Preprosthetic and Reconstructive Surgery

C H A P T E R 9

Preprosthetic and Reconstructive Surgery

Daniel B. Spagnoli, DDS, PhDSteven G. Gollehon, DDS, MDDale J. Misiek, DMD

Preprosthetic surgery in the 1970s andearly 1980s involved methods to prepare orimprove a patient’s ability to wear com-plete or partial dentures. Most procedureswere centered around soft tissue correc-tions that allowed prosthetic devices to fitmore securely and function more comfort-ably. In severe cases bony augmentationwas incorporated and included such proce-dures as cartilage grafts, rib grafts, alloplas-tic augmentation, visor osteotomies, andsandwich grafts. Patients who were poorcandidates for surgery were often left withless-than-satisfactory results both func-tionally and esthetically.

In the late 1970s Brånemark and col-leagues demonstrated the safety and effica-cy of the implant-borne prosthesis.1 In the1990s implantology, distraction osteogene-sis, and guided tissue regeneration signifi-cantly expanded the capabilities of today’sreconstructive and preprosthetic surgeon.Genetically engineered growth factors willsoon revolutionize our thoughts aboutreconstructive procedures. As a result,more patients are able to tolerate proce-dures because they are given increasedfreedom and satisfaction with regard totheir prosthetic devices and, in many cases,undergo less-invasive techniques.

In spite of the fact that routine dentalcare has improved over the past century,approximately 10% of the population iseither partially or completely edentulousand > 30% of patients older than 65 yearsare completely edentulous.2 Althoughthese figures are predicted to decrease overthe next several decades, the treatment ofpartial and total edentulism will never becompletely eliminated from the oral andmaxillofacial surgeon’s armamentarium.

Since the primary goal in preprosthet-ic reconstructive surgery is to eliminatethe condition of edentulism, one mustconsider the etiology of the edentulousstate when evaluating patients and plan-ning treatment. In many cases the etiologyof a patient’s edentulism has a major bear-ing on the reconstructive and restorativeplan. Edentulism arising from neglect ofthe dentition and/or periodontal diseaseoften poses different reconstructive chal-lenges than does that resulting from trau-ma, ablative surgery, or congenital defects.Although restoration of a functional den-tition is the common goal, each specificetiology poses its own unique set of chal-lenges. The goal of preprosthetic andreconstructive surgery in the twenty-firstcentury is to establish a functional biolog-

ic platform for supportive or retentivemechanisms that will maintain or supportprosthetic rehabilitation without con-tributing to further bone or tissue loss.This environment will allow for a prosthe-sis that restores function, is stable andretentive, preserves the associated struc-tures, and satisfies esthetics.3

Characteristics of Alveolar Bonein the Edentulous PatientNative alveolar bone responds to the func-tional effects (or lack thereof) caused byedentulism. Increased resorption owing totraditional methods of oral rehabilitationwith complete and partial dentures oftenresults in an overall acceleration of theresorptive process. The mandible is affect-ed to a greater degree than the maxillaowing to muscle attachments and func-tional surface area.4 As a result, there isproportionally a qualitative and quantita-tive loss of tissue, resulting in adverseskeletal relationships in essentially all spa-tial dimensions (Figure 9-1).

General systemic factors, such asosteoporosis, endocrine abnormalities,renal dysfunction, and nutritional defi-ciencies, play a role in the overall rate ofalveolar atrophy. Local factors, including

158 Part 2: Dentoalveolar Surgery

jaw function, vascular changes, increasedphysical demands owing to decreasedmandibular plane angle, adverse prosthet-ic loading, mucosal inflammation, vascu-lar changes, and the number and extent ofprevious surgeries involving mucoperi-osteal elevation, also contribute to pro-gressive alveolar bone loss.5

Although the factors contributing tobone loss and the resulting patterns arewell understood, the rate of bone loss

varies significantly from individual toindividual. The consistent factor is theoverall duration of the patient’s edentu-lous state.

Functional Effects ofEdentulism The maxillomandibular relationship isaltered in all spatial dimensions as a resultof the loss of physiologic function andteeth. There is a progression toward

decreased overall lower facial height, lead-ing to the typical overclosed appearance,decreased alveolar support for traditionalprostheses, encroachment of muscle andtissue attachments to the alveolar crestresulting in progressive instability of con-ventional soft tissue–borne prostheticdevices, neurosensory changes secondary toatrophy, and an overall reduction in sizeand form in all three dimensions. Thesechanges result in an overall decrease in fitand increase in patient discomfort with theuse of conventional dentures. The pro-longed effects of edentulism compoundedwith systemic factors and functional physi-cal demands from prosthetic loading pro-duce atrophy that, in severe cases, places thepatient at significant risk for pathologicfracture. As a result of the above effects, agoal-oriented approach to treatment is themost appropriate. The overall objectivesinclude the following6: (1) to eliminate pre-existent or recurrent pathology; (2) to reha-bilitate infected or inflamed tissue; (3) toreestablish maxillomandibular relation-ships in all spatial dimensions; (4) to pre-serve or restore alveolar ridge dimensions(height, width, shape, and consistency)conducive to prosthetic restoration; (5) toachieve keratinized tissue coverage over allload-bearing areas; (6) to relieve bony andsoft tissue undercuts; (7) to establish prop-er vestibular depth and repositioning ofattachments to allow for prosthetic flangeextension if necessary; (8) to establishproper notching of the posterior maxillaand palatal vault proportions; (9) to pre-vent or manage pathologic fracture of theatrophic mandible; (10) to prepare the alve-olar ridge by onlay grafting, corticocancel-lous augmentation, sinus lift, or distractionosteogenesis for subsequent implant place-ment; and (11) to satisfy facial esthetics,speech requirements, and masticatory chal-lenges. To satisfy these goals, a treatmentplan directly addressing each existing con-dition is indicated. Such a plan shouldinclude correction of maxillomandibularrelationship, restoration of ridge form and

FIGURE 9-1 The diagrams show patterns and varying degrees of severity of mandibular atrophy.A, Mandible shows minimal alveolar bone resorption. B, Cross-section of large alveolar ridgeincluding mucosal and muscular attachments. C, Mandible shows severe loss of alveolar bone thathas resulted in residual basal bone only. D, Cross-section shows resorbed alveolar ridge, with mus-cular attachments. Adapted from Tucker MR. Ambulatory preprosthetic reconstructive surgery. In:Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles of oral and maxillofacial surgery.Vol 2. Philadelphia (PA): JB Lippincott Company; 1992. p. 1104.

A B

C D

Preprosthetic and Reconstructive Surgery 159

soft tissue relationship including histologictype and condition, bone and/or soft tissuegrafting/repositioning, options regardingimplant-supported or -stabilized prosthetictreatment, immediate versus delayedimplant placement, preservation of existingalveolar bone with implants, and correctionor minimization of the effects of combina-tion syndrome in cases involving partiallyedentulous patients.

Prior to developing a plan one mustconsider the amount and source of boneloss. Common causes of primary boneloss include trauma, pathology such asperiodontal disease, destructive cysts ortumors, and bone loss associated withextraction and alveoloplasty. Secondarybone loss, if not prevented, can follow allof the primary types listed above. Sec-ondary maxillary/mandibular bone lossis an insidious regressive remodeling ofalveolar and even basal bone that is asequela of tooth loss. This secondaryprocess is referred to as edentulous boneloss and varies in degree based on anumber of factors. The pathophysiologyof edentulous bone loss relates to anindividual’s characteristic anatomy,metabolic state, jaw function, and prioruse of and type of prosthesis. Anatomi-cally, individuals with long dolicho-cephalic faces typically have greater ver-tical ridge dimensions than do those withshort brachycephalic faces. In addition,those with shorter faces are capable of ahigher bite force. Metabolic disorderscan have a significant impact on apatient’s potential to benefit fromosseous reconstructive surgery. Nutri-tional or endocrine disorders and anyassociated osteopenia, osteoporosis, andespecially osteomalacia must beaddressed prior beginning bone recon-struction.5 Mechanical influences on themaxilla and mandible have a variableeffect on the preservation of bone. Thenormal nonregressive remodeling ofbone essentially represents a balancebetween breakdown and repair that

maintains bone osteons, the functionalunit of bone, and consequently the via-bility of bone shape and form. Bonerequires stimulation often referred to as“the minimum essential strain” to main-tain itself. Both insufficient strain andexcessive loads can lead to regressiveremodeling of bone, with the classicexample being denture compressionleading to an anterior-posterior andtransverse deficient maxilla opposing awide mandible that is excessive in itsanterior-posterior dimension.

Residual ridge form has beendescribed and classified by Cawood andHowell7 (Figures 9-2 and 9-3) as follows:

• Class I—dentate• Class II—postextraction• Class III—convex ridge form, with

adequate height and width of alveolarprocess

• Class IV—knife-edge form with ade-quate height but inadequate width ofalveolar process

• Class V—flat-ridge form with loss ofalveolar process

• Class VI—loss of basal bone that maybe extensive but follows no predictablepattern

Modifications to this classification thatmay be relevant to contemporary recon-structive methods include subclassifica-tions in II and VI: Class II—no defect,buccal wall defect, or multiwall defect ordeficiency; and Class VI—marginal resec-tion defect or continuity defect.

Medical ConsiderationsDuring the patient evaluation process,particular attention to the patient’s chiefcomplaint and concerns is imperative; athorough understanding of the past med-ical history is mandatory in the treatmentand evaluation of any patient. A currentor previous history regarding thepatient’s success or failure at maintainingprevious prosthetic devices is also neces-sary. Careful attention to patient’s func-

tional, cognitive, and physical ability toparticipate with the reconstructive plan iscrucial to the success of future restora-tions and overall patient satisfaction. Theevaluation process should include a com-prehensive work-up of the patient’spredilection for metabolic disease,including serum calcium, phosphate,albumin, alkaline phosphatase, and calci-tonin levels.5 Decreased renal functionand the presence of a vitamin D deficien-cy should also be ruled out. The mainte-nance of bone mass requires a balancedcalcium metabolism, a functionalendocrine system, and physiologic load-ing of bone tissue. Secondary medicalcomplications affecting edentulouspatients include candidiasis, hyperkerato-sis, fibrous inflammatory hyperplasia,dysplasia, papillomatosis, breathingchanges, and diet compromise away fromnatural foods high in fiber and toward anincrease in processed foods.

Hard and Soft Tissue ExaminationA problem-oriented physical examinationshould include evaluation of the maxillo-mandibular relationship; existing alveolarcontour, height, and width; soft tissueattachments; pathology; tissue health;palatal vault dimension; hamular notch-ing; and vestibular depth. Identification ofboth soft tissue and underlying bone char-acteristics and/or deficiencies is essentialto formulate a successful reconstructiveplan. This plan should be defined and pre-sented to the patient both to educate thepatient and to allow him or her to play arole in the overall decision-making processwith all members of the dental team.

The soft tissue evaluation shouldinvolve careful visualization, palpation,and functional examination of the overly-ing soft tissue and associated muscleattachments (Figure 9-4). Retraction ofthe upper and lower lips help one identifymuscle and frenum attachments buccally.A mouth mirror can be used lingually to


tent the floor of mouth to evaluate themylohyoid–alveolar ridge relationship.Careful palpation with manipulation ofboth upper and lower alveolar ridges is thebest diagnostic determinant of loose and

excessive soft tissue. One must be aware ofoccult bony abnormalities obscured bysoft tissue excess, especially in cases whereadequate alveolar ridge height and width isimperative for implant placement (Figure

9-5). Such abnormalities can lead toembarrassing and unexpected changes inthe restorative plan at the time of mucope-riosteal reflection of the overlying soft tis-sue. If conventional prosthetic restorationsare planned, attention to bony and soft tis-sue undercuts that oppose the prostheticpath of insertion must be addressed. Crit-ical attention should be given to deficien-cies in the palatal vault or buccal/lingualvestibule, defects in the alveolar ridge, andthe presence of buccal, palatal, or lingualexostoses. During this evaluation process,final decisions should be made regardingthe prognosis of any existing teeth andtheir role in the overall rehabilitation andcontribution to the long-term success ofthe treatment plan. Finally, careful neu-rosensory evaluation of the patient withsevere regressive remodeling may play asignificant role in the determination offuture grafting or repositioning proce-dures aimed at maintaining proper neu-rosensory function in conjunction withprosthetic rehabilitation.

Radiographic EvaluationTo date, the panoramic radiograph pro-vides the best screening source for theoverall evaluation and survey of bonystructures and pathology in the maxillofa-cial skeleton. From examination radi-ographs, one can identify and evaluatepathology, estimate anatomic variationsand pneumatization of the maxillarysinus, locate impacted teeth or retainedroot tips, and gain an overall appreciationof the contour, location, and height of thebasal bone, alveolar ridge, and associatedinferior alveolar neurovascular canal andmental foramina.8

Calibration of radiographs for magnifi-cation is necessary to determine the spatialdimensions needed to plan implant restora-tions adjacent to neurovascular structuresor the maxillary sinus, to determine defectsize and shape in distraction osteogenesis,and to predict the necessary dimensions ofplanned augmentation materials.

