to the depth of the sulcus, and the
wound is ieft for secondary healing. ~~~~~~~~~t~~ ~~~~~~~e~
the result5 of 90 such surgeries and codssded that 6,
deney for relapse is common and that only about 50% of
the surgically created extension ~~~~~~~~ s&r 2 years.
This result has been re~~od~~~~ in otbe!r studies iPig 2).
ique to create a. vestb&r &ens in
the maxilla in case of ~ns~~~~ent su$cus depth combined
with mild atrophy.
Where medium atrophy is present, the ~~~~~~~~~
method is preferred because of its high &gee of predict-
ered, oral mucosa is heid ;c ba superior to
skin as a graft materiai, ~~t~o~~~ the technique is more
time-co~s~~rn~n~. Mucosal grafts tend ::o stay wef, and they
provide a more resitient seat for the de.nIXre7 and rhe june-
tion between mueosal graft and hosl~ m&o&3 is softer,
which gives a tighter seal with the dentrare fhmge.
 HILLERUP
THE JOURNAL OF PROSTHETIC DENTISTRY

Mandibular vestibuloplasty
A comparison of 3 types of graft
Sulcus depth, mm
12

4 -._

* Edlan flap
2 __ ..-..-_

;it Split skin graft

I / I , I
0
0 2 4 6 8 10 12 14 16 18 20 22 24
Months postoperative
Fig. 3. Extension curves from mandibular vestibuloplasty with crestally pedicled flap,
buccal mucosal graft, and split skin graft. Data from Hillerup,27-gwith permissionfrom
W.B. Saunders Company, Philadelphia, Pa.

Sulcoplasty techniques for the mandible Vestibuloplasty

The morbidity associatedwith comprehensive surgical
techniquesin the mandiblehasevoked a move toward more
limited procedures. The desire to limit surgery, reduce
morbidity, and predict successfulresults has fostered a
number of clinical and radiographic studies on limited
vestibuloplasty procedures.20-35
Lowering the floor of the mouth
Lowering the floor of the mouth may be indicated in
specialcases,A mandibular denture is loaded on the facets
of the cuspsthat face anteriorly and laterally, so that the
logical counterhold is provided by the anterior denture
flange. Transverse dislodging forces may of coursealso be
taken up by a lingually extended denture flange. The sur-
gical procedure of lowering the floor of the mouth is based
on the healing mode of secondary epithelization.36,37In
spite of the poor results obtained with this method in the
vestibulum of the oral cavity, a clinically satisfactory
maintenanceof sulcusdepth is observedin the floor of the
mouth, In a study of 282 patients, Steinhtiuser3sreported
that 85% maintained deep extension, 12% experienced
partial relapse,and 3% experienceda pronounced relapse.
Correspondingly, in a clinical examination of 84 patients,
Hjarting-Hansen et al.37found a deep extension in 86% ,
complete relapse in 8%) and 6 % of the patients were not
classifiedin either category.
The biologic basisfor vestibuloplasty wound healing is
comparableto that of a full thicknessexcisionwound, since
contraction eventually reduces the size,of the wound by
approximating the wound edges.3g, 4oThe only reasonable
way to circumvent the obstacleof contraction is to graft the
vestibuloplasty wound.i7a41
Follow-up studies of vestibular extension in properly
grafted vestibuloplasty with metric recordsbasedon tattoo
marks show a mean extension over the long term without
clinically significant relapse (Fig. 3). The curves in Fig. 3
illustrate the meanextension of measuringsitesin the first
molar, canine, and midline regions.The Edlan flap method
tends to lose about 20% of the surgically created vestibu-
lar extension, whereasthe buccal mucosal graft and the
skin graft methods do not lose any appreciable amount of
the extension, and their curvesfollow a similar slope.It may
benoticed that a lossof extensionis encounteredduring the
first month after surgery, followed by a recovery of exten-
sion.This is a reflection of the reactionsknown from wound
healing studies as wound contraction and wound retrac-
tion.
Properties of different types of graft in
vestibuloplasty
The biologic potentials and shortcomingsof a graft in
vestibuloplasty relate to its capacity to maintain a surgi-

