Prof.

Hassan Abdel-Dayem & Hala Mokhtar

PRE-PROSTHETIC
SURGERY
BASI & ADVANCED
 BASIC PREPROSTHETIC SURGERY

RATE OF ALVEOLAR ATROPHY

A. SYSTEMIC FACTORS
• Osteoporosis
• Endocrine abnormalities.
• Renal dysfunction.
• Nutritional deficiencies.

B. LOCAL FACTORS
• Jaw function.
• Vascular changes.
• Increased physical demands. owing to decreased mandibular plane angle.
• Mucosal inflammation.
• Number and extent of previous surgeries involving mucoperiosteal elevation.

IRREGULARITIES OF DENTURE BEARING TISSUES

A- IN THE UPPER JAW

• Frenum labii.
• Muscle attachments.
• Denture granuloma.
• Fibro epithelial polyp of the palate.
• Flabby upper ridge .
• Shallow sulcus.
• Fibrous enlargement of tuberosities.

B- IN THE LOWER JAW

• Frenum linguae
• Denture fissuratum
• Denture granulomata
• Shallow sulcus.
• Flabby ridge
• Fibro-epithelial polyp
• Muscle attachments

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OBJECTIVES OF SURGICAL TREATMENT

(1)To eliminate preexistent or recurrent pathology.

(2)To rehabilitate infected or inflamed tissue.

(3)To reestablish maxilla-mandibular relationships in all spatial dimensions.

(4) to preserve or restore alveolar ridge dimensions (height, width, shape, and
consistency) conducive to prosthetic restoration.

(5)To achieve keratinized tissue coverage over all load-bearing areas.

(6)To relieve bony and soft tissue undercuts.

(7)To establish proper vestibular depth and repositioning of attachments to allow

for prosthetic flange extension if necessary.

(8)To establish proper notching of the posterior maxilla and palatal vault
proportions.
( (9)To prevent or manage pathologic fracture of the atrophic mandible.

(10)To prepare the alveolar ridge by onlay grafting, corticocancellous

augmentation, sinus lift, or distraction osteogenesis for subsequent implant
placement.

(11)To satisfy facial esthetics, speech requirements, and masticatory challenges.

SURGICAL PROCEDURES USED IN THE PREPARATION OF THE MOUTH

FOR DENTURES

CLASSIFICATION OF PREPROSTHETIC SURGERY

1- PREVENTIVE PROCEDURES

A- At the time of the surgery

1-Most patients do not require any special surgical preparation .
2-Extraction should be carried out carefully to preserve alveolar bone and to avoid
tearing of the soft tissue .
3-Socket should be compressed so that expanded alveolar bone is repositioned .
4-Bony undercuts , sharp spurs and loose pieces of bone should be eliminated .
5-Attached mucoperiosteum should not be sacrificed in attempt to oppose the
gingival margins .
6-Access to residual roots made from the lateral aspect of alveolar process .
7- Avoid radical alveolotomies.

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 8-Radiographic examination to exclude presence of buried teeth, retained roots
or intrabony pathology.
9-Gingival inflammation should be treated to speed healing and avoid
development of hyperplastic tissues.

B- Alveoloplasty
Surgical contouring / remodeling of the ridge by the removal of all sharp and rough
bony projections to achieve the most ideal “denture bearing surface”.

The procedure ranging from single tooth to full arch done immediately after extraction
or secondarily as a corrective procedure.

1- SIMPLE ALVEOLOPLASTY

Simple alveolar recontouring after extractions consists of compression and in-

fracture of the socket; however, one must avoid overcompression and over-
reduction of irregularities.

2- ALVEOLOPLASTY

a- Multiple irregularities produce undercuts that are obstructions to the path of

insertion for conventional prosthetic appliances:
• The elevation of mucoperiosteal flaps using a crestal incision with vertical
releases is necessary to prevent tears and to produce the best access to the
alveolar ridge.

• Periosteal and Woodson elevators are the most appropriate tools to prevent
excess flap reflection, devitalization, and sequestrum formation.

• The use of a rongeur or file for advanced recontouring is preferred to rotary

instruments to prevent over-reduction.
• For large bony defects, rotary instrument recontouring is preferred.

• Normal saline irrigation is used to keep bony temperatures < 47˚C to maintain
bone viability.

• Excessive soft tissue is removed to relieve mobile tissue that decreases the fit and
functional characteristics of the final prosthesis.

• Closure with a resorbable running/lock-stitch suture is preferred because fewer

knots are less irritating for the patient.

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 b- Interseptal alveoloplasty is rarely indicated due to the following
disadvantages:
• The overall decrease in ridge thickness, may result in a ridge that may be too
thin to accommodate future implant.