Alveolar

Basal

Greater palatine foramen


Widest part ofalveolar process

Widest part of alveolar process

Crest of alveolar process

Crest of alveolarprocess

Incisive foramen

0

10

20

10 mm 0 mm II III IV V VI

Incisive foramen

Res

orpt

ion

(mm

)

0

10

10 mm 0 mm II III IV V VI


Res

orpt

ion

(mm

)

FIGURE 9-2 Maxillary horizontal measurements (A). Classification of resorption of maxillary alveolar ridge:anterior (B) and posterior (C). Adapted from Cawood JI, Howell RA.7

A

B

C


Posteroanterior and lateral cephalo-metric radiographs can be used to evaluateinterarch space, relative and absolute skele-tal excesses or deficiencies existing in themaxilla or mandible, and the orientation ofthe alveolar ridge between arches. Theseare exceptionally useful when the presenceof skeletal discrepancies may necessitateorthognathic correction to provide accept-able functional relationships for prostheticrehabilitation. Cephalometric analysis incombination with mounted dental modelshelps one establish the planned path ofinsertion of future prosthetic devices aswell as identify discrepancies in interarchrelationships that affect the restorative plan(Figure 9-6).9

In recent years computed tomography(CT) has played an increased role in thetreatment planning of complex cases.Detailed evaluation of alveolar contour,neurovascular position, and sinus anato-my is available for the subsequent plan-ning of advanced implant applications.Zygomatic implants that obviate the needfor sinus lifting can be used in casesinvolving edentulous atrophic maxillarysinuses (Figure 9-7). Careful evaluation ofthe path of insertion is easily accom-plished using coronal CT examination ofthe maxillary sinuses. CT can also providethe clinician with information regardingbone quantity and volume as well as den-sity (Figure 9-8).

In many cases the combination ofimaging modalities and mounted modelswith diagnostic wax-ups can be helpful indetermining the reconstructive plan. Theseelements are also useful in the fabrication ofsurgical stents guiding implant placementor grafting procedures. Surgical stents fab-ricated from CT-based models combineesthetic and surgical considerations; bridgethe gap between the model surgery and theoperation; and allow cooperation betweenthe surgeon, laboratory technician, peri-odontist, prosthodontist, and orthodontist,which results in a cost-effective prostheticreconstruction with improved esthetic

results (Figure 9-9). In addition, accuracyof the surgical procedure can be greatlyincreased with an overall decrease in theduration of the procedure.

Treatment Planning ConsiderationsThe conventional tissue-borne prosthesishas given way to implant-borne devicesthat have proven superior in providingincreased patient function, confidence,and esthetics. Preprosthetic surgicalpreparation of areas directly involved withdevice support and stability are of prima-ry importance and should be addressedearly in the treatment plan.

Overlying soft tissue procedures neednot be attempted until satisfactory posi-tioning of underlying bony tissues is com-plete. As a general rule, one should alwaysmaintain excessive soft tissue coverage

where available until the final bony aug-mentation is complete. Complicationssuch as dehiscence, loss of keratinizedmucosa, and obliteration of vestibulardepth can be avoided if respect is given tooverlying soft tissue. Once bony healing iscomplete, if the overlying tissue is clearlyexcessive, removal of the excess soft tissuecan proceed without complication. Usingthe classification of edentulous jawsaccording to Cawood and Howell,7 thereconstructive surgeon can plan treatmentfor his or her patients accordingly.

Many excellent reconstructive plansachieve less-than-satisfactory resultsbecause of inadequate anesthetic manage-ment of the patient during the procedure.Although many procedures can be accom-plished under local anesthesia or sedation,the clinician must have a low threshold toprovide general anesthesia in a controlled

25

35

15

5

15 mm5 mm

III III IV V VI VII VIII

25

35

15

5

15 mm5 mm

25

35

15

5

15 mm5 mm

Symphysis

Parasymphysis

Molar

Res

orpt

ion

(mm

)

FIGURE 9-3 Modified Cawood and Howell classification of resorption. The thicker line illustrates the amountof attached mucosa, which decreases with progressive resorption. Adapted from Cawood JI, Howell RA.7


operative setting to allow for appropriatemanipulation of the surgical site to achievethe necessary goals of the surgical proce-dure. Patient desires, health issues, surgeoncomfort, and the magnitude of the defor-mity should all be considered when mak-ing decisions regarding anesthetic type.

The loss of maxillary and mandibularbone can have mild to severe effects on anindividual’s well-being. Interestingly, thesize of the defect does not always correlatewith the level of debilitation perceived bythe patient. Individuals missing a singleanterior tooth with an associated buccalwall defect can feel quite compromised,whereas, although it is rare, we haveencountered totally edentulous patientswho live and function without even aremovable denture. This variability under-scores the need for the dental team tounderstand the patient’s chief complaintand desired restorative goals. After obtain-ing a medical dental history and diagnos-tic database, time spent educating thepatient about his or her problem may helpthe patient refine goals and make it easierto develop a satisfactory treatment plan.Since acceptable prosthetic reconstructioncan be achieved with a variety of treat-ments that vary in complexity, invasive-ness, time to completion, simplicity of

maintenance, functional attributes, esthet-ic attributes, and cost, it is reasonable todevelop more than one treatment planthat can address the patient’s needs.

The patient’s overall health status, com-pliance potential, patience, and ability tomaintain the final prosthesis/prosthesesmust be considered when planning recon-structive preprosthetic surgical proceduresas well as future prosthetic rehabilitation.Moreover, a multidisciplinary approachinvolving the patient’s input is imperative forlong-term success and patient satisfaction.3

Principles of Bone RegenerationThere are many approaches available forreconstructing a deficiency or defectiveosseous anatomy of the alveolar portionsof the facial skeleton. These include bio-logically viable autogenous bone grafts,nonviable homologous allogeneic or het-erogeneic bone implants, recombinanthuman bone morphogenetic protein-2(rhBMP-2), and tissue regeneration bydistraction histogenesis. These techniquescan be used alone or in combination and

A B

FIGURE 9-4 A, Example of mandible with muscular attachments at or near the crest of the ridge. Also notethe absence of fixed keratinized tissue over the alveolar ridge area. B, Example of maxilla with inadequatevestibular depth anteriorly, frenal attachments near the crest of the alveolar ridge, and flabby soft tissue overthe alveolar ridge crest. Reproduced with permission from Tucker MR. Ambulatory preprosthetic recon-structive surgery. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles of oral and maxillofa-cial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company; 1992. p. 1107.

FIGURE 9-5 A, Evaluation of the bone in themandible reveals contour irregularities of theanterior region and a vertical alveolar deficiencyin the posterior mandible area bilaterally. B, Grossirregularities are evident along the maxillaryalveolar ridge, with bilateral contour defects in thecanine-premolar area. C, Mounted casts are usedto evaluate mandibular alveolar ridge deficiencyand anteroposterior skeletal deficiency of themandible. Reproduced with permission fromTucker MR. Ambulatory preprosthetic reconstruc-tive surgery. In: Peterson LJ, Indresano AT, Mar-ciani RD, Roser SM. Principles of oral and max-illofacial surgery. Vol 2. Philadelphia (PA): JBLippincott Company; 1992. p. 1106.

A B

C


often are enhanced by the application ofadjunct procedures such as rigid fixationand guided bone regeneration. The choiceof a reconstructive technique is influencedby many variables, including the location,ridge relationships, dimensions of thedefect, dimensions of underlying bonestock, soft tissue availability and viability,and esthetic goals.

Beyond choosing a reconstructivetechnique, one must also consider inher-

ent properties of facial bone and its natur-al growth and remodeling characteristics.For bone to grow or regenerate in directpressure areas, it must go through anendochondral replacement process such asthat in active long bones or the mandibu-lar condyle. Areas of the skeleton that areunder pressure must be covered by carti-lage—a tissue adapted to this function

because it grows interstitially; is minimal-ly calcified, avascular, turgid, and nour-ished by diffusion; and does not require amembrane for nutrition. In contrast, bonecannot withstand significant pressurebecause of compression closure of the vas-cular bed in the periosteum. Because bonematrix is calcified, it must be vascularizedto grow, regenerate, or be sustained. In

FIGURE 9-6 A, Panoramic radiograph shows anapparently adequate alveolar ridge height. B, Lat-eral cephalometric radiograph of the same patientshows a concavity in the anterior area of the alve-olar ridge, which produces a knife-edge ridgecrest. This type of alveolar ridge deformity cannotbe fully appreciated except on a cephalometricradiograph. Reproduced with permission fromTucker MR. Ambulatory preprosthetic recon-structive surgery. In: Peterson LJ, Indresano AT,Marciani RD, Roser SM. Principles of oral andmaxillofacial surgery. Vol 2. Philadelphia (PA):JB Lippincott Company; 1992. p. 1107.

A

B

FIGURE 9-7 A, Preoperative computed tomog-raphy (CT) scan of the maxillary sinuses toallow for angulation and size measurement of atransantral implant restoration. B, The informa-tion gained from the CT evaluation is applied tothe surgical placement of implants. C, Postoper-ative panoramic radiograph of the implantplacement traversing the maxillary sinus.

A

B

C

FIGURE 9-8 Computed tomography-based imaging used to evaluatebone density, quality, contour, and volume. This information, whichhas cross-sectional tomographic and three-dimensional components,can be used to plan treatments for complex cases of implant place-ment. (Courtesy of SimPlant Technologies)


addition, calcification of the matrix pre-cludes interstitial growth, so bone can onlygrow by the appositional activity of itsmembranes. Periosteum has a dense con-nective tissue component and is struc-turally adapted to transfer tensile forcesthat are generated by muscles, tendons,and ligaments to bone.

The majority of the facial skeleton isnot under load during development; thusit does not require an endochondral phase,so it develops by an intramembranousprocess. In the natural state, alveolar boneis protected from load by the dentitionand is actually stimulated by strain forcestransferred to the alveolus via the peri-odontal ligament. Although technology todate has not been able to exactly replicatethis interface, osseointegrated implantshave a similar protective effect on underly-ing bone, native or reconstructed, and thusshould be a component of all alveolarbone reconstructive plans.

Another aspect of facial bone growthand development relevant to reconstruc-tion that needs to be clearly understood isthe regional differences in periosteumactivity that exist in association with facialbones. It is a misconception that the cor-tices of growing facial bones are producedonly by periosteum. In fact, at least half ofthe facial bone tissue is formed by endos-teum, the inner membrane lining themedullary cavity. Of great significance tothe placement of alveolar ridge or alveolardefect bone grafts are the findings thatabout half of the periosteal surfaces of facialbones are resorptive in nature and half aredepository. These properties exist becausefacial growth is a complex balance betweendeposition and resorption that adds to thesize and shape of a bone while it is beingdisplaced to achieve its final position andrelationships to the bones of the facial cra-nial skeleton. One can study the works anddiagrams of Enlow and colleagues to gain abetter understanding of these concepts andthe regional variations of naturally resorp-tive and depository surfaces of the facialskeleton.10 This understanding should helpone better determine the most efficaciouslocation for graft placement. For example,the anterior surface of the maxillary andmandibular alveolar ridges are resorptiveand thus are best treated by the placementof interpositional grafts in association withthe endosteal aspects of these bones, as seenin Figure 9-10. Interestingly, the periosteallining of the maxillary sinus is also mostlyresorptive. Successful bone grafting via thesinus lift technique has been demonstratedby numerous authors using a variety ofgraft techniques. It has been our experiencethat sinus lift grafts of autogenous cancel-lous bone, and bone induced to grow byrhBMP-2, secondarily treated with osseo-integrated implants remodel over time. A follow-up of > 5 years of some of ourpatients has shown that the grafts becomescalloped over the surfaces of the implants,similar to the relationship seen when natur-al roots extend above the floor of a pneu-

matized sinus. This finding suggests thatthe capacity for remodeling by theperiosteal membrane exists even after theface is mature, and that viable bone estab-lished by autogenous grafts or rhBMP-2-mediated induction responds to thisprocess.11

Another concept of facial growth thatbears relevance to contemporary methodsof reconstruction is the functional matrixconcept that has largely been described byMoss.12 This concept states that bone,itself, does not regulate the rate of bonegrowth. Instead, it is the functional softtissue matrix related to bone that actuallydirects and determines the skeletal growthprocess. The vector and extent of bonegrowth are secondarily dependent on thegrowth of associated soft tissue. Bone, byvirtue of its matrix maturity, gives feed-back to this process by either inhibiting itor allowing it to accelerate. Thus, the vol-ume of bone generated is based on geneticproperties of the soft tissue and a mechan-ical equilibration between bone and itssoft tissue matrix. These principles are vis-ited when distraction forces are applied toosteotomized bone.

In 1989 Ilizarov forwarded the theoryof tension-stress applied to bone as amechanism of lengthening bone.13,14 Hestated that controlled mechanicallyapplied tension-stress allows bone and softtissue to regenerate in a controlled, reli-able, and reproducible manner. During thelatency phase of distraction, there is aperiosteal and medullary revascularizationand recovery. Simultaneously a relativelyhypovascular fibrous interzone developsthat is rich in osteoprogenitor cells andserves as a pseudo–growth plate. Adjacentand connected to the interzone are areas ofhypervascular trabeculae aligned in thedirection of the distraction. Osteoprogen-itor cells in the interzone differentiate intoosteoblasts and line the trabeculae. As dis-traction progresses, appositional bonegrowth enlarges the trabeculae. Thisunderscores the idea that mechanical

FIGURE 9-9 A, Computer-generated surgicalstent for implant placement. B, Clinical photo-graph of implants placed with the use of a com-puter-generated surgical stent.

A

B


stress applied to the soft tissue matrix ofosteotomized bone can reactivate thesenative growth processes.

