‫ علي الحسيني‬.‫د‬.

‫ا‬

Preprosthetic Surgery

By definition prosthetics is the replacement of missing teeth and contiguous oral and
maxillofacial tissues, with artificial substitute to compensate the cosmetic and function.
A significant number of patients, who can't use dentures effectively, because of bone atrophy,
soft tissue hypertrophy or localized soft and hard tissue problems, which have progressed
beyond the point of prosthetic accommodation. It is in these patients, that preprosthetic
surgery offers a significant contribution.
Preprosthetic surgery is carried out to reform soft and/or hard tissues, by eliminating
biological obstacles to receive comfortable and stable prosthesis.
Pathophysiology of Edentulous Bone Loss
Complete denture retention and stability is dependent on the physical features of the alveolar
process such as contour and height. Over the years, the progressive bone loss, which is seen in
the individuals, can negatively impact prosthetic stability and retention.
Causes of bone loss:
1. Metabolic factors:
Bone loss due to metabolic factors:
A. Osteoporosis:
Loss of bone mass, where there is thinning of cortex, and volume loss of cancellous
bone. Ratio of unmineralized organic matrix (osteoid) to mineralized matrix is normal.
It occurs due to senile osteoporosis, postmenopausal osteoporosis, hyperparathyroidism,
and Cushing's syndrome.
B. Osteomalacia:
Loss of bone volume, increase in the ratio of unmineralized organic matrix to
mineralized matrix. It occurs due to vitamin D deficiency, malnutrition, renal
osteodystrophy, and secondary hyperparathyroidism.
2. Aging; Continuous pneumatization of the maxillary sinus. Continuous resorption of
the alveolar ridges after teeth extractions over the years.
3. Trauma; Bone loss secondary to trauma affects the dentoalveolar process and
overlying tissue.
4. Periodontal disease; Generalized bone loss is seen due to extensive periodontal
problems. The alveolar process loss in the vertical fashion more than the width.
5. Disuse atrophy; It can cause alveolar bone loss. But, it is of less importance, when
compared with the bone loss in denture wearers.
6. Long-term denture usage; compressive forces result in bone resorption. Forces applied
to the denture bearing areas by the denture are compressive in nature. This results in
resorption of the alveolar ridges. Ill-fitting dentures offer excessive compressive
forces.

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 Patterns of bone loss
1. Tallgren in 1972 stated that most of the bone loss occurs in the first year of denture
wearing and it is ten times greater than the loss seen in the following years. The
edentulous bone loss is up to 1 mm per year.
2. The bone loss in the mandible is four times more than in the maxilla over the years
(maxilla distributes the compressive forces over a wider surface area).
3. Extractions of teeth done at different times with long-time gaps will exhibit irregular
bony ridge pattern.
Aims of preprosthetic Surgery
1. Provide adequate bony tissue support for the placement of removable partial or
complete denture (optimum ridge height and width).
2. Provide adequate soft tissue support.
3. Elimination of pre-existing bony deformities, e.g. tori, prominent mylohyoid ridge,
genial tubercle.
4. Elimination of pre-existing soft tissue deformities, e.g. epulis, flabby ridges,
hyperplastic tissues.
5. Correction of maxillary and mandibular ridge relationship.
6. Relocation of frenum and muscle attachments.
7. Transposition of mental nerve.
8. Establishment of correct vestibular depth.
Treatment planning and Examination:
For proper treatment planning, the medical and dental history should be given from the
patient and a good clinical examination which include careful assessment of both soft and
hard tissues, facial esthetic examination, study models and radiological examination.
Extraoral Examination:
Facial symmetry, TMJ, mouth opening, salivary glands, lymph nodes, jaws relationship, etc.
Intraoral Examination:
Examination of the alveolar ridges, both maxillary and mandibular should be carried out
along with the soft tissue examination of the entire oral cavity including posterior pharynx.
Inspection and palpation should be carried out.
1. Ridge form, height and width should be inspected.
2. Quality and quantity of the overlying soft tissues of the denture bearing areas to be
ascertained (vestibular depth, flabby tissue).
3. Location of labial and lingual frenum and muscle attachments in relation to the alveolar
crest should be noted.
4. Presence or absence of soft tissue and bony pathology, exostosis, undercuts, tori should be
looked for.
5. Relationship of the maxillary alveolar arch to the mandibular alveolar arch in all three
planes (horizontal, vertical and transverse).
6. The amount of keratinized tissue firmly attached to the underlying bone or freely movable
tissue.
7. Inflammatory areas, scars, ulcers, hyperplastic tissues due to ill-fitting dentures should be
looked for.

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 Radiological evaluation:
Radiological assessment should include Periapical, Occlusal, OPG or Cephalometric
radiographs, and in difficult case it may needs CBCT. The radiographs should be studied to
detect any bony pathological lesions, bony trabecular pattern, distance of the neurovascular
bundle from the alveolar crest, level of mental foramen, and pneumatization of maxillary
sinus.
Diagnostic models:
It should be mounted on an articulator with proper vertical dimension and studied.

Preprosthetic Surgical Procedures:

Preprosthetic surgical procedures can be classified as basic procedures and advanced surgery
procedures.
The basic procedures can be carried out under LA, while advanced procedures will require
hospitalization and general anesthesia.
The procedures can be carried out for the following:
1. Alveolar ridge correction
2. Alveolar ridge extension
3. Alveolar ridge augmentation.