• Removal of interseptal bone eliminates endosteal growth potential, which is

necessary for ridge preservation.

• After hard tissue recontouring, excessive soft tissue is removed to relieve mobile
tissue that decreases the fit and functional characteristics of the final prosthesis

• Closure with a resorbable running/lock-stitch suture is preferred because fewer

knots are less irritating for the patient.

I- CORRECTIVE PROCEDURES FOR BONY ABNORMALITIES

1- TORUS PALATINUS

• Developmental bony growth in the midline of the palate , single or multiloculated

bony mass in the palate. , present in 20-25% of the patients.

• Composed of compact bone.

• It prevents denture stabilization and causes pain and ulceration of thin overlying
mucosa.

• In the dentate patient they are rarely indicated for removal except for repeated
overlying mucosal trauma and interference with normal speech and mastication.

OPERATIVE PROCEDURE

1-Local anesthesia:
• Bilateral greater palatine and incisive blocks are performed to achieve adequate
anesthesia. Local infiltration of the overlying mucosa.

• Incision along crest of the ridge in edentulous patient , or around the palatal
gingival margin if teeth are present or a double Y- shaped midline incision

.
2-Reflection of the mucoperiosteal flap which is held back with sutures.

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 3-Bony mass divided by surgical bur. A round bur may be used for small areas; a
cross-cut fissure bur for large tori under copious irrigation.

4- Each piece removed by chisel or osteotome.

5- Smoothening by bone file or bur and irrigation.

6- Excess soft tissues trimmed and sutured

7- Pre-surgical fabrication of a thermoplastic stent or acrylic plate , made from

dental models with the defect removed, in combination with a tissue conditioner helps to:
• Eliminate resulting dead space,
• Increase patient comfort.

2-TORUS MANDIBULARIS

• Developmental exostosis on lingual surface of mandible in canine premolar area.

• Single or multiple , usually bilateral.
• May cause pain , ulceration and difficulty in denture wearing.
• Composed of cancellous bone covered by compact bone.
• Bilateral radiodensities overlying the apices of the mandibular teeth.

OPERATIVE PROCEDURE
1- Local anesthesia:
anesthesia: bilateral inferior alveolar and lingual nerve blocks as well as
local infiltration.

2- Incision is made 2mm mesial and 2mm distal to the torus .

3- Mucoperiosteal flap reflected lingually to 1cm below the torus .Maintenance of

the periosteal attachment in the midline reduces hematoma formation and
maintains vestibular depth.

4- Torus removal:
• Small protuberances can be sheared away with a mallet and osteotome.
• Large tori are divided superiorly from the adjacent bone with a fissure bur
parallel to the medial axis of the mandible and are out-fractured away from the
mandible by an osteotome.
• Bone smoothened by a large surgical bur .

5- Irrigation and suturing .

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 6- Temporary denture delivery or gauze packing lingually may be used to prevent
hematoma formation.

Complications:
Wound dehiscence and breakdown with exposure of underlying bone treated with local
irrigation with normal saline.

3- BONY EXOSTOSES

• Undercuts and exostoses are:

• More common in the maxilla than in the mandible,
• Are rare
• Asymptomatic.
• No therapy except for those cases with severe esthetic and functional problems.

4- BONY ENLARGED MAXILLARY TUBEROSITY

Enlargement may be bony or fibrous , in buccopalatal or vertical direction , unilateral or

bilateral

Diagnosis:
• Sounding, which is performed with a needle, can differentiate between the causes
with a local anesthetic needle or by panoramic radiograph.
• It interferes with fitness of upper denture and causes pain in the soft tissue
overlying the coronoid process.
• Excessive vertical depth may reduce the inter-alveolar space.
OPERATIVE PROCEDURE
• Straight incision along the crest of the ridge from the posterior aspect of the
tuberosity to the first molar region using a no. 12 scalpel blade.

• Flap reflected buccally and palatally

• Bony Tuberosity reduced using chisel or surgical bur , smoothened and irrigated .

• Careful evaluation of the level of the maxillary sinus must be done before bony
recontouring is attempted in the area of the tuberosity.

• Excess soft tissue trimmed and closed.

5. BONY EXOSTOSES AND UNDERCUTS

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 • Bony prominence with undercuts are usually the product of careless extraction.
• They interfere with denture construction.
• Undercuts and exostoses are more common in the maxilla than in the mandible.
OPERATIVE PROCEDURE

1- Local anesthetic

a- In the maxilla:
Infiltration for adequate anesthesia as well as an aid in hydrodissection of the
overlying tissues, which facilitates flap elevation.

b- In the mandible:
Inferior alveolar block and infiltration

2- Incision along the crest of the ridge 1.5 cm beyond each end of the area
requiring contour should be completed.