It is interesting to note that if the dis-traction device lacks sufficient mechanicalstability or if the rate of distraction pro-gresses too rapidly, the tissue establishedmay mature very slowly or not at all. On theother hand, if distraction progresses tooslowly, the regenerate may mature prema-turely or there may be increased pain duringthe procedure. We have found that if there isrecurrent pain associated with the activa-tion of a distractor, a slight increase in therate of distraction usually reduces the pain.In many ways distraction histogenesis reca-pitulates the process of native bone growthdirected by the influence of the soft tissuematrix. Premature maturation of the matrixincreases resistance to distraction necessitat-ing increased distraction force and the per-ception of pain by the patient. This suggeststhat even the feedback role of the bonematrix is active during this process. In most

cases the net result of distraction histogene-sis is the formation of a bone ossicle that isvascular and rich in osteolysis, has a shapesimilar to the native bone, and has anappropriate soft tissue envelope. Often dis-traction histogenesis alone is sufficient toregenerate deficient alveolar ridge anatomy.In other cases distraction can be used inassociation with bone grafting, especiallywhen the associated bone stock is of less-than-ideal shape or volume. In some cases,particularly in the posterior mandible, thedistraction osteotomy can be extendedbeyond the area of intended implants sothat the distraction process actually growsthe bone needed for the graft. Bone graftsplaced adjacent to regenerate typicallymature very rapidly owing to the vasculari-ty, cellularity, and high concentration ofnatural BMP in regenerate.

Bone GraftsBone graft principles are discussed inChapters 12, “Bone Grafting Strategies for

Vertical Alveolar Augmentation,” 39,“Bony Reconstruction of the Jaws,” 40,“Microvascular Free Tissue Transfer,” and43, “Reconstruction of the Alveolar Cleft.”Nonetheless, some of the characteristics ofgrafts and bone implants pertinent to pre-prosthetic surgery are examined here. Byfar the most common graft type is the freeautogenous viable bone graft. Since thesegrafts are from the patient, they do notelicit an immune-rejection response.Common areas for procurement includethe maxilla, mandible, cranium, tibialplateau, iliac crest, and rib. The shape,form, and volume of the graft procuredare linked to the defect to be reconstruct-ed. These grafts are used as corticocancel-lous blocks or particulate cancellous graftscompacted and shaped by various mem-branes or trays. In many instances purelycancellous blocks or cancellous particulatebone is used again with membranes or traysor sandwiched in unloaded osteotomies ordefects. A third form includes purely corti-cal grafts, primarily used to form a wall orstrut in association with a defect that issimultaneously packed with particulatecancellous bone. Cortical grafts revascu-larize very slowly and have minimal to nocell survival; thus, they are not ideal forimplant placement.15

Cancellous grafts have the greatestconcentration of osteogenic cells, and theparticulate form of these grafts has thegreatest cell survival owing to better diffu-sion and rapid revascularization. Thesegrafts must completely undergo a two-phase mechanism of graft healing.16

Osteoblasts that survive transplantationproliferate and form osteoid. This processis active in the first 2 to 4 weeks, and thedefinitive amount of bone formed is relat-ed to the quantity of osteoid formed inphase one. Phase two starts around the sec-ond week after grafting, and although itpeaks in intensity at approximately 4 to 6 weeks, it continues until the graftmatures. The initiation of phase two ismarked by osteoclastic cell activity within

FIGURE 9-10 Growth and remodeling field of the craniofacial skeleton. Resorptive fields are shadedand depository fields are free of shading.


the graft. Osteoclasts remove mineral,forming Howship’s lacunae along the tra-beculae. This resorptive process exposesthe extracellular matrix of bone, which isthe natural location of the bone-inductiveglycoprotein BMP. Exposure of BMP initi-ates an inductive process characterized bychemotaxis of mesenchymal stem cells,proliferation of cells in response to mito-genic signals, and differentiation of cellsinto osteoblasts.17 Inducible cell popula-tions may be local or distant from the graftsite. Examples of local cell populations thatmay contribute to the graft include osteo-progenitor cells in the graft endosteum,stem cells of the transplanted marrow, orcells in the cambium layer of adjacentperiosteum. Additional inducible pluripo-tent cells may arrive at the graft site withbudding blood vessels. During phase twothere is progressive osteoclastic resorptionof phase one osteoid and nonviable grafttrabeculae; this continues to expose BMP,which perpetuates the differentiation ofosteoblasts, leading to the formation ofmature vascular osteocyte-rich bone.

This two-phase bone graft healingprocess is the one that most reliably andquickly can regenerate bone with charac-teristics suitable for implant placement.When choosing a bone graft, one mustconsider its ultimate purpose; since mostgrafts associated with preprostheticsurgery are designed to support implants,these grafts must provide the biologicenvironment necessary for osseointegra-tion. Osseointegration is a biologicprocess, and its long-term success requiresvascular osteocyte-rich bone.

Another adjunct to preprostheticbone reconstruction is the use of allo-geneic bone. Since these grafts are nonvi-able, they are technically implants. Allo-geneic bone is procured in a fresh sterilemanner from cadavers of geneticallyunrelated individuals. American Associa-tion of Tissue Bank standards require thatall donors be screened, serologic tests beperformed, and all specimens be sterilized

and verified by culture prior to release.Processing of allogeneic bone is designedto achieve sterility and reduce immuno-genicity. Bone cell membranes have bothclass I and II major histocompatibilitycomplexes on their surfaces. These are themain sources of immunogenicity withinallogeneic bone grafts. Allogeneic boneimplants are processed to remove theorganic matrix and only retain the miner-al components; architecture is generallyconsidered to be nonimmunogenic.Implants retaining both mineral andorganic components or demineralizedimplants with only the organic compo-nent are washed and then lyophilized toreduce immunogenicity. In most casesthis process reduces the immune responseto clinically insignificant levels. In addi-tion to this treatment, allogeneic bankbone is irradiated with γ-rays, a processthat assures sterility and further reducesantigenicity. Unfortunately, this requires 2 to 3 Mrad per radiation dose, whichdestroys BMP and thus the ability of theseimplants to be osteoinductive.18

Common applications of allogeneicbone implants for preprosthetic surgeryinclude mandibles, iliac crest segments, andcalcified or decalcified ribs that can be pre-pared and used as biologic trays for the place-ment and retention of cancellous bone grafts.Additional uses include mineral matrix ordemineralized particulate implants used asosteoconductive graft extenders or forextraction-site shape and form preservation.Research on particle size suggests that parti-cles in the range of 250 to 850 µm are themost useful.Although the current carrier sys-tem used for rhBMP-2 bone induction is acollagen membrane, Becker and colleaguesshowed that BMP extracted from the bonecan be added to particulate 200 to 500 µmdemineralized freeze-dried bone allograftsobtained from four American tissue banks;this resulted in the transformation of non-inductive particles to particles with osteoin-ductive properties.19 Heterogeneous bonegrafts, or xenografts, are specimens trans-

ferred from one species to another. Implantsof this type contain an organic componentthat would elicit a strong immuneresponse; thus, they are not used in con-temporary practice. Bovine implants thathave undergone complete deproteinizationto remove the organic component havebeen shown to be nonimmunogenic. Theseimplants remain as an inorganic mineralscaffold that can be used for their osteocon-ductive properties as graft extenders or forextraction-site preservation.

The above discussion has identifiedtwo reconstructive methods that can reli-ably restore bone with the characteristicsnecessary for maintaining osseointegratedimplants. These methods include autoge-nous cancellous bone grafts and distrac-tion histogenesis alone or with graft sup-plementation. A third approach alluded toabove is the use of rhBMP-2.20 rhBMP-2has been studied extensively in animalmodels, and human clinical trials in theareas of orthopedic surgery, spine surgery,and maxillofacial surgery have been ongo-ing during the past decade. rhBMP-2/ACS,which is the clinical combination of BMPwith an absorbable collagen sponge carrierplaced with a metal cage, received US Foodand Drug Administration (FDA) approvalfor spine fusion surgery in 2002. To date,US human clinical trials related to maxillo-facial reconstruction include complete fea-sibility studies, safety and efficacy studies,and dose-response studies involving eitheralveolar ridge buccal wall defects or poste-rior maxillary alveolar bone deficiency atsinus lift bone sites. Safety has been estab-lished, and a dose of 1.5 mg/mL, the samedose used for spine fusion, was chosen formaxillofacial applications after completionof a sinus lift dose-response study. A 20-center study of pivotal sinus lifts is nearcompletion; its dual end points include theevaluation of bone regeneration at endpoint one and the evaluation of 2-yearloaded implant data at end point two. Todate, a time frame for submitting this datafor FDA approval has not been established.


At our center 9 patients were enrolled inthe pivotal study, with 21 evaluated sinuslifts sites. All study sites were confirmedbefore treatment by CT scan to have 5 mmor less of natural bone. Six months aftergraft placement, comparative CT scanswere obtained from all study sites and thepresence of graft and graft dimensionswere assessed. All sites had enough bonefor placement of implants at least 4 mm indiameter and 12 mm high. Trephine-procured biopsy specimens obtained at thetime of implant placement were used toverify the presence of homogeneous vascu-lar osteocyte-rich bone with a normal tra-becular and marrow-space architecture. Atour center all 21 implants have remainedfunctionally loaded for at least 36 months.These results are preliminary and may notreflect the findings of all centers. Similar tonatural BMP, rhBMP-2/ACS has beenshown to stimulate the cascade of bone-regeneration events, including chemotaxis,induction of pluripotent cells, and prolifer-ation. Our results to date show that thistechnique has the potential to significantlyenhance patient care by providing anunlimited supply of nonimmunogenicsterile protein that can induce de novo

bone formation. Bone regenerated by thisprocess has characteristics of bone desir-able for implant placement (Figure 9-11).

Hopefully, the discussion of hostproperties and regenerative or graft tech-niques in this section will aid one in deter-mining the best graft for sites to be recon-structed as part of a preprosthetic surgicaltreatment plan.

Hard Tissue Recontouring

Current Trends in Alveolar PreservationAs dental implants continue to grow inpopularity and play a major role in pros-thetic reconstruction, the need for tradi-tional bony recontouring at the time ofextraction has been de-emphasized. Cur-rent trends tend to lean toward preserva-tion of alveolar bone and overlyingperiosteal blood supply, which enhancesand preserves future bone volume. Alterna-tives to traditional alveoloplasty haveemerged in an effort to maintain boneheight and volume for the placement ofimplants to provide a stable platform forprosthetic reconstruction. Such alternativesinclude orthodontic guided tooth/root

extraction, conservative extraction tech-niques using periosteotomes to maintainalveolar continuity, immediate grafting ofextraction sites, relief of undercuts usingbone grafts or hydroxylapatite (HA) aug-mentation, and guided tissue regeneration.In cases where bony abnormalities orundercuts require attention, selective alveo-lar recontouring is indicated.

Advances in implant technology haveplaced a greater emphasis on planning foralveolar ridge preservation. Beginning atthe initial consultation, all extraction sitesshould be considered for implant recon-struction. Regardless of the reason forextraction (ie, pulpal disease, periodontaldisease, or trauma), every effort should bemade to maintain alveolar bone, particu-larly buccal (labial) and lingual (palatal)walls. However, even with alveolar bonemaintenance, there can be unpredictableresorption in a short period of time.21

Multiple adjacent extractions may alsocontribute to extensive alveolar bone lossprecluding implant reconstruction.

Historically, techniques for alveolarridge preservation were developed tofacilitate conventional denture prostheses.HA materials were the first materials not

FIGURE 9-11 Stages of bone maturation are evident in these photomicrographs of autogenous bone grafts, autogenous grafts with bone morphogenetic protein(BMP), and distraction-regenerate. A, Autogenous tibial plateau with no filler was placed in this sinus lift site with < 5 mm of native bone, procured by trephine,and sampled at 6 months after the graft. Viable osteocyte-rich bone trabeculae are evident with normal marrow spaces with a few residual foci of nonviable graft(×100 original magnification; hematoxylin and eosin stain). B, BMP was placed in an identical site to that shown in Figure A (×75 original magnification:hematoxylin and eosin stain). This specimen reveals viable trabeculae with normal haversian canals, de novo bone growth, and no nonviable components.C, Regenerate was procured at the time of the distractor removal at this mandibular distraction site. The regenerated growth represents woven bone with somemature haversian systems (×128 original magnification: hematoxylin and eosin stain).

A B C


plagued by host rejection and fibrousencapsulation. Previously, the use of poly-methyl methacrylate, vitreous carbon,and aluminum oxide had led to poorresults. Root form and particulate HAboth were adapted and successful in pre-serving alveolar ridge form.22 The obviouslimitation with nonresorbable materials isthat they preclude later implant recon-struction. Tricalcium phosphate is aresorbable ceramic that was originallythought would solve this problem, but itproved not to be truly osteoconductive asit promoted giant cell rather than osteo-clastic resorption.23 This resulted in limit-ed osteogenic potential. Another alloplastthat has been used for this purpose isbioactive glass, which consists of calcium,phosphorus, silicone, and sodium, but,again, the biologic behavior of thereplacement bone was never felt to be sat-isfactory for implant reconstruction.24

The gold standard for use for bonyreconstruction anywhere has always beenautogenous grafts. The dilemma with auto-genous grafts involves donor site morbidi-ty: whether from an intraoral or extraoralsource, the additional surgery and inconve-nience to the patient has precluded its gen-eral use. To avoid the use of a donor site,various allogeneic bone preparations havebeen advocated. Stringent tissue bank regu-lations have provided the public withgreater confidence in the use of these mate-rials. Anorganic bone has most recentlybeen adapted for use in alveolar ridgepreparation. Two products are currentlyavailable commercially. The first is axenograft derived from a bovine source.The main advantage of this type of materi-al is that it is available in an almost unlim-ited supply and is chemically and biologi-cally almost identical to human bone.Minimal immune response is elicitedbecause of the absence of protein; however,the resorption rate of bovine cortical boneis slow. In both animal and human studies,remnants of nonvital cortical bone havebeen shown to be present 18 months or

longer in the grafted site.25 A second prod-uct, derived from human bone, is processedby solvent extraction and dehydration. Ani-mal studies have shown that there is near-complete remodeling with little or no rem-nant of the human anorganic bone left inthe specimen.26

Both the deproteinized bovine boneand the solvent dehydrated mineralizedhuman bone appear to have great potentialin alveolar ridge preservation. These materi-als take a long time to resorb, so a ridge formis maintained over an extended period oftime, and are resorbed and remodeled viaan osteoclastic process that results in boneideally suited for implant placement.