554 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 72 NUMBER 5

ea!ly created sulcus depth, its availability in sufficient 3, A review of clinical follow-up r6~uir.s ;&er d.~~e~e~~
amounts, its function as a denture-bearing tissue and, in kinds and co~b~~~at~o~s of v~stjb~~~~~~~~s~,~ based on more
the case of a Jkin graft, its response to the intraoral envi- than 700 reexamined patients showed thar at least 80 %I of
ronment. The capacity of grafts of skin and oral mucosa to the p&ients considered the operation sur:~&ul when im-
maintain a suicus extension is equal and satisfactory,27, 2s provement of dent,ure function was conrpered with their
and this ability is no criterion for selection between the two expectations. 48 Of all the patients, 75 % were wllhng to un-
materials. No such capacity has been demonstrated with dergo surgery again, 12 % were dissati&d with. the result,
allografts and xenografts, and the clinical results with these and 13% were undecided. The 1ip;chi.n s~-~ai,ion had
graft substitutes have not encouraged their further use. changed in 2 5 5 of 654 cases. Change imhrded any kind
Because of tbe availability of fresh autograft material and of mild periodic or severe permanent altered senaa,tior:, and
the predictability of results with its application, the alter- it did not always result in a compiaint fr~nm the patient. A
native grafts will be of limited clinical importance. The re- duplication technique wili be more wilhngly accepted by
stricted avaiiability of oral mucosal graft material may re- the patient than a conventional method, &at may introduce
strict its apphcstion in major reconstruction. However, an unacceptabibre chaage associated v.+,l- the ~~~~~s~~~~ of
trials of oral mucosal meshgraft techniques are in progress new dentures after vestibuloplasty.
to compensate for this limited availability, and these will
probably provide an improved attachment method of the
graft to the periosteum.42
The ability of skin and oral mucosa to sustain the den- An overdenture stabilized and retained j7y iaqiants m:;g
ture load differs only insignificantly; skin is more prone to be the most rewarding and cost-elective indication for oral
react on traumatic overload with hyperkeratinization, and implants. This relatively simple t:ear,rnerrt meets the
oral mucosa with ulceration.* However, reports of fre- objectives assoc.iated with dramatic ~~~~~~~~~e~t in den-
quent occurrence of Candida infection in intraoral skin ture wearing, negligible surgical t~ranma, a& ICW morbid-
grafts44, 45 with associated significantly increased ridge re- ity. Hopefully, it will replace mu& ma$:. ~f~~t~~~~~o~~as,~~
sorption may be considered a major disadvantage that and ridge a~gnlentat~o~ surgery on the atrophic msndi-
may have been overlooked. As a consequence of these find- ble.4g Even in situations of advanced reSi$ua.ridge reduc-
ings, patients with intraoral skin grafts should be encour- Con, implants for support of an ~~~er~~~~~,~~~ are possibL
aged to self-examine the site for changes of graft appear- Triplett et aLFOshowed a favorable ou:co~~$?cI of implant-
ance. In case of skin graft changes of speckled or total supported prostheses in mandibles with I& iO mm ante-
reddening ascribable to infection with Candida, an appro- rior height or less. With tbe progression of m~~d.~b~~a~ al-
priate antimycotic therapy should be instituted to prevent veolar ridge atrophy, the residual bone cez~5s *e be more
excessive bone resorption under the graft.46 Biologically, dense in structure, and thus favors the ~~r~e~jm~~lar~t mm-
ora! mucosa seems to be the most suitable graft material in tact area. This is contrary to the rnaxr?la~ where ridge atro-
vestibuloplasty. phy is coupled with osteoporosis of the r~idua! bone,

cations, and side effects

1. Dysesthesia is a relatively frequent postoperative Onlaytechniques have been used IStoreconstruct the
complicstion or side effect that tends to resolve with time. atrophic in full denture wearers, and ~ho?~co~~~~s
maxilla
There is a distinction between a mild, periodic altered sen- have been encountered in terms of rapid gtaf?. resorption.
sation, which is the most frequent type, and the more se- Au~me~tat~ou of the atrophic maxi&* with interposi-
vere dysesthesia that leads to patient complaints.s7 Avoid- tiona: autogenous bone grafts has beal done wkh cbe max-
ance of surgical error is of importance in reducing dyses- illaay le Fort I osteotomy, according to standard technique,
thesis--that is, the avoidance of physical injury to the with reasonable success.s-. Farmanc!i combi&&. he horae-
nerve of the surgicai area. shoe sandwich osteotomy with a me&tied ~~,~~~~~~s ves-
2. Soft tissue profile changes of considerable magnitude tibuloplasty with seemingly excelienr r~e~iuits. Fifteen pa-
and uniform pattern have been found, even when the sur- tients were followed from 3 to 15 man dks. and the average
gical preparation is restricted. The most significant alter- resorption measured on Iateral c~~~~~~~~K~~~,~~cfilms was I
ations that occur during the first month after surgery to 2 mm.
involved the lower lip and chin. Contemporary maxillary ridge ~ug~~~~.~~~~~n includes a
The lower lip height was reduced by a mean value of 1.75 number of grafting techniques &al. serve 6x2 plUJ3oSk5 of
mm (4 < 0.001) in a pooled material of different vestibulo- implant instahation. These math& 8 iwlude day graft-
&sties, and the chin thickness was increased by 2.33 mm ing, osteolomy with sandwich graiting;j3 grafting of kid.