3- A full mucoperiosteal flap is reflected to expose all the areas of bony

protuberance.

4- Removal of Deformity:
a. In large areas: with chisel or surgical bur

b. In small areas: bone file and the cut surface is smoothened.

5- Flap trimmed , replaced and sutured.

5-SHARP MYLOHYOID RIDGE (LINGUAL BALCONY)

• Prominent internal oblique ridges from advanced resorption of the alveolar

process.
• Affects stability of the denture and causes pain by compression of the overlying
soft tissue.

OPERATIVE PROCEDURE

1- Anesthesia is achieved with buccal ,inferior alveolar , and lingual nerve blocks

2- Incision on crest of the ridge from 3rd molar to canine region buccally directed to
avoid the lingual nerve and flap elevated.

3- Subperiosteal dissection along the medial of the mandible reveals the attachment
of the mylohyoid muscle to the adjacent ridge.

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 4- Muscle can be sharply separated with electrocautery to minimize muscle
bleeding
5- Chisel is placed with its cutting edge parallel to the base of the ridge and a light
tap is sufficient to detach it .

6- Grasped by allies forceps and removed.

7- Smoothening ,irrigation and suturing .

6- KNIFE EDGE RIDGE

• The ridge is sharp and narrow.

• Severe pain when thin overlying mucosa is compressed.

• Trimming usually diminishes the height of the ridge but does not smoothen it as
it is thin from base to crest.

• Ideal solution if the ridge has undercut is to thicken its contour by bone graft .

OPERATIVE PROCEDURE

1-Incision on the crest of the ridge , reflect the flap minimally .

2-Conservative trimming of the sharp spines of bone with rongeur or file.

3-Trim excess soft tissue and suture.

7- INADEQUATE VERTICAL SPACE

• Malunited fractures and over eruption of teeth are the causes

• Additional space can be obtained by trimming the alveolar process in upper or

lower jaw.

9-PROMINENT GENIAL TUBERCLES

• The genioglossus muscle attaches to the lingual aspect of the anterior mandible.
As the edentulous mandible resorbs, this tubercle may become significantly
pronounced.

• In case of extensive ridge atrophy , genial tubercles may project and interfere
with seating of lower denture.

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OPERATIVE PROCEDURE

1- Local anesthesia bilateral lingual nerve blocks.

2- A crestal incision from the midbody of the mandible to the midline bilaterally is
necessary for proper exposure.

3- A subperiosteal dissection exposes the tubercle and its adjacent muscle

attachment.

4- Sharp excision of the muscle from its bony attachment may be performed with
electrocautery, with careful attention to hemostasis.

5- The bony tubercle may then be relieved using rotary instrumentation or a rongeur.

COMPLICATIONS

• Hematoma in the floor of the mouth may lead to airway embarrassment and life-
threatening consequences if left unchecked.

II- CORRECTIVE PROCEDURE FOR SOFT TISSUE ABNORMALITIES

1- FIBROUS ENLARGEMENT OF THE MAXILLARY TUBEROSITY

• It is common for fibrotic tissue to accumulate in the maxillary tuberosity region.

• It may be unilateral or bilateral ; firm or mobile.

OPERATIVE PROCEDURE

1- Elliptical V shaped wedge incision is carried deep down to bone isolating the
mass which is grasped with an allies forceps and removed.

2- Buccal and palatal flaps are undermined trimmed and sutured.

OR
3- Enlargement may be pared down with scalpel leaving raw area to granulate.

2- SHORT LABIAL FRENUM

• Labial frenum attachments consist of thin bands of fibrous tissue covered with
mucosal fold which becomes prominent after excessive atrophy of alveolar ridge
has occurred.

• The height of this attachment varies from individual to individual.

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 • It interferes with peripheral seal, fit and stability of the denture produce
discomfort, and dislodge the overlying prostheses, especially if it is attached to
the crest of the ridge.
OPERATIVE PROCEDURE

A- Several surgical methods are effective in excising labial frenum

1- Local anesthetic is performed in a regional fashion avoiding direct infiltration

because it distorts the anatomy and leads to misidentification of the frenum .

2- The frenum is held by 2 mosquitoes ,the first parallel to labial mucosa and second
parallel to alveolar ridge.

3- Scissor or scalpel is used to cut outside the hemostats .

4- An elliptic incision around the proposed frenum is completed in a supraperiosteal

fashion.

5- Margin undermined and sutured.

6- Sharp dissection of the frenum using curved scissors removes mucosa and
underlying connective tissue leading to a broad base of periosteum attached to the
underlying bone.