The technique for alveolar ridge preser-vation at the time of extraction has beendescribed by Sclar.27 Atraumatic extractionis essential. Preservation of buccal or labialbone may be facilitated by the use of micro-osteotomes, and, whenever possible, buccalor labial mucoperiosteal elevation is to beavoided or limited. The socket should begently curetted and irrigated, and in thepresence of periodontal infection, topicalantibiotics may be helpful. Tetracyclinepowder mixed with the deproteinizedbovine bone or the solvent dehydrated min-eralized human bone may allow for the useof either of these types of bone in almostany clinical situation. It is not essential thatthe graft have complete watertight mucosalcoverage. Collagen membrane is used toprevent spillage of the material from thesocket, particularly in maxillary extractions.When temporary restorations are employedat the time of surgery, an ovate pontic pro-visional restoration helps to support theadjacent mucosa during soft tissue matura-tion. In selected instances immediate place-ment of implants in the extraction site canbe done in conjunction with the use of thesedeproteinized bone preparations. Becauseof the slow resorptive nature of both ofthese bone preparations, they may be ideal-ly suited for buccal or labial defects thatwould otherwise be grafted with autoge-nous cortical bone.

AlveoloplastyOften hard and soft tissues of the oralregion need to undergo recontouring toprovide a healthy and stable environmentfor future prosthetic restorations. Simplealveolar recontouring after extractionsconsists of compression and in-fracture ofthe socket; however, one must avoid over-compression and over-reduction of irreg-ularities. Current trends endorse a selec-tive stent-guided approach to site-specificbony recontouring, eliminating bonyabnormalities that interfere with prosthet-ic reconstruction or insertion. Multipleirregularities produce undercuts that areobstructions to the path of insertion forconventional prosthetic appliances. Theseobstructions need a more complex alve-oloplasty to achieve desired results. Inmany cases the elevation of mucoperi-osteal flaps using a crestal incision withvertical releases is necessary to preventtears and to produce the best access to thealveolar ridge. During mucoperiosteal flapresection, periosteal and Woodson eleva-tors are the most appropriate tools to pre-vent excess flap reflection, devitalization,and sequestrum formation. These condi-tions increase pain and discomfort for thepatient and increase the duration neededbefore prosthetic restoration can proceed.The use of a rongeur or file for advancedrecontouring is preferred to rotary instru-ments to prevent over-reduction. For largebony defects, rotary instrument recon-touring is preferred. Normal saline irriga-tion is used to keep bony temperatures < 47˚C to maintain bone viability.

Owing to the physiology of bone andcurrent restorative options available,interseptal alveoloplasty is rarely indicat-ed. The main disadvantage of this proce-dure is the overall decrease in ridge thick-ness, which results in a ridge that may betoo thin to accommodate future implantplacement.9 Removal of interseptal boneeliminates endosteal growth potential,which is necessary for ridge preservation.Therefore, if this technique is to be used,


one must be cognizant of ridge thicknessand reduce the labial dimension onlyenough to lessen or eliminate undercuts inareas where implants are not anticipated.

After hard tissue recontouring, exces-sive soft tissue is removed to relieve mobiletissue that decreases the fit and functionalcharacteristics of the final prosthesis. Clo-sure with a resorbable running/lock-stitchsuture is preferred because fewer knots areless irritating for the patient.

Treatment of ExostosesUndercuts and exostoses are more commonin the maxilla than in the mandible. In areasrequiring bony reduction, local anestheticshould be infiltrated. This produces ade-quate anesthesia for the patient as well as anaid in hydrodissection of the overlying tis-sues, which facilitates flap elevation. In themandible an inferior alveolar neurovascularblock may also be necessary. A crestal inci-sion extending approximately 1.5 cmbeyond each end of the area requiring con-tour should be completed. A full mucoperi-osteal flap is reflected to expose all the areasof bony protuberance. Vertical releasingincisions may be necessary if adequateexposure cannot be obtained since traumaof the soft tissue flap may occur. Recontour-ing of exostoses may require the use of arotary instrument in large areas or a handrasp or file in minor areas. Once removal ofthe bony protuberance is complete andvisualization confirms that no irregularitiesor undercuts exist, suturing may be per-formed to close the soft tissue incision. Ifnonresorbable sutures are used, they shouldbe removed in approximately 7 days.

In areas likely to be restored withimplants or implant-supported prosthe-ses, irregularities and undercuts are besttreated using corticocancellous grafts froman autogenous or alloplastic source. Thiscan be done using a vertical incision onlyadjacent to the proposed area of grafting.A subperiosteal dissection is used to createa pocket for placement of the graft mater-ial. Visual inspection and palpation of the

area should be done at the conclusion ofthe procedure to verify the relief of thedefect. The incision can be closed withresorbable sutures. In areas that require alarge amount of graft material, scoring ofthe periosteum can assist in closure of softtissue defects. In addition, the use of aresorbable collagen membrane can beused to prevent tissue ingrowth into thesurgical site.

Tuberosity ReductionExcesses in the maxillary tuberosity mayconsist of soft tissue, bone, or both. Sound-ing, which is performed with a needle, candifferentiate between the causes with a localanesthetic needle or by panoramic radi-ograph. Bony irregularities may be identi-fied, and variations in anatomy as well as thelevel of the maxillary sinuses can be ascer-tained. Excesses in the area of the maxillarytuberosity may encroach on the interarchspace and decrease the overall freeway spaceneeded for proper prosthetic function.Access to the tuberosity area can be obtainedeasily using a crestal incision beginning inthe area of the posterior tuberosity and pro-gressing forward to the edge of the defectusing a no. 12 scalpel blade. Periosteal dis-section then ensues exposing the underlyingbony anatomy. Excesses in bony anatomy areremoved using a side-cutting rongeur. Care-ful evaluation of the level of the maxillarysinus must be done before bony recontour-ing is attempted in the area of the tuberosity.Sharp undermining of the overlying soft tis-sue may be performed in a wedge-shapedfashion beginning at the edge of a crestalincision to thin the overall soft tissue bulkoverlying the bony tuberosity. Excess overly-ing soft tissue may be trimmed in an ellipticfashion from edges of the crestal incision toallow a tension-free passive closure (Figure9-12). Closure is performed using a nonre-sorbable suture in a running fashion. Smallsinus perforations require no treatment aslong as the membrane remains intact. Largeperforations must be treated with a tension-free tight closure as well as antibiotics,

preferably a penicillinase-resistant penicillinsuch as an amoxicillin/clavulanate potassi-um preparation or a second-generationcephalosporin. The patient is instructed totake sinus medications including antihista-mines and decongestants for approximately10 to 14 days and not to create excessivetransmural pressure across the incision siteby blowing his or her nose or suckingthrough straws.

Genial Tubercle ReductionThe genioglossus muscle attaches to thelingual aspect of the anterior mandible. Asthe edentulous mandible resorbs, thistubercle may become significantly pro-nounced. In cases in which anteriormandibular augmentation is indicated,leaving this bony projection as a base forsubsequent grafting facilitates augmenta-tion of mandibular height. During conven-tional mandibular denture fabrication, thisbony tuberosity as well as its associatedmuscle attachments may create displace-ment issues with the overlying prostheses.In these cases it should be relieved. Floor-of-mouth lowering procedures should alsobe considered in cases in which genioglos-sus and mylohyoid muscle attachmentsinterfere with stability and function ofconventional mandibular prostheses.

Bilateral lingual nerve blocks in thefloor of the mouth are necessary to achieveadequate anesthesia in this area. A crestalincision from the midbody of the mandibleto the midline bilaterally is necessary forproper exposure. A subperiosteal dissectionexposes the tubercle and its adjacent muscleattachment. Sharp excision of the musclefrom its bony attachment may be per-formed with electrocautery, with carefulattention to hemostasis. A subsequenthematoma in the floor of the mouth maylead to airway embarrassment and life-threatening consequences if left unchecked.Once the muscle is detached, the bonytubercle may then be relieved using rotaryinstrumentation or a rongeur. Closure isperformed using a resorbable suture in a


running fashion. The genioglossus muscleis left to reattach independently.

Tori RemovalThe etiology of maxillary and mandibulartori is unknown; however, they have anincidence of 40% in males and 20% infemales.28 Tori may appear as a single ormultiloculated bony mass in the palate oron the lingual aspect of the anteriormandible either unilaterally or bilaterally.In the dentate patient they are rarely indi-cated for removal. Nevertheless, repeatedoverlying mucosal trauma and interfer-ence with normal speech and masticatorypatterns may necessitate treatment. In thepatient requiring complete or partial con-ventional prosthetic restoration, they maybe a significant obstruction to insertion orinterfere with the overall comfort, fit, andfunction of the planned prosthesis.

In the maxilla, bilateral greater palatineand incisive blocks are performed toachieve adequate anesthesia. Local infiltra-tion of the overlying mucosa helps withhemostasis and hydrodissection that facili-tates flap elevation. A linear midline inci-sion with posterior and anterior verticalreleases or a U-shaped incision in thepalate followed by a subperiosteal dissec-tion is used to expose the defect. Rotaryinstrumentation with a round acrylic burmay be used for small areas; however, forlarge tori, the treatment of choice is sec-tioning with a cross-cut fissure bur. Oncesectioned into several pieces, the torus iseasily removed with an osteotome. Caremust be taken not to over-reduce the palateand expose the floor of the nose. Final con-touring may be done with an egg-shapedrecontouring bur (Figure 9-13). Copiousirrigation is necessary throughout the pro-

cedure. Closure is performed with aresorbable suture. Presurgical fabricationof a thermoplastic stent, made from dentalmodels with the defect removed, in combi-nation with a tissue conditioner helps toeliminate resulting dead space, increasepatient comfort, and facilitate healing incases in which communication occurs withthe nasal floor. Soft tissue breakdown is notuncommon over a midline incision; how-ever, meticulous hygiene, irrigation, andtissue conditioners help to minimize thesecomplications.

Mandibular tori are accessed usingbilateral inferior alveolar and lingualnerve blocks as well as local infiltration tofacilitate dissection. A generous crestalincision with subsequent mucoperiostealflap elevation is performed. Maintenanceof the periosteal attachment in the mid-line reduces hematoma formation andmaintains vestibular depth. Nevertheless,when large tori encroach on the midline,maintenance of this midline periostealattachment is impossible. Careful flapelevation with attention to the thin fri-able overlying mucosa is necessary as thistissue is easily damaged. Small protuber-ances can be sheared away with a malletand osteotome. Large tori are dividedsuperiorly from the adjacent bone with afissure bur parallel to the medial axis ofthe mandible and are out-fractured awayfrom the mandible by an osteotome,which provides leverage (Figure 9-14).The residual bony fragment inferiorlymay then be relieved with a hand rasp orbone file. It is not imperative that theentire protuberance be removed as longas the goals of the procedure areachieved. Copious irrigation during thisprocedure is imperative, and closure iscompleted using a resorbable suture in arunning fashion. Temporary denturedelivery or gauze packing lingually maybe used to prevent hematoma formationand should be maintained for approxi-mately 1 day postoperatively. Wounddehiscence and breakdown with exposure

FIGURE 9-12 A, Area of soft tissue to be excisedin an elliptic fashion over the tuberosity. B,Removal of tissue and undermining of buccal andpalatal flaps completed. C, Final tissue closure.

A B

C


of underlying bone is not uncommonand should be treated with local irriga-tion with normal saline.

Mylohyoid Ridge ReductionIn cases of mandibular atrophy, the mylo-hyoid muscle contributes significantly tothe displacement of conventional den-tures. With the availability of advancedgrafting techniques and dental implants,there are fewer indications for the reduc-tion of the mylohyoid ridge. In severe casesof mandibular atrophy, the externaloblique and mylohyoid ridges may be theheight of contour of the posteriormandible. In these cases the bony ridgemay be a significant source of discomfortas the overlying mucosa is thin and easilyirritated by denture flanges extending intothe posterior floor of the mouth. As aresult, reduction of the mylohyoid ridgemay accompany grafting techniques toprovide greater relief and comfort for sub-sequent restorations. Historically, this pro-cedure has been combined with loweringof the floor of the mouth; however, withthe advanced armamentarium availabletoday, there are few, if any, indications forthese procedures alone or in combination.