on average (p < 0.001). This was followed by a mean bone defects,j* grafting of the Boor of ti:.e maxillary sinus,
increase of the Lepper lip height of 1.04 mm (p < 0.05). The and so forth. There is no clear ~~~~~~~~~~~ whether implant
changes were positively correlated to the magnitude of the insertion should be preceded by ridge ~~~.~~~~~e~~~~~~or be
.surgical
. correction. performed as a simultaneous proced~e,~ and ~~~~?.~~c~~t
THE JOURNAL OF PROSTHETIC DENTISTRY HILLERUP

long-term follow-up studies are few. Still, the extremely the specific needs and expectations of the patient; (2) an
atrophic maxilla in an individual with advanced general- informed consent to an individually-tailored treatment
ized osteoporosis presents a problem of reconstruction and plan that limits the extent of surgery (and thereby its as-
rehabilitation with implants because the quality of the sociated morbidity) to a possible minimum; (3) expertise in
bone graft material available may be insufficient. With surgery, prosthodontics, and implant procedures; and (4)
advanced osteoporosis, the bone graft/implant contact interdisciplinary cooperation.
area may be reduced to critical levels for microfractures Preprosthetic surgical and implant procedures should be
to occur within the anchoring bone, leading to implant considered as cooperative treatment alternatives, each
failure. with its advantages and disadvantages, rather than as
competitive procedures. To provide optimal service, a
Mandibular augmentation procedures sound combination of traditional preprosthetic surgery
Only in extreme cases of insufficient mandibular ridge and implant surgery should be available for elderly citizens
does a ridge augmentation procedure come into question, with denture troubles caused by pathology of the denture-
and in contemporary practice only for the accommodation bearing tissues or by atrophy of the residual alveolar ridges.
of endosseous implants. The correction of pathologic conditions in the denture-
Early methods of mandibular ridge augmentation were bearing tissues is associated with minimal discomfort and
based on onlay type grafts. Wang et a1.57 found in six pa- morbidity, and patient needs are easily satisfied. This type
tients that only 11% of the augmentation remained after of correction deserves top priority at teaching centers of
3 years. Obwegeserlg introduced the use of autogenous rib oral and maxillofacial surgery.
grafts. With this technique, Davis et a1.58 found a total av- Limited vestibuloplasty may still play a role in ridge im-
erage loss of 10.4 mm over 7 years in 18 mandibles that had provement as a cost-effective low tech intervention. This
an augmentation of 15.1 mm. type of correction is less demanding than implant treat-
A major breakthrough in mandibular ridge augmenta- ment, especially in terms of aftercare.
tion came with the concept of pedicled bone flaps, visor os- Most patients with advanced atrophy of the mandible
teotomy,5g and sandwich osteotomy.60 Resorption is re- and corresponding troubles with denture retention and
duced because the osteotomized bone flap retains its own stability will benefit tremendously from implants to sup-
blood supply through the attached soft tissue pedicle. port an overdenture. The question of preference of tightly
Cancellous autologous bone chips can be added to use their bound or keratinized periimplant oral mucosa is still
osteogenetic potential, add bulk and height, and hasten somewhat controversial. In cases with such requirements,
healing. modern vestibuloplasty techniques with free grafting of
Follow-up studies of these methods of augmentation of palatal mucosa are available, and excellent results have
the atrophic ridge show an impressive gain in ridge height been indicated with the combination of limited vestibulo-
and a postsurgical ridge reduction of greater magnitude plasty and implant-supported mandibular overdentures.
than other types of surgery. The main disadvantage of the The minority of these patients need an augmentation.
Visor and the Sandwich osteotomies is the high inci- Ridge augmentation should not be done when there will
dence of sensibility disturbances in the chin and lower lip. be subsequent treatment with a simple removable denture.
The dissection of the nerve out of its canal apparently en- Sufficient evidence exists that such a procedure is fruitless.
sures a certain amount of dysesthesia. In 63 patients who The main problem is that although the graft becomes re-
had undergone visor osteotomies of various designs sup- vascularized and integrated as a bony structure, it never
plemented with iliac bone grafts, Mercier et a161 found only attains any physiologic or functional stimulation to main-
39% of the sample group free of neurosensory problems. tain equilibrium in the turnover of bone resorption and
For this reason, the sandwich and visor techniques have apposition. Conversely, the biologic environment for ridge
been more or less abandoned. augmentation with subsequent implant installation for
The only longitudinal data available about mandibular denture support provides a much better prognosis, because
ridge augmentation with autogenous iliac or rib bone grafts the denture-bearing surface of the bone is not loaded and
and endosseous implants have been provided by Weingart some physiologic function may be introduced. It should be
et a1.62 In this study, 10 consecutive ridge augmentations remembered that advanced age may present a contraindi-
were performed with simultaneous installation of 45 Bon- cation for major oral and maxillofacial reconstructive sur-
efit/ITI implants for support of fixed partial dentures. No gery.
implant failure occurred during a 3-year observation pe-
riod. The vertical bone loss was on average 0.2 mm between CONCLUSIONS
the first and second years of observation, and about 0.1 mm 1. Preprothetic surgery is still a relevant treatment op-
between 2 and 3 years of observation. tion for elderly patients.
2. Well-defined prosthodontic needs of ridge improve-
DISCUSSION ment may be satisfied in a simple and cost-effective man-
The provision of optimal preprosthetic surgery to the ner with the aid of preprosthetic surgery.
elderly population demands (1) a thorough identification of 3. The combination of preprosthetic surgery and im-