7- Margin undermined and sutured.

B- Z - plasty

1- In Z-plasty technique excision of the connective tissue is done.

2- Two releasing incisions creating a Z shape .

3- The two flaps are undermined and rotated to close the initial vertical incision
horizontally.

4- By using transpositional flaps vestibular depth increase alveolar height.

3- SHORT LINGUAL FRENUM

• High lingual frenum attachments may consist of different tissue types including
mucosa, connective tissue, and superficial genioglossus muscle fibers.

Problems caused by Ankyloglossia or tongue-tie:

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 • Speech defect ,

• It interferes with seating of the denture .

• Limits the tongue’s range of motion. The patient is unable to clean away food
lodged in the palate and labiobuccal sulci.

• Some patients may develop lisp or irregularity of lower anterior teeth.

OPERATIVE PROCEDURE
1. Bilateral lingual blocks and local infiltration in the anterior mandible
provide adequate anesthesia for the lingual frenum excision

2. A stitch or Gillis hook is inserted in the midline of the tongue to lift it

high.

3. Frenum is cut midway between the tip of the tongue and its origin ,
parallel to the floor of the mouth.

4. Gapping wound is produced , edges are undermined and sutured . closure

in a linear direction

5. Care taken not to severe sublingual veins Careful attention must be given
to Wharton’s ducts.

4- DENTURE GRANULOMA

• Occurs in the upper and lower jaw and may be localized or generalized .

• Caused by wearing old ill-fitting dentures that causes trauma leading to

formation of granulation tissues which organize to fibrous tissue.

• An underlying fungal etiology most often is the source of the inflammatory

process and appears to coincide with mechanical irritation and poor hygiene
practices.

• In severe cases , there are several false ridges of granulation tissue.

OPERATIVE PROCEDURE

a- In early stages the lesion can regress with the

1. Removal of the denture.

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 2. Improvement of hygiene practice

3. The use of antifungal therapy such as nystatin tid alternating with clotrimazole
troches intermittently

4. Nocturnal soaking of the prosthesis in an antifungal solution or in an extremely

dilute solution of sodium hypochlorite helps decrease the overall colonization of
the prosthesis.

OPERATIVE PROCEDURE

1- Surgical removal.
2- Loop electrocautery.
3- Carbon dioxide laser.

Surgical removal:

1. The lesion is grasped with allies forceps or by a stitch taken through it .

2. Mucosa around the lesion is incised and lesion is dissected out with periosteal
elevator supraperiosteally to prevent exposure of underlying palatal bone.

3. Resulting raw area is covered by tissue conditioner if large or it is undermined

and sutured if small.

4. A split skin graft is may be necessary in some cases.

5. Pathological examination should be done for neoplastic changes.

5- FLABBY RIDGE

• It is a soft tissue gingival ridge with lack of bone support .

• Occurs in patients with upper full denture opposing lower natural teeth ,
excessive occlusal trauma causes bone resorption in the upper anterior part , the
space become occupied by fibrous tissue.

OPERATIVE PROCEDURE

1-Denture is removed 7-10 days before surgery for inflammation to subside .

2-Flabby ridge is grasped by several allies forceps and held up.

3-Cut V shaped incision through the mass down to the bone and remove it .

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 4-Edges are approximated and sutured.

6- DENTURE HYPERPLASIA "EPILUS FISSURATUM”

• Fibrous inflammatory hyperplasia is often the result of an ill-fitting
denture that produces underlying inflammation of the mucosa and
eventual fibrous proliferation.

OPERATIVE PROCEDURES

• Early management consists mainly of adjustment of the offending denture

flange with an associated soft reline of the prosthesis

• Laser ablation with a carbon dioxide laser is the method of choice.

OPERATIVE PROCEDURE
1. Local anesthesia

2. The lesion is grasped with surgical forceps and is gradually excised along the
length of the lesion superficial to the underlying periosteum

3. The incision, is sutured with the intact periosteum along its entire length, thus
creating a void

4. maintenance of a supraperiosteal plane with repositioning of mucosal edges

allowing for subsequent granulation is preferred over approximation of wound
edges that results in. alteration of the vestibular depth.

5. Replacement of old denture, immediately after the end of the operation, retaining
the depth of mucosa of the newly created sulcus. The internal surface of the
denture is lined with tissue conditioner.

7- MUSCLE ATTACHMENTS

• Small fibrous bands in the buccal sulcus often , the result of scarring following
extraction but may be congenital.

• Contain no muscle “scar bands”.

• May have high attachment and interfere with buccal extension of the denture.

• Operation is similar to that used in removal of frenum labii .