Anesthesia is achieved with buccal,inferior alveolar, and lingual nerveblocks. A crestal incision over the heightof contour is made, erring toward thebuccal aspect to protect the lingualnerve. Subperiosteal dissection along themedial aspect of the mandible reveals theattachment of the mylohyoid muscle tothe adjacent ridge. This can be sharplyseparated with electrocautery to mini-mize muscle bleeding. Once the overly-ing muscle is relieved, a reciprocatingrasp or bone file can be used to smooththe remaining ridge. Copious irrigationand closure with particular attention tohemostasis is completed. Placement of astent or existing denture may also aid inhemostasis as well as inferiorly reposi-tioning the attachment. Again, these pro-cedures are rarely indicated and are

included here essentially for historic ref-erence, not for routine use.

Soft Tissue RecontouringWith the eventual bony remodeling thatfollows tooth loss, muscle and frenumattachments that initially were not in aproblematic position begin to create com-plications in prosthetic reconstruction andto pose an increasing problem with regardto prosthetic comfort, stability, and fit.Often these attachments must be alteredbefore conventional restoration can beattempted. As dental implants becomecommonplace in the restoration of par-tially and totally edentulous patients, sur-

gical alteration of these attachments isindicated less often. Nevertheless, inflam-matory conditions such as inflammatoryfibrous hyperplasia of the vestibule orepulis, and inflammatory hyperplasia ofthe palate must be addressed before anytype of prosthetic reconstruction can pro-ceed. Obviously, any lesion presentingpathologic consequences should undergobiopsy and be treated accordingly beforereconstruction commences. In keepingwith reconstructive surgery protocol, softtissue excesses should be respected andshould not be discarded until the finalbony augmentation is complete. Excesstissue thought to be unnecessary may be

FIGURE 9-13 A, Preoperative view of a maxillary torus with the midline incision indicated (dashed line). B,Removal of sectioned elements of the torus with an osteotome. C, Final smoothing of irregularities with a rotarybur. D, Final closure.

A B

C D


valuable after grafting or augmentationprocedures are performed to increase theoverall bony volume.

Hypermobile TissueWhen excess mobile unsupported tissueremains after successful alveolar ridgerestoration, or when mobile tissue exists inthe presence of a preserved alveolar ridge,removal of this tissue is the treatment ofchoice. Usually infiltrative local anesthesiacan be performed in selected areas. Sharpexcision parallel to the defect in asupraperiosteal fashion allows for removalof mobile tissue to an acceptable level.Beveled incisions may be needed to blendthe excision with surrounding adjacent tis-sues and maintain continuity to the sur-rounding soft tissue. Closure withresorbable suture then approximates resid-ual tissues. Impressions for prosthesis fabri-cation should proceed after a 3- to 4-weekperiod to allow for adequate soft tissueremodeling. In cases in which dentureflange extension is anticipated, the clinicianmust be careful to preserve the vestibulewhen undermining for soft tissue closure.Granulation is a better alternative if resid-ual tissues cannot be approximated because

it maintains the vestibule and increases thewidth of the attached keratinized mucosa.

Fibrous Inflammatory HyperplasiaFibrous inflammatory hyperplasia is oftenthe result of an ill-fitting denture that pro-duces underlying inflammation of themucosa and eventual fibrous proliferationresulting in patient discomfort and adecreased fit of the overlying prosthesis.Early management consists mainly ofadjustment of the offending dentureflange with an associated soft reline of theprosthesis. When there is little chance ofeliminating the fibrous component, surgi-cal excision is necessary. In most caseslaser ablation with a carbon dioxide laseris the method of choice. When the treat-ment of large lesions would result in sig-nificant scarring and obliteration of thevestibule, sharp excision with undermin-ing of the adjacent mucosa and reapproxi-mation of the tissues is preferred. Again,maintenance of a supraperiosteal planewith repositioning of mucosal edgesallowing for subsequent granulation ispreferred over approximation of woundedges that results in the alteration of

vestibular depth. This is accomplishedwith local anesthetic infiltrated into theproposed tissue bed, which is closed only ifnecessary with resorbable sutures.

Inflammatory Papillary Hyperplasia Once thought to be a neoplastic process,inflammatory papillary hyperplasia occursmainly in patients with existing prostheticappliances.29 An underlying fungal etiolo-gy most often is the source of the inflam-matory process and appears to coincidewith mechanical irritation and poorhygiene practices. The lesion appears asmultiple proliferative nodules underlyinga mandibular prosthesis likely colonizedwith Candida. Early stages are easily treat-ed by an improvement of hygiene practicesand by the use of antifungal therapy suchas nystatin tid alternating with clotrima-zole troches intermittently. Nocturnalsoaking of the prosthesis in an antifungalsolution or in an extremely dilute solutionof sodium hypochlorite helps decrease theoverall colonization of the prosthesis.

In proliferative cases necessitating sur-gical treatment, excision in a supraperi-osteal plane is the method of choice.Many methods are acceptable, includingsharp excision with a scalpel, rotarydébridement, loop electrocautery asdescribed by Guernsey, and laser ablationwith a carbon dioxide laser.30–32 Becauseof the awkward access needed to removethe lesions, laser ablation is the methodwe employ. Treatment proceeds suprape-riosteally to prevent exposure of under-lying palatal bone. Subsequently, place-ment of a tissue conditioner and adenture reline is helpful to minimizepatient discomfort.

Treatment of the Labial and Lingual Frenum

Labial FrenectomyLabial frenum attachments consist of thinbands of fibrous tissue covered with

FIGURE 9-14 A, Rotary trough exposes a mandibular torus and creates a cleavage plane between thetorus and mandible. B, Osteotome shears the remaining attachment of the torus from mandible.

A B


mucosa extending from the lip and cheekto the alveolar periosteum. The height ofthis attachment varies from individual toindividual; however, in dentate individualsfrenum attachments rarely cause a prob-lem. In edentulous individuals frenumattachments may interfere with fit and sta-bility, produce discomfort, and dislodgethe overlying prostheses.

Several surgical methods are effectivein excising these attachments. Simple exci-sion and Z-plasty are effective for narrowfrenum attachments (Figures 9-15 and 9-16). Vestibuloplasty is often indicatedfor frenum attachments with a wide base.

Local anesthetic infiltration is per-formed in a regional fashion that avoidsdirect infiltration into the frenum itself;such an infiltration distorts the anatomyand leads to misidentification of thefrenum. Eversion of the lip also helps oneidentify the anatomic frenum and assistswith the excision. An elliptic incisionaround the proposed frenum is completedin a supraperiosteal fashion. Sharp dissec-tion of the frenum using curved scissorsremoves mucosa and underlying connec-tive tissue leading to a broad base ofperiosteum attached to the underlyingbone. Once tissue margins are under-mined and wound edges are approximat-ed, closure can proceed with resorbablesutures in an interrupted fashion. Suturesshould encounter the periosteum, espe-cially at the depth of the vestibule to main-tain alveolar ridge height. This alsoreduces hematoma formation and allowsfor the preservation of alveolar anatomy.

In the Z-plasty technique, excision ofthe connective tissue is done similar tothat described previously. Two releasingincisions creating a Z shape precedeundermining of the flaps. The two flapsare eventually undermined and rotated toclose the initial vertical incision horizon-tally. By using the transposition flaps, thistechnique virtually increases vestibulardepth and should be used when alveolarheight is in question.

FIGURE 9-15 A, Retracted lip exposes a frenalattachment. B, Isolation and excision of the fre-nal attachment. C, Complete excision revealingthe underlying periosteum. D, Closure of under-mined edges of the incision.

A

C

B

D

Flaps forclosing incision



FIGURE 9-16 A, Excision of a frenum withproposed Z-plasty incisions. B, Underminedflaps of the Z-plasty. C, Transposed flapslengthening the incision and lip attachment.

A B

C


Wide-based frenum attachments maybest be treated with a localized vestibulo-plasty technique. A supraperiosteal dissec-tion is used to expose the underlying perios-teum. Superior repositioning of the mucosais completed, and the wound margin issutured to the underlying periosteum at thedepth of the vestibule. Healing proceeds bysecondary intention. A preexisting dentureor stent may be used for patient comfort inthe initial postoperative period.

Lingual FrenectomyHigh lingual frenum attachments mayconsist of different tissue types includingmucosa, connective tissue, and superficialgenioglossus muscle fibers. This attach-ment can interfere with denture stability,speech, and the tongue’s range of motion.Bilateral lingual blocks and local infiltra-tion in the anterior mandible provide ade-quate anesthesia for the lingual frenumexcision. To provide adequate traction, asuture is placed through the tip of thetongue. Surgical release of the lingualfrenum requires dividing the attachmentof the fibrous connective tissue at the baseof the tongue in a transverse fashion, fol-lowed by closure in a linear direction,which completely releases the ventralaspect of the tongue from the alveolarridge (Figure 9-17). Electrocautery or a

hemostat can be used to minimize bloodloss and improve visibility. After removalof the hemostat, an incision is createdthrough the area previously closed withinthe hemostat. Careful attention must begiven to Wharton’s ducts and superficialblood vessels in the floor of the mouth andventral tongue. The edges of the incisionare undermined, and the wound edges areapproximated and closed with a runningresorbable suture, burying the knots tominimize patient discomfort.

Ridge Extension Procedures inthe Maxilla and Mandible

Submucous VestibuloplastyIn 1959 Obwegeser described the submu-cous vestibuloplasty to extend fixed alve-olar ridge tissue in the maxilla.33 Thisprocedure is particularly useful inpatients who have undergone alveolarridge resorption with an encroachmentof attachments to the crest of the ridge.Submucous vestibuloplasty is ideal whenthe remainder of the maxilla is anatomi-cally conducive to prosthetic reconstruc-tion. Adequate mucosal length must beavailable for this procedure to be success-ful without disproportionate alteration ofthe upper lip. If a tongue blade or mouthmirror is placed to the height of the max-

illary vestibule without distortion orinversion of the upper lip, adequatelabiovestibular depth is present (Figure 9-18).9 If distortion occurs then maxil-lary vestibuloplasty using split-thicknessskin grafts or laser vestibuloplasty is theappropriate procedure.

Submucous vestibuloplasty can be per-formed in the office setting under outpa-tient general anesthesia or deep sedation. Amidline incision is placed through themucosa in the maxilla, followed by mucosalundermining bilaterally. A supraperiostealseparation of the intermediate muscle andsoft tissue attachments is completed. Sharpincision of this intermediate tissue plane ismade at its attachment near the crest of themaxillary alveolus. This tissue layer maythen be excised or superiorly repositioned(Figure 9-19). Closure of the incision andplacement of a postsurgical stent or den-ture rigidly screwed to the palate is neces-sary to maintain the new position of thesoft tissue attachments. Removal of thedenture or stent is performed 2 weekspostoperatively. During the healing peri-od, mucosal tissue adheres to the underly-ing periosteum, creating an extension offixed tissue covering the maxillary alveo-lus. A final reline of the patient’s denturemay proceed at approximately 1 monthpostoperatively.

FIGURE 9-17 A, Lingual frenum attachment encroaching on an atrophic mandibular alveolus. B, Excision of the frenum with underminingof mucosal edges. Note: Care must be taken to avoid causing damage to Wharton’s ducts. C, Final closure of mucosal edges.

A B C


Maxillary VestibuloplastyWhen a submucous vestibuloplasty is con-traindicated, mucosa pedicled from theupper lip may be repositioned at the depthof the vestibule in a supraperiosteal fashion.The exposed periosteum can then be left toepithelialize secondarily. Split-thicknessskin grafts may be used to help shorten thehealing period. In addition, placement of arelined denture may minimize patient dis-comfort and help to mold and adapt under-lying soft tissues and/or skin grafts.

Another option in this situation islaser vestibuloplasty. A carbon dioxidelaser is used to resect tissue in a supraperi-osteal plane to the depth of the proposedvestibule. A denture with a soft reline isthen placed to maintain vestibular depth.Removal of the denture in 2 to 3 weeksreveals a nicely epithelialized vestibule thatextends to the desired depth (Figure 9-20).

Lip-Switch VestibuloplastyBoth lingually based and labially basedvestibuloplasties have been described.34,35

In the former an incision in the lower lip

and submucosa undermining to the alveolusis followed by a supraperiosteal dissection tothe depth of the vestibule (Figure 9-21).The mucosal flap is then sutured to thedepth of the vestibule and stabilized with astent or denture. The labial denuded tissueis allowed to epithelialize secondarily.

In the transpositional vestibuloplasty,the periosteum is incised at the crest of thealveolus and transposed and sutured to thedenuded labial submucosa. The elevatedmucosal flap is then positioned over theexposed bone and sutured to the depth ofthe vestibule (Figure 9-22).

These procedures provide satisfactoryresults provided that adequate mandibularheight exists preoperatively. A minimumof 15 mm is acceptable for the above pro-cedures. Disadvantages include unpre-dictable results, scarring, and relapse.

Mandibular Vestibuloplasty and Floor-of-Mouth LoweringProceduresAs with labial muscle attachments and softtissue in the buccal vestibule, the mylohyoidand genioglossus attachments can precludedenture flange placement lingually. In a com-bination of the procedures described byTrauner as well as Obwegeser and MacIn-tosh, both labial and lingual extension proce-dures can be performed to effectively lowerthe floor of the mouth (Figure 9-23).36–38

This procedure eliminates the componentsinvolved in the displacement of conven-tional dentures and provides a broad baseof fixed tissue for prosthetic support. Again,adequate mandibular height of at least 15 mm is required. Split-thickness skingrafting is used to cover the denudedperiosteum and facilitate healing.