556 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 72 NUMBER 5

plants may solve problems that neither of the two disci-
&es carz do alone.
4. Interdiscipkinary cooperation is a prerequisite for op-
timal service.
32. Xosecquist J. Prepsosthetic surgery in the fr,xis wyyori _ : ofihe mandibie.
Ent J O:al Surg 1975;4:!8-26.
33. Edian E. ire-prosthetic surgery--a new leci~;ii:~w m the cdcn:ulou~
I. Hopkhx R. A colour atlas of preprosthetic oral surgery. London: Woife lower jaw. In: Kaw LW, ed. Oral surgery. ?rswc~et~ons of the WJ,!I In-
,Medical Publications, 1987:?36-43. ternationai Conference on %-al Surgery. (OpenfPngen. M::nks~aard,
2. Gbwegeser H. Die chirurgische Vorbereitung der Kiefer fur die Proth- 1973;1.91-4.
es?. In Haunfeider D, Hupfauf I,, Ketterl WandSchmuth G,: Praxis der 34. Teiser ,I, Esser E. Metric studies after i:?FtibL;i,?ilstYPii:hf~ce rnt~~~a.
Zahheilkunde. Rd III. Muenchen: Iirban & Schwartzenberg, 1969. [German]. hch Zahnaerztl 2: 1980;35z9?9-82
3. Tallgren A. The continuing reduction of the residual alveolar ridges in 35. Tideman H. A technique of vestibui~ p&y zxr*ip t\ free mucosa graft
complete denture wearers: a mixed-longitudinal study covering 25 from the cheek. Int J Oral Surg 1972;I:Z23!i.
~e2l3.J ~ROWHhT r)lENT ;972;27:12@32. 36. Trauner It. Die Alveolarkammplastik im Untexiefbr arii der lingualen,
4. Atwood DA. Reduction of residual ridges: a major oral disease entity. Srite zur Losung des Problems der uweren Fr.&xe, ?tsch Zshrraentl
j hWST:WI DO&T 1.$1;26:266-79. 7A 195o~7:20-6!.
..( I#
5. Atwood DA, Coy WA. Clinicaf, cephalometric and densitometric study 37. flj$rting-Hansen E, Adawy AM, Hitlerup 8. Mandibu:tir ventibuiolin-
of reduction of residual ridges. 3 PROSTHW DENT 1971;26:280-95. g-ml si*lco.plaa~y with free skin graft: a five .yesr i iinicd fc~ioiu-up stlldy.
6. Baylink DJ, Wergedal JR, Yamamoto K, Manske E. Systemic factors J Oral Maxiilofac Surg 1983;4?:iX-6.
in alveoiar bone loss. d PROWHET DENT 1974;37:486-505. 38. Steinh+iuser E. Ten years of pteprosthetic suqerlj--c-xperie?c~~s and
7. Merciex P, Vinet A. Local and systemic factors in residual alveolar ridge resuks. [German]. Dtsch Zahnaerztl % 197li:25:~ 13.20.
atrophy, Ine J Oral surg 1981~10(Supp1):65-70. 34. Carrel A. The treatment of wouixis. _4 hst ai.:ck. JAMA 19Lii;65:2148-
8. Carlsson GE, Pcrsson G. Morphologic changes of the mandible after 50.
extra&m and wearing of dentures. Odontol Rev 1967;18:27-54. 40. Rudolph R. Contraction and the control .,i aor.craction. ;I:orid .l Surg
9. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral 1980;4:279-87.
Maxillofac Surg 198R;17:232-6. 41. Schuchardt K. Die Epidermistranspiantatior: izi der Mundvorkofpias-
IO. Atwood DA. Bone loss of edentulous alveolar ridges. J feriodont tik. Dtsch Zehnaerztl Z ?952;7::164.9.
1979;Specia: issae:il-2f. 42. Hi4xle F. Atlas der praprothetischen Operationen. Pdhrer;chea, wien:
11. M~lier E. The chewing apparatus. Acta Physiol Stand 1966;69(suppl Cari Hanser Verlag, 1989.
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558 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 72 NUMBER 5