preprostheticsurg

8/7/2019 preprostheticsurg

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Preprosthetic SurgeryDavid L. Basi, DMD, PhD

Epidemiology of Aging

Elderly is defined as persons over theage of 65.

Between 1900 and 1990 the elderlypopulation increased from 3.1 million to31.1 million.

Currently, one in eight Americansconsists of the elderly population.

Epidemiology of Aging

By 2030, one in five Americans will be elderly(approximately 23% of the pop.).

Considered on of the fastest growing agegroups in the United States. (Some expertsbelieve that this is the only segment of thepopulation that is expected to growsignificantly in the future.)

Edentulous US population

10% entire US population 35% of the 65 and older population

Objective

To create supporting oral structures for placement of partial or completedentures

Ideal denture support:

1. Adequate bone height and width2. Fixed Tissue under dentures3. Adequate ridge relationships4. Adequate space between ridges5. Adequate buccal and lingual sulci6. Absence of redundant tissue7. No obstructing frena or scar bands8. No displacing muscle attachments9. Adequate saliva


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Ideal Denture Support:

Mylohyoid mm

mucosa

mandible

Deep

Vestibular depth

Broad Alveolar ridge

Adequate FOM

Ideal vs atrophicmandible

Lack of FOM or vestibular depth

Resorption of Maxilla Atrophy of Edentulous Mandible

Patient Evaluation

Evaluate maxilla and mandible for: Alveolar undercuts Palatal tori Mandibular exostosis Ridge relationship Ridge contour : broad vs. knife edge Ridge height and width


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Alveolar UndercutEvaluate for Exostoses

Maxillary Tori

Evaluate for soft tissue problems

Lingual fremum

Evaluate Interarch

Relationships


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Class IIIskeletalrelationship

Could besecondary to over closure of mandible

(loss of VDO)

Surgical Preparation of Mouth for Prostheses

Alignment of jaws (Orthognathic Surgery)

Removal of teeth (and roots)

Surgical Preparation of Mouth for Prostheses

Osseous surgeryMinor alveoloplasty (sharp areas)Adequate interarch distanceEliminate opposing undercutsEliminate tori

Soft tissue surgeryRelease frena

Thin fibrous tuberositiesPreserve attached gingiva

Alveoloplasty/ Alveolectomy

Simple (sharp edges)-Primary-Secondary

Interradicular (interseptal)

RadicalHorizontal or vertical problemsPre-radiation

Preserve Attached Gingiva!

General Considerations for PreprostheticSurgery

Most can be done w/ L.A.

Advanced forms of pain control are helpful

Patients are often old, infirm, and require workup andmonitoring

Restorative phase in 4 8 weeks postop


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Simple Alveoloplasty Simple Alveoloplasty

Intraseptal Alveoloplasty

Periosteal attachment ismaintained

Alveolar height is preserved

Alveolar width is lost

Removal of Tori & Exostoses

IndicationsChronic irritationInability to construct prosthesisOpposing undercutsHorizontal & vertical problems

Removal of Tori & Exostoses

ProblemsPneumatization of palatal torusThin mucosa over tori

Removal of Tori

Use LA to help balloon thin lingual tissue

Raising the flap is the most tedious portion

Remove Tori with:Surgical drill and fissure bur Osteotome and MalletA combination of both

Assure a dry field and inspect wound before closure


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Removal of Lingual Tori

Lingual

Removal of Palatal Tori

Removal of Buccal Exostoses Maxillary Tuberosity Reduction

Excess tissue in the maxillary tuberosity interferes withdenture construction

X-rays help delineate whether this excess tissue is soft or bony.

X-rays also demonstrate pneumatization of the max sinus

Models are often helpful.


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Soft Tissue Surgery

Release of Freni

Thin Palatal Fibromatoses

ALWAYS design flaps to preserve attached gingiva

FrenectomyFrenectomy

Z-plasty:

More useful for theshort vestibule


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Palatal papillary hyperplasia

Secondary to chronic denture irritation

Denture relief and oral antifungals can reduce the sizeof the lesion.


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Palatal papillary hyperplasia

Treatment Options

Large rotary bur Cryosurgery

*Laser Ablation

Post op splint or denture w/ liner is very helpful

Epulis Fissuratum

Epulis Fissuratum The Immediate Denture

The denture can be considered a temporary

Mandibular immediate dentures are difficult

The Immediate Denture

Remove all Max and Mand teeth except Max anterior

Perform necessary bone & soft tissue surgery

After adequate healing construct dentures

Remove anterior teeth and insert dentures

Reline after remodeling occurs (1 6 months)

The Immediate Denture

Potential Problems

Bone trim is difficult without a clear stent

Immediates work better when fewer teeth are extracted

Dont forget about tori, exostoses, & freni


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Class IIIskeletalrelationship

Needsorthognathicsurgery tocorrect skeletal

discrepancy

Complex preprosthetic

surgery


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Vestibuloplasty

Lowering the FOM

Preprosthetic Surgery

Complex Preprosthetic Surgery has been largelyobviated by the osseointegrated implant.


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Preprosthetic Surgery

Many preprosthetic procedures are done today in support of the implant.

Mucosal Grafts

Partial Thickness palatal dissection

de-fat the connective tissue side

Supraperiosteal dissection on themandible

Sew graft mucosa side up

Splints or a relieved denture can behelpful

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