Today, with the incorporation ofendosteal implants and the fabrication ofimplant-borne prostheses, lingual and buc-colabial flange extensions to stabilizemandibular prostheses are not necessary.Consequently, attention is directed towardpreservation or preparation of the alveolusfor implants rather than extension of the

fixed tissue attachments. As a result, theseprocedures are rarely used today.

Hard Tissue AugmentationAs stated previously, the overall goals ofreconstructive preprosthetic surgery are toprovide an environment for the prosthesisthat will restore function, create stabilityand retention, and service associatedstructures as well as satisfy esthetics andprevent minor sensory loss. There aremany classification systems of rigid defi-ciencies associated with many treatmentoptions; nevertheless, each patient must beevaluated individually. When atrophy ofthe alveolus necessitates bony augmenta-tion, undercuts, exostoses, and inappro-priate tissue attachments should be identi-fied and included in the overall surgicalplan prior to prosthetic fabrication.

Maxillary AugmentationIn the past, vestibuloplasties were theprocedure of choice to accentuate thealveolus in the atrophic maxilla. Unfortu-nately, poor quality and quantity of bonecombined with excessive occlusal loadingby conventional prostheses continued toaccelerate the resorptive process. Eitheraugmentation or transantral implantcross-arch stabilization must be consid-ered when anatomic encroachment of thepalatal vault or zygomatic buttress andloss of tuberosity height affect overall fitand function of a conventional prosthe-sis. This section discusses conventionalaugmentation procedures of the maxillato restore acceptable alveolar form anddimensions.

There is a fourfold increase in resorp-tion in the mandible compared with thatin the maxilla, combination syndromesnot withstanding. When severe resorptionresults in severely atrophic ridges(Cawood and Howell Classes IV–VI),some form of augmentation is indicated.Onlay, interpositional, or inlay grafting arethe procedures of choice to reestablishacceptable maxillary dimensions.

FIGURE 9-18 A mirror presses the vestibularmucosa to the desired height to evaluate the ade-quacy of lip mucosa. In this example, extension ofthe vestibular mucosa superiorly on the alveolarridge does not result in thinning or intrusion of thelip. Reproduced with permission from Tucker MR.Ambulatory preprosthetic reconstructive surgery.In: Peterson LJ, Indresano AT, Marciani RD, RoserSM. Principles of oral and maxillofacial surgery.Vol 2. Philadelphia (PA): JB Lippincott Company;1992. p. 1126.


Ridge Split Osteoplasty Ridge-splittingprocedures geared toward expanding theknife-edged alveolus in a buccolingualdirection help to restore the crucialendosteal component of the alveolus thatis associated with preservation and

response to transligamentary loading andmaintains the alveolus during the dentatestate. Replacement of this tissue allows fordental implant stimulation of the sur-rounding bone that can best mimic thissituation and preserve the existing alveolus

Mucosa

Shallow submucosal tissueand muscle attachments

FIGURE 9-19 Maxillary submucosal vestibuloplasty. A, Following the creation of a vertical midline inci-sion, scissors are used to bluntly dissect a thin mucosal layer. B, A second supraperiosteal dissection is created using blunt dissection. C, Interposing submucosal tissue layer created by submucosal andsupraperiosteal dissections. D, Interposing tissue layer is divided with scissors. The mucosal attachmentto the periosteum may be increased by removal of this tissue layer. E, Connected submucosal andsupraperiosteal dissections. F, Splint extended in to the maximum height of the vestibule, placing themucosa and periosteum in direct contact. G, Preoperative appearance of the maxilla with muscularattachments on the lateral aspects of the maxilla. H, Postoperative view. A,B,E,F adapted from TuckerMR. Ambulatory preprosthetic reconstructive surgery. In: Peterson LJ, Indresano AT, Marciani RD, RoserSM. Principles of oral and maxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company;1992. p. 1126–7. C,D,G,H reproduced with permission from Tucker MR. Ambulatory preprostheticreconstructive surgery. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles of oral andmaxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company; 1992. p. 1127.

D

CBA

Submucosalincisions

Submucosalincision

Mucosa

Splint

E F

G

H


and possibly stimulate future bonegrowth. Adequate dimensions, however,should exist that allow for a midcrestalosteotomy to separate the buccal and lin-gual cortices (Figures 9-24 and 9-25). Alabial incision originates just lateral to thevestibule and continues supraperiosteallyto a few millimeters below the crest of thealveolus. A subperiosteal flap then origi-nates exposing the underlying crest. Copi-ous irrigation accompanies an osteotomycircumferentially anterior to the maxillarysinus from one side to the other. Mobiliza-tion of the labial segment can be achieved

with careful manipulation with anosteotome, taking care to maintain thelabial periosteal attachment. An interposi-tional cancellous graft can then be placedin the resulting defect, replacing the lostbony mass. Closure of the incision is awayfrom the graft site and usually requiressuturing of the flap edge to the periosteumwith subsequent granulation of theremainder of the exposed tissue bed.Endosteal implants can be placed approxi-mately 3 to 4 months later; waiting thislength of time has been shown to increaseoverall long-term implant success.

Onlay Grafts When clinical loss of thealveolar ridge and palatal vault occur(Cawood and Howell Class V), verticalonlay augmentation of the maxilla is indi-cated. Initial attempts at alveolar restora-tion involved the use of autogenous ribgrafts; however, currently corticocancellousblocks of iliac crest are the source ofchoice.39,40 In a similar approach to thatdescribed above, the crest of the alveolus isexposed and grafts are secured with 1.5 to2.0 mm screws. Studies show increased suc-cess with implant placement in a second-stage procedure rather than using them as

FIGURE 9-20 Open submucosal vestibuloplasty. A, Submucosal dissection between two anterior vertical incisions followed by an incision on the crest of the alve-olar ridge. B, Preoperative appearance of the maxilla; hydroxylapatite augmentation had been performed but resulted in inadequate vestibular depth. C, Intra-operative photograph after elevation of the mucosal flap and removal of submucosal tissue. D, Appearance at the time of splint removal. A adapted from and B–Dreproduced with permission from Tucker MR. Ambulatory preprosthetic reconstructive surgery. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principlesof oral and maxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company; 1992. p. 1128.

DCB

A


FIGURE 9-21 Kazanjian flap vestibuloplasty.A, An incision is made in the labial mucosa, anda thin mucosal flap is dissected from the under-lying tissue. A supraperiosteal dissection is per-formed on the anterior aspect of the mandible.B, The labial mucosal flap is sutured to thedepth of the vestibule. The anterior aspect of thelabial vestibule heals by secondary intention.Adapted from Tucker MR. Ambulatory prepros-thetic reconstructive surgery. In: Peterson LJ,Indresano AT, Marciani RD, Roser SM. Princi-ples of oral and maxillofacial surgery. Vol 2.Philadelphia (PA): JB Lippincott Company;1992. p. 1120.

A B

FIGURE 9-22 Transpositional flap (lip-switch)vestibuloplasty. A, After elevation of the mucosal flap,the periosteum is incised at the crest of the alveolarridge and a subperiosteal dissection is completed onthe anterior aspect of the mandible. B, The periosteumis then sutured to the anterior aspect of the labialvestibule, and the mucosal flap is sutured to thevestibular depth at the area of the periosteal attach-ment. C, Elevation of the mucosal flap. D, Periostealincision along the crest of the alveolar ridge. E,Mucosa is sutured to the vestibular depth at the areaof the periosteal attachment. Note amount of vestibu-lar depth extension compared with the old vestibulardepth, which is marked by the previous dentureflange. A, B adapted from and C–E reproduced fromTucker MR. Ambulatory preprosthetic reconstructivesurgery. In: Peterson LJ, Indresano AT, Marciani RD,Roser SM. Principles of oral and maxillofacialsurgery. Vol 2. Philadelphia (PA): JB Lippincott Com-pany; 1992. p. 1121.

A B

D E

C


sources of retention and stabilization of thegraft and alveolus at the time of augmenta-tion. Implant success ranges from > 90%initially and falls to 75% and 50%, respec-tively, at 3 and 5 years postoperatively.41–45

Implant success may be directly propor-tional to the degree of graft maturation andincorporation at the time of implant place-ment. As a result, 4 to 6 months of healingis an acceptable waiting period when long-term implant success may be affected.

Interpositional Grafts Interpositionalgrafts are indicated when adequate palatalvault height exists in the face of severealveolar atrophy (Cawood and HowellClass VI) posteriorly, resulting in anincreased interarch space. Because thismethod involves a Le Fort I osteotomy,true skeletal discrepancies between themaxilla and mandible can be corrected atthe time of surgery. The improvement ofmaxillary dimensions as a result of inter-positional grafts may obviate the need forfuture soft tissue recontouring to provideadequate relief for prosthetic rehabilita-tion (Figure 9-26). Although early studiesentertained the simultaneous placementof dental implants at the time of augmen-tation, recently several authors havedemonstrated better success rates forimplants placed in a second-stage proce-dure; this alleviates the need for excessivetissue reflection for implant placementand allows for a more accurate placementat a later date.41 A relapse of 1 to 2 mm hasbeen demonstrated in interpositionalgrafts using the Le Fort I technique withrigid fixation.46–50 More data are needed todetermine long-term overall success andrelapse with these procedures.

Sinus Lifts and Inlay Bone Grafts Sinuslift procedures and inlay bone graftingplay a valuable role in the subsequentimplant restoration of a maxilla that hasatrophied posteriorly and is unable toaccommodate implant placement owingto the proximity of the maxillary sinus to

FIGURE 9-23 Floor-of-mouth lowering. A, Mucosal and muscular attachments near the crest of thealveolar ridge. B, Inferior repositioning of the mucosal flap after the mucosal incision and sectioningof mylohyoid muscle have been performed. C, Bolsters placed percutaneously to secure the flap inferi-orly. D, Inferior mandibular “sling” sutures provide inferior traction on the mucosal flap. E, Buttonssecure the mucosal flap sutures. F, Postoperative appearance of the floor-of-mouth extension. A,B,E,Freproduced with permission from Tucker MR. Ambulatory preprosthetic reconstructive surgery.In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles of oral and maxillofacial surgery.Vol 2. Philadelphia (PA): JB Lippincott Company; 1992. p. 1122–3. C,D adapted from Tucker MR.Ambulatory preprosthetic reconstructive surgery. In: Peterson LJ, Indresano AT, Marciani RD, RoserSM. Principles of oral and maxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company;1992. p. 1122.

A B

C D

E F


the alveolar crest. Incisions just palatal tothe alveolar crest are created, followed bysubperiosteal exposure of the anteriormaxilla. A cortical window 2 to 3 mmabove the sinus floor is created with theuse of a round diamond bur down to themembrane of the sinus. Careful infractureof the window with dissection of the sinusmembrane off the sinus floor creates thespace necessary for graft placement; thelateral maxillary wall is the ceiling for thesubsequent graft (Figure 9-27). Cortico-cancellous blocks or particulate bone maybe placed in the resulting defect. Tears inthe membrane may necessitate coveragewith collagen tape to prevent extrusionand migration of particulate graftsthrough the perforations. Althoughimplant placement can proceed simulta-neously when 4 to 5 mm of native alveolusexists, we have found few cases where the

alveolus meets these requirements andtherefore elect to place implants approxi-mately 6 months later. Block and Kenthave reported an 87% success rate with

sinus-grafting procedures. They also havestated that in the literature there is anoverall success rate ranging from 75 to100%.51,52 As these procedures gain popu-larity and are routinely incorporated intomainstream preprosthetic surgery treat-ment plans, more accurate data and long-term follow-up will be available.

Treatment of Skeletal and Alveolar Ridge DiscrepanciesSupraeruption of teeth and associated alve-olar bone into opposing edentulous spacesin partially edentulous patients precludesprosthetic rehabilitation owing to function-al loss of freeway space and the fact that theopposing arch cannot be restored withoutthe extraction of the offending supraerupt-ed dentition. With segmental alveolarsurgery, these teeth can be repositioned toachieve a more appropriate relationshipwith the adjacent dentition and to increasethe interarch space to allow for properprosthetic restoration of the opposing den-tition. A preoperative work-up shouldinclude a thorough extraoral and intraoralexamination. Cephalometric analysis andstudy models should be obtained. Closecommunication with the restorative dentistis necessary to determine expectationsregarding the final position of the tooth-bearing segment postoperatively. Mounted

FIGURE 9-24 A, Diagram shows bone cuts and the position of the buccal fragment after the osteoto-my. The bone grafts are already in position. Adapted from Stoelinga PJW.61 B, Handpiece in positionwith small crosscut fissure bur performing osteotomy along the crest of the alveolar ridge. C, Osteoto-my completed and buccal plate outfractured to complete ridge split. The defect is now ready for inter-positional graft to maintain the increased buccolingual width. D, Completed ridge split with interpo-sitional corticocancellous and allogeneic bone used to fill the defect and maintain the increasedbuccolingual dimension.

A B

C D

FIGURE 9-25 A, Schematic drawing of the bone graft position in relation to the nasalfloor. Note the reflected buccal periosteum after palatal incisions. B, Position ofendosteal implants after the bone graft has healed. Adapted from Stoelinga PJW.61

A B


models, model surgery to reposition thesegment, and diagnostic wax-ups of theproposed opposing dentition help one toverify the feasibility and success of thefuture prosthetic reconstruction. Surgicalsplint fabrication is necessary to supportand stabilize the segment postoperatively.Increased stability is obtained if as manyteeth as possible are included in the splintto help stabilize the teeth in the reposi-tioned segment. The splint can be thick-ened to the opposing edentulous alveolarridge to prevent relapse and to maintain thenew vertical alignment of the repositionedsegment. Techniques for segmental surgeryare discussed Chapter 57, “MaxillaryOrthognathic Surgery,” and in other texts.An adequate healing period of approxi-mately 6 to 8 weeks should precede pros-thetic rehabilitation.