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 8- FIBROEPITHELIAL POLYP OF THE PALATE
• Pedunculated polyp beneath the upper denture .
• May grow to a considerable size.
• Removed by diathermy or cryoprobe.
ADVANCED PRE-PROSTHETIC SURGERY

FACTORS WHICH RESULT IN REDUCTION OR OBLITERATION OF THE

SULCUS

1-Resorption of the alveolar process .

2-Abnormally high muscle attachment.
3-Scar tissue resulting from trauma or infection.

CLASSIFICATION OF RESIDUAL RIDGE FORM

classified by Cawood and Howell
• Class I—dentate
• Class II—post extraction
• Class III—convex ridge form, with adequate height and width of alveolar
process.
• Class IV—knife-edge form with adequate height but inadequate width of alveolar
process.
• Class V—flat-ridge form with loss of alveolar process.
• Class VI—loss of basal bone that may be extensive but follows no predictable
pattern.

SURGICAL CORRECTION OF ALVEOLAR ATROPHY AND FLAT RIDGES

SHALLOW SULCUS (FLAT RIDGE)

COMPLICATIONS
• Poor denture retention.

• Denture instability: lateral instability is influenced by the short size and shape of
the denture flange.

• Pain due to the pressure caused by small denture base area.

I- RELATIVE HIGHTENING PROCEDURES

(SULCUS DEEPENING VESTIBULOPLASTY)

1- SUBMUCOSAL VESTIBULOPLASTY "Obwegeser"

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INDICATIONS
• If a tongue blade or mouth mirror is placed to the height of the maxillary
vestibule without distortion or inversion of the upper lip, adequate labiovestibular
depth is present.

• If distortion occurs then maxillary vestibuloplasty using split-thickness skin

grafts or laser vestibuloplasty is the appropriate procedure.

SURGICAL PROCEDURE

1. Midline vertical incision from anterior nasal spine to crest of the ridge .

2. Curved scissor is used to dissect the mucosa from underlying tissue, starting from
the crest to new sulcus depth .

3. A tunnel is formed that is filled with connective tissue, the tissue is either removed
or displaced superiorly.

4. Midline vertical incision from anterior nasal spine to crest of the ridge .

5. Mucosal undermining bilaterally: Curved scissor is used to dissect the mucosa

from underlying tissue , starting from the crest to new sulcus depth .

6. A supraperiosteal separation of the intermediate muscle and soft tissue

attachments is completed.

7. A tunnel is formed that is filled with connective tissue, the tissue is either removed
or displaced superiorly avoiding nerve injury.

8. It is considered a closed method

a. .
9. Buccinator and mentalis muscles are displaced as much as possible in the
mandible.

10. The tunnel is bounded externally by the mucosa and internally by the periosteum.

11. This tissue layer may then be excised or superiorly repositioned.

12. Closure of the incision mucosa is held against the bone in its new position by a
pre-operatively constructed denture with large flange lined with gutta percha and
held by per alveolar wires.

13. Denture or stent is performed 2 weeks postoperatively.

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 14. During the healing period, mucosal tissue adheres to the underlying periosteum,
creating an extension of fixed tissue covering the maxillary alveolus.

15. A final reline of the patient’s denture may proceed at approximately 1 month
postoperatively.

2- SECONDARY EPITHELIZATION VESTIBULOPLASTY

INDICATIONS

• If mucosa is either insufficient in quantity or poor in quality as affected

by inflammatory hyperplasia, ulceration or scar tissue.

A- Kazanjian’s Technique ( Raw lip substance ) (lip-switch)

SURGICAL PROCEDURE

PRINCIPLE
•
A labial mucosa is raised and transferred to line the osseous side of the
deepened vestibule.
INDICATIONS

• Adequate anterior mandibular height (at least 15 mm).

• Inadequate labial and buccal vestibular depth from mucosal and muscular
attachments in the anterior mandible.

• The presence of an adequate vestibular depth on the lingual aspect of the

mandible.

B- Clark's technique (Raw Ridge)

SURGICAL PROCEDURES

1. Labio – buccal circumferential incision 3 mm away from the alveolar crest

incision is done 1mm away from alveolar crest .

2. Supra periosteal dissection to reflect the mucosal flap , and displace mentalis ,
buccinator muscles downward to the desired depth.

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 3. The free mucosal margin is sutured to periosteum at the newly created sulcus
depth using continuous sutures leaving the periosteal surface to granulate and
epithelialize .

4. Pre-operatively constructed denture is lined with soft liner and fixed with
circumferential wiring

Disadvantages of secondary epithelization vestibuloplasty

• Unpredictability of the amount of relapse of the vestibular depth, scarring in the

depth of the vestibule, and problems with adaptation of the peripheral flange area
of the denture to the depth of the vestibule
C- Floor-of-Mouth Lowering Procedures

• The mylohyoid and genioglossus attachments can preclude denture flange

placement lingually.

• In a combination both labial and lingual extension procedures can be performed

to effectively lower the floor of the mouth.

“Indications”
• The buccal and lingual combination procedures eliminate the components
involved in the displacement of conventional dentures and provides a broad base
of fixed tissue for prosthetic support.

• Again, adequate mandibular height of at least 15 mm is required.

• Split-thickness skin grafting is used to cover the denuded periosteum and

facilitate healing.

ADVANTAGES
• These techniques provide a predictable increase in vestibular depth and
attachment of mucosa over the denture-bearing area.

• A properly relined denture can often be worn immediately after the surgery or
after removal of the splint, and impressions for final denture

• Relining or construction can be completed 2 to 3 weeks after surgery

3-LASER VESTIBULOPLASTY:

1.Another option in this situation is laser vestibuloplasty.

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 2.A carbon dioxide laser is used to resect tissue in a supraperiosteal plane to the
depth of the proposed vestibule.

3.A denture with a soft reline is then placed to maintain vestibular depth.

4.Removal of the denture in 2 to 3 weeks reveals a nicely epithelialized vestibule that

extends to the desired depth.

GRAFTING PROCEDURES

1- PRINCIPLES OF SKIN GRAFTS "AUTOGRAFTS"

• Skin should be taken from a hair free area like the upper arm.

• Recipient site should be free from infection and with adequate blood supply.

• Graft should be positioned over periosteum rather than bare bone.

B- Allografting Materials

II-ABSOLUTE HIGHTENING PROCEDURES (RIDGE AUGMENTATION)

A- MAXILLARY AUGMENTATION PROCEDURES

1-RIDGE SPLIT OSTEOPLASTY

GENERAL CONSIDERATIONS

• It is expanding the knife-edged alveolus in a buccolingual direction.

• It helps to restore the crucial endosteal component of the alveolus that is

associated with preservation and response to transligamentary loading and
maintains the alveolus during the dentate state.

• Replacement of this tissue allows for dental implant stimulation of the

surrounding bone that can best mimic this situation and preserve the existing
alveolus and possibly stimulate future bone growth.

INDICATIONS
• Adequate dimensions, should exist that allow for a midcrestal osteotomy to
separate the buccal and lingual cortices.

OPERATIVE PROCEDURES

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 1- A labial incision originates just lateral to the vestibule and continues
supraperiosteally to a few millimeters below the crest of the alveolus.

2- A subperiosteal flap then originates exposing the underlying crest.

3- Copious irrigation accompanies an osteotomy circumferentially anterior to the

maxillary sinus from one side to the other.

4- Mobilization of the labial segment can be achieved with careful manipulation

with an osteotome, taking care to maintain the labial periosteal attachment.

5- An interpositional cancellous graft can then be placed in the resulting defect,

replacing the lost bony mass.

6- Closure of the incision is away from the graft site and usually requires suturing of
the flap edge to the periosteum with subsequent granulation of the remainder of
the exposed tissue bed.

7- Endosteal implants can be placed approximately 3 to 4 months later; waiting this

length of time has been shown to increase overall long-term implant success..

2- ONLAY GRAFTS

INDICATIONS
• In class V ridge resorption clinical loss (alveolar ridge and palatal vault).

• Vertical onlay augmentation of the maxilla is indicated.

• Initial attempts at alveolar restoration involved the use of autogenous rib grafts.

• However, currently cortico-cancellous blocks of iliac crest are the source of

choice.

OPERATIVE PROCEDURES

• In a similar approach to that described above, the crest of the alveolus is exposed
and grafts are secured with 1.5 to 2.0 mm screws.

• Studies show increased success with implant placement in a second stage

procedure rather than using them as sources of retention and stabilization of the
graft and alveolus at the time of augmentation.

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3-INTERPOSITIONAL GRAFTS

ADVANTAGES
• It maintains the blood supply to the repositioned portion of the maxilla and
generally results in more predictability with less extensive resorption
postoperatively.

• Provide stable and predictable results by changing the maxillary position in the
vertical, anteroposterior, and transverse directions

INDICATIONS

• Bone-deficient maxilla, where the palatal vault is found to be adequately formed

but ridge height is insufficient (particularly in the zygomatic buttress and
posterior tuberosity areas and when excessive interarch space exists)

• Correction of anteroposterior and transverse discrepancies between the maxilla

and mandible

• When adequate palatal vault height exists in the face of severe alveolar atrophy
(Class VI) posteriorly, resulting in an increased interarch space.