In totally edentulous patients withskeletal abnormalities that prevent suc-cessful prosthetic reconstruction owing toan incompatibility of the alveolar arches,orthognathic surgical procedures may cre-ate a more compatible skeletal and alveolarridge relationship. This can aid therestorative dentist in the fabrication offunctional and esthetic restorations (Fig-

ure 9-28).46 During the evaluation andtreatment planning stage, the restorativedentist should play a major role in deter-mining the final position of the maxillaryand mandibular arches. Clinical examina-tion, radiographic and cephalometricexaminations, and articulated modelsshould be attained to determine appropri-

ate presurgical vertical and horizontaldimensions. This information should becombined with a cephalometric predictionanalysis to determine the overall problemlist and surgical treatment plan. Indexedsurgical splints that can be rigidly fixed tothe edentulous arches should be fabricatedpreoperatively at the time of modelsurgery; these splints aid in surgical repo-sitioning of the maxilla, mandible, orboth. Surgical procedures describing repo-sitioning of the maxilla and mandible withrigid fixation are discussed in Chapter 56,“Principles of Mandibular OrthognathicSurgery” and Chapter 57, “MaxillaryOrthognathic Surgery.” Prosthetic recon-struction can usually proceed at 6 to 8 weeks postoperatively.

Mandibular AugmentationOne of the most challenging procedures inreconstructive surgery remains the recon-struction of the severely atrophic mandible(Cawood and Howell Classes V and VI).Patients exhibiting these deficits are charac-teristically overclosed, which creates anaged appearance, are usually severely debil-itated from a functional perspective, and

FIGURE 9-26 Graphic (A) and clinical presentation (B) of interpositional iliac crest grafts tothe maxilla.

A B

FIGURE 9-27 A, Sinus lift procedure with an inward trapdoor fracture of lateral sinus wall. B, Graft materi-al is placed on the floor of the sinus. The sinus lining should not be perforated during the elevation of the bone.Adapted from Beirne OR. Osseointegrated implant systems. In: Peterson LJ, Indresano AT, Marciani RD,Roser SM. Principles of oral and maxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company;1992. p. 1146.

A B


often present with significant risk forpathologic fracture of the mandible.Because the ideal graft should be vascular-ized and eventually incorporated into thehost bone through a combination of osteo-conduction and induction, autogenousbone grafts consistently meet these require-ments and offer the most advantages to thereconstructive plan. Unfortunately, graftresorption and unpredictable remodelinghave complicated grafting procedures;however, rigid fixation and later incorpora-tion of dental implants have allowed forthe needed stability postoperatively withregard to resorption and have promotedbeneficial stimulation to preserve existinggraft volume. Initially, mandibular aug-mentation with autogenous rib and ileumenjoyed little long-term success. However,recent incorporation of rigid fixation,delayed implant placement 6 months aftergrafting (allowing for the initial stage ofgraft resorption), guided tissue regenera-tion, and BMP have all contributed toincreased success rates in onlay augmenta-tion of the mandible.53–57

Inferior Border Augmentation Inferiorborder augmentation has been demon-strated using autogenous rib or composite

cadaveric mandibles combined with auto-genous cancellous bone (Figure 9-29).58–60

The following describes our technique forinferior augmentation of the atrophicmandible using the latter method.

Incisions are placed as inconspicuous-ly as possible from one mandibular angleto the other and proceed circumferentially

3 to 4 mm below the inferior border of themandible and anteriorly to the contralat-eral side. The superficial layer of the deepcervical fascia is sharply dissected. The fas-cia is then incorporated in the reflection; anerve tester is used to perform a carefulevaluation for the marginal mandibularbranch of the facial nerve. Reflection

FIGURE 9-29 A, Cadaveric mandible tray rigid-ly fixed to an atrophic mandible with autoge-nous cancellous bone sandwiched between nativeand cadaveric bone. Note that bur holes havebeen created to facilitate the revascularization ofthe graft. B, Cadaveric tray filled with autoge-nous bone before insetting. C, Graft and cadav-eric tray inset for inferior border augmentation.

A

B

C

A B C D

FIGURE 9-28 A and B, Preoperative views of a 52-year-old patient show severely collapsed circumoral tissues. C and D, The same patient 6 months postopera-tively. Note the improvement of the sagging chin and support for circumoral muscles. Better support for the lower lip also favorably affects the position of the upperlip. The patient is not wearing dentures in any of the photographs. Reproduced with permission from Stoelinga PJW. 61


superficial to the capsule of the sub-mandibular gland allows dissection to theinferior border. Facial blood vessels arelocated and managed with surgical tiesaccordingly. The inferior border is exposedin a subperiosteal dissection with greatcare to avoid intraoral exposure. Cadaver-ic mandibular adjustment involves reliev-ing the condyles and superior rami, thin-ning the bone to a uniform thickness ofapproximately 2 to 3 mm, and creating ascalloped tray to incorporate the autoge-nous bone. Repeated try-ins are necessaryto evaluate the overall adaptation to thenative mandible. Osseous interfaces as wellas form and symmetry as they relate to theoverall maxillomandibular relationshipare evaluated. Once appropriate dimen-sions have been reached, the atrophicmandible fits securely inside the cadavericspecimen without creating a Class IIIappearance, and flap closure is attainable,bur holes are drilled throughout the spec-imen to facilitate vascularization. Autoge-nous bone is then obtained from theileum, morselized, and placed in thecadaveric specimen. BMP soaked in colla-gen is placed in the recipient bed as well asin a layered fashion over the autogenousgraft. The entire specimen is fixed rigidlyto the native mandible using screw fixa-tion posterior to the area of futureimplant placement and in the mandibularmidline, where implants are usually notplaced. Postoperatively patients can func-tion with their preexisting prosthesis andenjoy increased stabilization of themandible. When combined with implantplacement at 4 to 6 months, this proce-dure results in an overall resorption rateof < 5% and is associated with low rates ofinfection and dehiscence intraorallyowing to the maintenance of mucosal bar-riers during reconstruction.

Pedicled and Interpositional GraftsPlacement of pedicled or interpositionalgrafts in the mandible is based on themaintenance of the lingual periosteum.

The lingual periosteum maintains ridgeform and its presence results in minimalresorption of the transpositioned basalarbone, as described by Stoelinga.61 Petersonand Slade as well as Harle described thevisor osteotomy in the late 1970s (Figure9-30).62,63 Unfortunately, labial bone graft-ing of the superiorly repositioned lingualsegment was necessary to reproduce alveo-lar dimensions that were compatible withprosthesis use. Schettler and Holtermannand then Stoelinga and Tideman describeda horizontal osteotomy with interposi-tional grafts to augment mandibularheight, with repositioning of the inferioralveolar neurovascular bundle (Figures 9-31 and 9-32).64,65 Unfortunately, neu-rosensory complications and collapse ofthe lingual segment became significantdisadvantages to this technique. With theincorporation of mandibular implantsand the success of full mandibular pros-theses that are supported by four or fiveanterior implants between mental forami-na, many of these pedicled and interposi-tional procedures are in decline today.

Alveolar Distraction OsteogenesisAs alluded to previously, growing bone viathe application of tension or stress has been

shown to be a viable solution to defects ofthe long bone, mandible, and midface.Application to alveolar bone has been limit-ed only by technologic advancement inappliances—the principles are still thesame. Alveolar distraction offers some dis-tinct advantages over traditional bone-grafting techniques. No donor site morbidi-ty is involved, and the actual distractionprocess from the latency period throughactive distraction and consolidation is actu-ally shorter than Phase I and Phase II boneremodeling and maturation. The quality ofthe bone grown in response to this ten-sion/stress application is ideal for implantplacement. The vascularity and cellularity ofthe bone promote osseointegration of den-tal implants. The greatest successes are relat-ed to the achievement of vertical graft sta-bility. One of the biggest problems inalveolar bone grafting historically has beenmaintaining vertical augmentation of bonegraft sites. When distraction is used, thetransported alveolar segment does notundergo any significant resorptive processbecause it maintains its own viabilitythrough an intact periosteal blood supply.The intermediate regenerate quickly trans-forms into immature woven bone andmatures through the normal processes ofactive bone remodeling. The sequencing of

FIGURE 9-30 Visor osteotomy devised by Harle F.Adapted from Stoelinga PJW61 and Harle F.63

FIGURE 9-31 Sandwich osteotomy designed bySchettler and Holtermann. Adapted from Stoelin-ga PJW61 and Schettler D and Holtermann W.64


events is crucial to maintaining the newlyaugmented bone and is definitely applicablein cases in which the alternatives are limited.

Diagnosis and treatment planning of atypical case for alveolar distraction osteo-genesis involves good clinical and radi-ographic examinations, primarily usingpanoramic radiographs. Anatomic struc-tures such as adjacent teeth, the sinusfloor, the nasal floor, and the inferior alve-olar canal are all easily identifiable in thesesituations. It is rare that CT or other moresophisticated imaging studies are required.The prosthetic work-up for these cases isalso important. The ideal placement of thenew alveolar crest both vertically and buc-colingually determines the success of thedistraction. The final position of the alve-olus determines the exact alignment of thetransport device and how it should bepositioned in the bone.

The shape of the residual alveolar boneis also important to identify. Often verticalbone defects are accompanied by a signifi-cant horizontal bone loss. This bone lossmust be dealt with either by further reduc-tion of the vertical height to achieve ade-quate horizontal width or by some type ofpre- or postdistraction bone graft augmen-tation to achieve an adequate width.

Although the success rates with alveo-lar distraction are very high when cases are

properly planned, there are surgical pitfallsto be avoided to ensure that alveolar dis-traction succeeds. First and foremost ismaintenance of the blood supply of thedistracted or transported segment. Manytimes this is difficult when access to theosteotomies is limited. Although there isno minimum height or width for thetransport segment, it should not exceedthe distance across which the segment isbeing transported. Mistakes are oftenmade related to the application of the dis-traction appliances. In the posteriormandible, the appliances are ofteninclined too far lingually for implantreconstruction. Similarly, in the anteriormaxilla, an adequate labial projection ofbone is difficult to achieve unless theappliance is proclined to transport thealveolus inferiorly and labially. Additional-ly, care must be taken when handling softtissues at alveolar ridge distraction sites.Mucosal flaps maintained with a substan-tial vascular supply are necessary toachieve predictable wound healing. Inaddition, we recommend both periostealand mucosal closure to prevent segmentaldehiscence during the distraction process.

There are both intraosseous and extra-osseous devices that have been designed foralveolar distraction. The Lead R Systemdevice designed by Chin is a simple one

consisting of two bone plates and a distrac-tion rod.66 A horizontal osteotomy is creat-ed, and the distraction rod is inserted froma crestal direction. The transport boneplate is then engaged and positioned on thetransport section with a bone screw; thebasal bone plate is engaged and likewisesupported on the bone with a screw. Thereare some limitations with this devicebecause the distraction rod may limit itsuse in areas where the vertical dimensionof occlusion is compromised. The rod isalso visible anteriorly, which may be anesthetic issue. Finally, the rod may interferewith future implant placement unless theimplant can be placed directly into the sitevacated by the rod.

The Robinson Inter-Oss alveolardevice was designed to be used in a one-stage procedure in which the transportappliance actually becomes the implantwhen the regenerate has matured.Anatomic limitations require a fairly sig-nificant crestal bone height and width foruse. A similar device, the ACE distractiondental implant system, allows for a distrac-tor that can be placed and then replacedwith a dental implant once the distractionhas been completed. Again, this is a simpleand easy implant to be placed, butanatomic constraints limit its use to cer-tain situations. Both the ACE device andthe Robinson Inter-Oss device have limita-tions in that they must be externallydirected or the distraction may veer offcourse. Other devices available commer-cially that are similar to those above arethe DISSIS distraction implant and theVeriplant. The Lead device mentionedabove provides relatively rigid stabilizationof the transport segment, but these otherdevices may violate one of the primerequirements of successful alveolar dis-traction, namely, rigid fixation of thetransport segments.

Extraosseous devices are much moresuccessful and practical for distraction andrigid fixation of the segments. The TrackPlus System manufactured by KLS Martin

A B

FIGURE 9-32 Sandwich-visor osteotomy according to Stoelinga and Tideman. A, Bone cut is outlined(dotted line). B, Cranial fragment is lifted, supported by bone struts, and secured by a wire tied in afigure of eight. Adapted from Stoelinga PJW61 and Schettler D and Holtermann W.64


and the bone plate device manufacturedby Walter Lorenz Surgical are two devicesthat adhere to the principles of distractionand rigid fixation (Figure 9-33).