• Because this method involves a Le Fort I osteotomy, true skeletal discrepancies

between the maxilla and mandible can be corrected at the time of surgery.

• The improvement of maxillary dimensions as a result of interpositional grafts

may obviate the need for future soft tissue recontouring to provide adequate relief
for prosthetic rehabilitation.

• Better success rates for implants when placed in a second-stage procedure.

• This alleviates the need for excessive tissue reflection for implant placement and
allows for a more accurate placement at a later date.

• A relapse of 1 to 2 mm has been demonstrated in interpositional grafts using the

Le Fort I technique with rigid fixation.

DISADVANTAGES
• Need to harvest bone from an iliac crest donor site from an iliac crest donor site
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4. HA AUGMENTATION

• In the maxilla a single midline incision is usually sufficient for adequate access to
both sides of the maxillary ridge, bilateral vertical maxillary incisions in the
canine and premolar areas can be used to improve visibility and access.

• Subperiosteal tunnels are created over the crest of the alveolar ridge, and
preloaded syringes are inserted into the most posterior aspect of these tunnels.

GENERAL CONSIDERATIONS

Characteristically:

• Severely atrophic mandible (Classes V and VI).

• Overclosure, which creates an aged appearance.

• Patients are usually severely debilitated from a functional perspective, and often
present with significant risk for pathologic fracture of the mandible.

ADVANTAGES
• Adds strength to a deficient mandible.

• Improves the height and contour of the available bone

• Adds strength to a deficient mandible.

INDICATIONS
Atrophy of the alveolar ridge area.

Prevention and management of fractures of the atrophic mandible.

5- SINUS LIFT AND INLAY BONE GRAFT

INDICATIONS
Plays a valuable role in the subsequent implant restoration of a maxilla that has atrophied
posteriorly and is unable to accommodate implant placement owing to the proximity of
the maxillary sinus to the alveolar crest.

SURGICAL PROCEDURES

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 1. Incisions are created, followed by subperiosteal exposure of the anterior maxilla.

2. A cortical window 2 to 3 mm above the sinus floor is created with the use of a
round diamond bur down to the membrane of the sinus.

3. Careful infracture of the window with dissection of the sinus membrane off the
sinus floor creates the space necessary for graft placement; the lateral maxillary
wall is the ceiling for the subsequent graft.

4. Corticocancellous blocks or particulate bone may be placed in the resulting

defect.

5. Tears in the membrane may necessitate coverage with collagen tape to prevent
extrusion and migration of particulate grafts through the perforations.

1-SUPERIOR BORDER AUGMENTATION

• Autogenous cortico-cancellous blocks, however, as much as 70% resorption of

iliac crest bone can occur with this technique.
• This is overcome by rigid fixation.
• Tissue-guided regeneration with the use of a membrane is often combined with
the bony augmentation. In some cases implants can be placed at the same time

Disadvantages
• There is a continuous resorption of the grafted site.
• Donor site morbidity.
• Trauma of two surgeries.
• The patient cannot wear a denture for a long time postoperatively.
• Obliterates the vestibule for which a second surgery needs to be done
• Oral mucosa may have dehiscence.

2- INFERIOR BORDER AUGMENTATION

• Inferior border augmentation has been demonstrated using autogenous rib or
composite cadaveric mandibles combined with autogenous cancellous bone.

OPERATIVE PROCEDURES

1. Incisions are placed as inconspicuously as possible from one mandibular angle to

the other and proceed circumferentially 3 to 4 mm below the inferior border of the
mandible and anteriorly to the contralateral side.

2. The superficial layer of the deep cervical fascia is sharply dissected.

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 3. The fascia is then incorporated in the reflection;

4. A nerve tester is used to perform a careful evaluation for the marginal mandibular
branch of the facial nerve.

5. Cadaveric tray filled with autogenous bone before insetting.

6. Reflection superficial to the capsule of the submandibular gland allows dissection

to the inferior border.

7. The inferior border is exposed in a subperiosteal dissection with great care to

avoid intraoral exposure.

8. Cadaveric mandibular adjustment involves relieving the condyles and superior

rami.

9. Thinning the bone to a uniform thickness of approximately 2 to 3 mm.

10. and creating a scalloped tray to incorporate the autogenous bone.

11. bur holes are drilled throughout the specimen to facilitate vascularization.

12. Autogenous bone is then obtained from the ileum, morselized, and placed in the
cadaveric specimen.

13. BMP soaked in collagen is placed in the recipient bed as well as in a layered
fashion over the autogenous graft.

14. The entire specimen is fixed rigidly to the native mandible using screw fixation
posterior to the area of future implant placement and in the mandibular midline,
where implants are usually not placed.