After placement of a distractiondevice, a latency period must be observed,the duration of which is 4 to 7 days,depending on the age of the patient andthe quality of tissue at the transport site.The latter is significant in patients whohave previously undergone irradiation,multiple surgical procedures, or trauma,resulting in scar tissue and compromisedblood supply. The active distraction peri-od varies depending on the distance thesegment is transported. Standard princi-ples must be followed. The rate andrhythm of transport is 1 mm/d in dividedsegments—0.25 mm four times a day isthe most practical for appliances as well asthe patient. The consolidation phase com-mences when the distraction is complete.Generally the consolidation period shouldbe three times the length of the distractionperiod. The extraosseous appliances pro-vide rigid fixation to promote faster matu-ration of the regenerated bone. At the con-clusion of the consolidation phase, theappliance can be removed. Rather than

waiting for full mineralization of theregenerate, one can place the implants,which then provide further rigidity to thetransport segment and allow for healing ofboth the implant and the immature regen-erate simultaneously. The total treatmenttime is thus much shorter than with con-ventional bone grafting with either auto-genous or allogeneic bone, and in mostcases the appliance does not interfere withday-to-day function. Other than theinability to wear a transitional prosthesis,there is minimal disruption of the normalactivity and diet. Morbidity is generallyminimal and is related strictly to manage-ment of soft tissue flaps, maintenance ofadequate transport segment blood supply,and proper positioning of osteotomies.

ConclusionWith the evolution and success of dentalimplant technology, guided tissue regener-ation, and genetically engineered growthfactors such as BMP, current indicationsfor grafting and augmentation are usuallyrelated to facilitation of implant place-ment. Time-honored reconstructive pro-cedures including bone grafting and aug-mentation are also evolving to create the

ideal environment for implant-supportedand -stabilized prosthetic reconstruction.

References

1. Brånemark PI, Hansson B, Adell R, et al.Osseointegrated implants in the treatmentof the edentulous jaw. Experience from a10-year period. Scand J Plast Reconstr SurgSuppl 1977;16:1–132.

2. Weintraub JA, Burt BA. Oral health status inthe United States: tooth loss and eden-tulism. J Dent Educ 1985;49:368–78.

3. Cawood JI, Stoelinga JPW, et al. Internationalresearch group on reconstructive prepros-thetic surgery—consensus report. Int J OralMaxillofac Surg 2000;29:139–62.

4. Tallgren A. The continuing reduction of resid-ual alveolar ridges in complete denturewearers: mixed longitudinal study covering25 years. J Prosthet Dent 1972;27:120–32.

5. Bays RA. The pathophysiology and anatomy ofedentulous bone loss. In: Fonseka R, DavisW, editors. Reconstructive preprostheticoral and maxillofacial surgery. Philadel-phia: W.B. Saunders; 1985. p 19–41.

6. Starshak TJ. Oral anatomy and physiology. In:Starshak TJ, Saunders B, editors. Prepros-thetic oral and maxillofacial surgery. St.Louis: Mosby; 1980.

7. Cawood JI, Howell RA. A classification of theedentulous jaws. Int J Oral Maxillofac Surg1988;17:232–6.

8. Crandal CE, Trueblood SN. Roentgenographic

FIGURE 9-33 A, Atrophic mandible in preparation foralveolar ridge distraction. B, Distraction device in place.C, Bony regenerate at the distraction site is visible at thetime of device removal.

B

A

C


findings in edentulous areas. Oral Surg1960;13:1342.

9. Ochs MW, Tucker MR. Preprosthetic surgery.In: Peterson LJ, Ellis E, Hupp J, Tucker M,editors. Contemporary oral and maxillofa-cial surgery. 4th ed. St Louis: Mosby; 2003.p. 248–304.

10. Enlow DH, Kuroda T, Lewis AB. The morpho-logical and morphogenetic basis for cranio-facial form and pattern. Angle Orthod1971;41:161–88.

11. Wozney JM. The bone morphogenetic proteinfamily and osteogenesis. Mol Reprod Dev1992;31:160–7.

12. Moss ML. The primary role of functionalmatrices in facial growth. Am J Orthod1969;55:566–77.

13. Ilizarov GA. The tension-stress effect on thegenesis and growth of tissues. Clin Orthop1989;238:249–81.

14. Ilizarov GA, editor. Transosseous osteosynthe-sis. Germany: Springer-Verlag; 1992.

15. Sullivan WG, Szwajkun PR. Revascularizationof cranial versus iliac crest bone grafts inthe rat. Plast Reconstr Surg 1991;87:1105–8.

16. Burchardt H. The biology of bone graft repair.Clin Orthop 1983;174:28–42.

17. Reddi AH, Weintroub S, Muthukumaran N.Biologic principles of bone induction.Orthop Clin North Am 1987;18:207–12.

18. Hosney M. Recent concepts in bone graftingand banking. J Craniomandib Pract 1987;5:170–82.

19. Becker WM, Urist M, Tucker L . Human deminer-alized freeze-dried bone: inadequate inducedbone formation in athymic mice. A prelimi-nary report. J Periodontol 1995;66:822–8.

20. Wozney JM, Rosen V, Celeste A, et al. Novel reg-ulators of bone formation: molecular clonesand activities. Science 1998;42:1528–34.

21. Dean OT. Surgery for the denture patient. J AmDent Assoc 1936;23:124–32.

22. Kent JN, Jarcho M. Reconstruction of the alveo-lar ridge with hydroxyapatite. In: Fonseca R,Davis W, editors. Reconstructive preprosthet-ic oral and maxillofacial surgery. Philadel-phia: WB Saunders; 1985. p. 853–936.

23. Wiltfang J, Schlegel K, Schultze-Mosgau S, etal. Sinus floor augmentation with beta-tricalciumphosphate (beta-TCP): doesplatelet-rich plasma promote its osseousintegration and degradation? Clin OralImplants Res 2003;14:213–8.

24. Stvrtecky R, Gorustovich A, Perio C, Gugliel-motti MB. A histologic study of boneresponse to bioactive glass particles usedbefore implant placement: a clinical report.J Prosthet Dent 2003;90:424–8.

25. Taylor JC, Cuff SE, Leger JP, et al. In vitro

osteoclast resorption of bone substitutebiomaterials used for implant site augmen-tation: a pilot study. Int J Oral MaxillofacImplants 2002;17:321–30.

26. Alexopoulou M, Semergidis T, Sereti M. Allo-genic bone grafting of small and mediumdefects of the jaws. Presented at the XIVcongress of the European Association forCranio-Maxillofacial Surgery. 1998 Sep-tember 1–5; Helsinki, Finland.

27. Sclar AG. Preserving alveolar ridge anatomyfollowing tooth removal in conjunctionwith immediate implant placement. TheBio-Col technique. Atlas Oral MaxillofacSurg Clin North Am 1999;7(2):39–59.

28. Kalas S. The occurrence of torus palatinus andtorus mandibularis in 2,478 dental patients.Oral Surg 1953;6:1134–43.

29. Bhaskar SN. Synopsis of oral pathology. 7th ed.St. Louis: Mosby; 1986.

30. Guernsey LH. Reactive inflammatory papillaryhyperplasia of the palate. Oral Surg1965;20:814–27.

31. Starshak TJ. Corrective soft tissue surgery. In:Sharshak TJ, Saunders, B, editors. Prepros-thetic oral and maxillofacial surgery. St.Louis: Mosby; 1980.

32. Hartwell CN Jr. Syllabus of complete dentures.Philadelphia: Lea & Febiger; 1968.

33. Obwegeser H. Die Submukose Vestibulumplaspik.Dtsch Zahnarztl Z 1959;14:629–38.

34. Kazanjian VH. Surgical operations as related tosatisfactory dentures. Dent Cosmos1924;66:387–91.

35. Keithley JL, Gamble JW. The lip-switch: amodification of Kazanjian’s labial vestibu-loplasty. J Oral Surg 1978;36:701–07.

36. Trauner R. Alveoloplasty with ridge extensionson the lingual side of the lower jaw to solvethe problem of a lower dental prosthesis.Oral Surg 1952;5:340–8.

37. MacIntosh RB, Obwegeser HL. Preprostheticsurgery: a scheme for its effective employ-ment J Oral Surg 1967;25:397–415.

38. Richardson D, Cawood JI. Anterior maxillaryosteoplasty to broaden the narrow maxil-lary ridge. Int J Oral Maxillofac Surg1991;20:343–8.

39. Terry BC, Albright JE, Baker RD. Alveolar ridgeaugmentation in the edentulous maxillawith the use of autogenous ribs. J Oral Surg1974;32:429–34.

40. Terry BC. Subperiosteal onlay grafts. In:Stoelinga PJW, editor. Proceedings Consen-sus Conference: 8th International CongressConference in Oral Surgery. Chicago:Quintessence International; 1984.

41. Nystrom E, Ahlqvist J, Kahnberg KE, Ronsen-quist JB. Autogenous onlay bone grafts

fixed with screw implants for the treatmentof severely resorbed maxillae. Radiographicevaluation of preoperative bone dimen-sions, postoperative bone loss, and changesin soft tissue profile. Int J Oral MaxillofacSurg 1996;25:351–9.

42. Vermeeren JI, Wismeijer D, van Wass MA.One-step reconstruction of the severelyresorbed mandible with onlay bone graftsand endosteal implants. A 5-year follow-up.Int J Oral Maxillofac Surg 1996;25:112–5.

43. Nystrom E, Lundgren S, Gonne J, Nilson H.Interpositional bone grafting in LeFort Iosteotomy for reconstruction of theatrophic edentulous maxilla. A two stagetechnique. Int J Oral Maxillofac Surg1997;26:423–7.

44. Keller EE, Eckerd SE, Tolman DE. Maxillaryantral and nasal one stage inlay compositebone graft. A preliminary report on 30recipient sites. J Oral Maxillofac Surg1994;52:438–48.

45. Astrand P, Nord PG, Brånemark PI. Titaniumimplants and onlay bone grafts to theatrophic edentulous maxilla. A three yearlongitudinal study. Int J Oral MaxillofacSurg 1996;25:25–9.

46. Bell WH, Profit WR, White RP Jr. Surgical cor-rection of dentofacial deformities. Philadel-phia: W.B. Saunders; 1980.

47. Piecuch J, Segal D, Grasso J. Augmentation ofthe atrophic maxilla with interpositionalautogenous bone grafts. J Maxillofac Surg1984;12:133–6.

48. Cawood JI, Stoelinga PJW, Brouns, JJ. A recon-struction of the severely resorbed, Class VIin maxilla. A two step procedure. Int J OralMaxillofac Surg 1994;23:219–25.

49. Piecuch JF, Silverstein K, Quinn PD. Bonegrafts in preprosthetic surgery. Oral Max-illofacial Surgery Knowledge Update, Vol II.Chicago (IL): American Association of Oraland Maxillofacial Surgeons; 1998. p. 11–31

50. Locher MC, Sailer HF. Results after a LeFort Iosteotomy in combination with titaniumimplants: sinus inlay method. Oral Maxillo-fac Surg Clin North Am 1994;6:679–88.

51. Block MS, Kent JN. Sinus augmentation for den-tal implants: the use of autogenous bone.J Oral Maxillofac Surg 1997;55:1281–6.

52. Thoma KH, Holland DJ. Atrophy of themandible. Oral Surg 1951;4:1477–81.

53. Curtis T, Ware W. Autogenous bone graft pro-cedures for atrophic edentulous mandibles.J Prosthet Dent 1977;38:366–79.

54. Saunders B, Cox R. Inferior border rib graftingfor augmentation of the atrophic edentulousmandible. J Oral Surg 1976;34:897–900.

55. Davis WH, Delo RI, Ward WB. et al. Long term


ridge augmentation with rib graft. J Max-illofac Surg 1975; 3:103–6.

56. Bell WH, Buche W, Kennedy J III, et al. Surgi-cal correction of the atrophic alveolar ridge:a preliminary report on a new concept oftreatment. Oral Surg 1977;43:485–98.

57. Baker RD, Connole PW. Preprosthetic aug-mentation grafting: autogenous bone. JOral Surg 1977;35:541–51.

58. Quinn PD. The atrophic mandible: an alterna-tive to superior border grafting. In: Wor-thington P, Evans J, editors. Controversiesin oral and maxillofacial surgery. Philadel-phia: W.B. Saunders; 1994. p. 460–6.

59. Quinn PD, Kent JN, MacAfee KA. Reconstruct-ing the atrophic mandible with inferior

border grafting and implants: a preliminaryreport. Int J Oral Maxillofac Implants1992;7:87–93.

60. Miloro M, Quinn PD. Prevention of recurrentpathologic fracture of the atrophicmandible using inferior border grafting:report of two cases. J Oral Maxillofac Surg1994;52:414–20.

61. Stoelinga PJW. Preprosthetic reconstructivesurgery. In: Peterson LJ, Indresano AT, Mar-ciani RD, Roser SM, editors. Principles oforal and maxillofacial surgery. Philadel-phia: JB Lippincott Co; 1992. p. 1169–207.

62. Peterson LJ, Slade E. Mandibular ridge augmenta-tion by a modified visor osteotomy: a prelim-inary report. J Oral Surg 1977;35:999–1004.

63. Harle F. A follow up investigation of surgicalcorrection of the atrophied alveolar ridgewith visor osteotomy. J Maxillofac Surg1979;7:283–93.

64. Schettler D, Holtermann W. Clinical and exper-imental results of a sandwich-technique formandibular alveolar ridge augmentation. JMaxillofac Surg 1977;5:199–202.

65. Stoelinga PJW, Tideman H. Interpositionalbone graft augmentation of the atrophicmandible: a preliminary report. J Oral Surg1978;36:30–2.

66. Chin M. Alveolar distraction osteogenesis. In:Samchucov ML, Cope JB, Cherkashin AM,editors. Craniofacial distraction osteogene-sis. St. Louis: Mosby; 2001. p. 387–92.

Preprosthetic and Reconstructive Surgery

Documents

Transcript of Preprosthetic and Reconstructive Surgery