DISADVANTAGES
It does not address abnormalities of the denture-bearing areas:

as the increased inter-arch distance, superior border irregularities, or exposed position of

the mental nerve, which result from mandibular atrophy.

3.PEDICLE OR INTERPOSITIONAL GRAFT:

• It is based on the maintenance of the lingual periosteum.

• The lingual periosteum maintains ridge form and its presence results in minimal
resorption of the transpositioned basalar bone.

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 • Unfortunately, neurosensory complications and collapse of the lingual segment
became significant disadvantages to this technique.

• With the incorporation of mandibular implants and the success of full mandibular
prostheses that are supported by four or five anterior implants between mental
foramina, many of these pedicled and interpositional procedures are in decline
today.
Horizontal Osteotomy or Sandwich Augmentation
cut horizontally and bone from the iliac crest, The lingual side has good blood supply.
Visor Osteotomy or Vertical Osteotomy ‚Visor

4.HYDROXYAPATITE AUGMENTATION (Onlay graft)

• A dense biocompatible material that can be synthetically or obtained from

biologic sources such as coral in granular, or particle, form.

• HA bonds physically and chemically when placed subperiosteally.

SURGICAL PROCEDURES
• A subperiosteal tunnel technique is used, which exposes the entire aspect of the
mandible in the area to be augmented but carefully avoids the neurovascular
bundles.

• A preloaded beveled syringe containing HA is inserted into the most posterior

aspect of the tunnel; HA is injected until the desired contour of the mandible is
obtained

ADVANTAGES
• Donor-site surgery is eliminated

• Most patients can undergo the procedure in an outpatient setting.

• HA being non-resorbable, no postoperative loss of the graft augmenting the

mandible occurs

• Vascular tissue ingrowth around the HA provides an adequate vascular bed for
future soft tissue grafts, if necessary.

DISADVANTAGES
• Difficulty sometimes encountered in containing the material within the
subperiosteal tunnel and in achieving the adequate contour that is often desirable.
Some nerve dysesthesias have also been associated with HA augmentation.

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5. GUIDED BONE REGENERATION ”Osteopromotion””

• The concept of guided regeneration, or osteopromotion, is based on the ability to

exclude undesirable cell types, is desired such as epithelial cells or fibroblasts,
from the area where bone healing is taking place.

• By placing a membrane covering over a bone graft, faster-growing fibroblasts

and epithelial cells can be walled off, allowing bone to grow in a relatively
protected environment.

• Many types of materials have been used as membrane covering either non-
resorbable or resorbable.

TYPES
• Expanded polytetrafluoroethylene (ePFTE) membrane: not resorbable and must
be removed after adequate bone healing occurs.

• Resorbable membranes such as homologous grafts and genetically engineered

materials such as collagen, eliminate the need for a second surgical procedure for
removal.

DENTAL IMPLANTS

ALVEOLAR DISTRACTION OSTEOGENESIS

ADVANTAGES:
• No donor site morbidity is involved,

• The actual distraction process from the latency period through active distraction
and consolidation is actually

• Shorter than Phase I and Phase II bone remodeling and maturation.

• The quality of the bone grown in response to this tension/ stress application is
ideal for implant placement.

• The vascularity and cellularity of the bone promote osseointegration of dental

implants.
• The greatest successes are related to the achievement of vertical graft stability.

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• When distraction is used, the transported alveolar segment does not undergo any
significant resorptive process because it maintains its own viability through an
intact periosteal blood supply.

• The intermediate regenerate quickly transforms into immature woven bone and
matures through the normal processes of active bone remodeling.

• The ideal placement of the new alveolar crest both vertically and buccolingually
determines the success of the distraction.

• The final position of the alveolus determines the exact alignment of the transport
device and how it should be positioned in the bone.

• There are both intraosseous and extraosseous devices that have been designed for
alveolar distraction.

Alveolar distraction osteogenesis

Intraoral device
• After placement of a distraction device, “a latency period “must be observed, the
duration of which is 4 to 7 days, depending on the age of the patient and the
quality of tissue at the transport site.

• The “active distraction period” varies depending on the distance the segment is
transported.

• The rate and rhythm of transport is 1 mm/d in divided segments—0.25 mm four

times a day is the most practical for appliances as well as the patient.

• The “consolidation phase” commences when the distraction is complete. It

should be three times the length of the distraction period.

• The extraosseous appliances provide rigid fixation to promote faster maturation

of the regenerated bone.

• At the conclusion of the consolidation phase, the appliance can be removed.

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