1. Alveolar Ridge Correction:

A. Bony surgeries:
❖ Alveoloplasty
Surgical recontouring of the alveolar process is termed as alveoloplasty. Clinically, after
extraction, whenever there is a presence of sharp margins at interseptal or labiobuccal alveolar
crest, they should be trimmed with rongeur or round bur and smoothened with bone file. The
trimming of the alveolar process should be carried out gently. Care is taken that only
minimum trimming of the areas. Too much bone loss will result into poor denture base.
The aim of Alveoloplasty is to recontour the alveolar' ridge for providing best possible tissue
contour for denture support by maintaining as much bone and soft tissue as possible.

❖ Alveoloplasty after multiple extractions

Immediately after extractions, the buccal and lingual plates should be compressed with gentle
digital pressure and the gingival tissue is repositioned and the entire ridge is palpated for
locating sharp bony spicules or undercuts. These should be trimmed with rongeur and the
edges smoothened with bone file. In case, if there is any excess redundant tissue is present,
then it should be trimmed with surgical scissors and interrupted suturing should be done.
Elevation of a mucoperiosteal flap and buccal cortex reduction can be done for removal of
undercuts with rongeur or a rotary bur.

❖ Interseptal Alveoloplasty – Dean's alveoloplasty with repositioning of labial cortical

bone
➢ Used in maxilla only (mainly in the anterior region).
➢ Technique is usually used to reduce gross maxillary overjet.
➢ To reduce the volume of cancellous bone, maintaining stress bearing cortical bone intact.
➢ Does not require raising a mucoperiosteal flap.

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 ➢ Carried out immediately after extractions of anterior teeth.
➢ Maintenance of periosteal attachment to the labial plate of bone (decreases postoperative
bone resorption and helps remodeling).
➢ To reduce a buccal undercut or labial prominence without significantly reducing the
height of the alveolar ridge.
Technique:
• Teeth should be extracted with minimum trauma (atraumatic extractions) to the labial cortex.
• With straight fissure bur attached to the surgical handpiece or with rongeur, interseptal bone
is cut from canine-to-canine region.
• With the same bur, vertical cuts are made only in the labial cortex at distal end of the canine
extraction sockets bilaterally, without perforation of labial mucosa in the Dean's technique.
• With periosteal elevator/osteotome placed into the base of canine sockets bilaterally, labial
cortex is fractured (greenstick fracture attached to labial mucosa(.
• Digital pressure is used to compress the fractured labial cortex into the palatal direction.
• Labial plate and palatal plate will come into approximation with each other.
• Any sharp margins at the newly created alveolar crest are filed with bone file.
• Interrupted or continuous suturing is carried out.

❖ Obwegeser's Modification for Interseptal Alveoloplasty

Repositioning of both labial and palatal cortices. It is used when the maxillary overjet is gross
and inward compression of only labial cortex is not sufficient to reduce the overjet.
• After cutting the interseptal bone, an inverted cone vulcanite bur is used to widen the socket
at the base.
• With small disc bur, horizontal cuts are made at the base of the extraction sockets in the labial
and palatal cortices.
• With a straight fissure bur, vertical cuts are then made bilaterally in both labial and palatal
cortices in the area distal to canine sockets.
• With digital pressure, both labial and palatal cortices are compressed together and sutures
done.

❖ Elimination of unfavorable undercuts

Due to severe atrophy of the mandible, unfavorable prominences may hinder with the proper
denture construction. These undercuts are usually seen in mandibular lingual aspect; genial
tubercle prominence, sharp mylohyoid ridge prominence can be noted. Sometimes ulceration
or inflammation at this region is also seen. Patient is asked to discontinue the use of the
dentures and surgery should be planned to relieve these undercuts.

❖ Reduction / Resection of the genial tubercles

The genial tubercles, the bony attachments of the genioglossus muscle can become an area of
interference, the gross resorption of the mandibular ridge. The level of the genial tubercles in
these cases is seen almost at the crestal level on the lingual aspect. A shelf like projection is
seen, which will dislodge the lower denture with slight amount of tongue movements.

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 Technique:
• After infiltration of local anesthetic solution, a crestal incision is made from the lower canine
to canine region,
• No reflection of the flap is done on the labial side.
• A full thickness mucoperiosteal flap is reflected to expose the genial tubercle.
• The muscle attachment is removed with sharp dissection.
• Excision of the tubercle is done by rotary instrumentation or rongeur
• Smoothening can be done with a bone file
• Copious irrigation of the area prior to suturing is needed

❖ Reduction of mylohyoid ridge

Usually there will be concavity present, immediately below the alveolar crest with
prominence of mylohyoid ridge below. This procedure can be performed by using local
anesthesia block technique of lingual nerves.
Technique:
• A crestal incision is done in the posterior ridge region
• Oblique releasing incision is given at the distal end of the incision, going toward buccal
cheek area to avoid damage to lingual nerve
• Mucoperiosteal flap reflected on the lingual side to expose the medial surface of the mandible
at the mylohyoid ridge region
• The tissue from the floor of the mouth and lingual mucoperiosteum is protected by inserting
flat blade of the tongue depressor in between the flap and the bone
• By using osteotome or round bur, the reduction of the mylohyoid ridge is carried out, after
dissecting mylohyoid muscle fibers away
• Bone is smoothened with bone file
• Reposition of the mylohyoid muscle inferiorly and the soft tissue flap is returned back. The
lingual vestibule checked with digital pressure for any sharp areas.
• After complete smoothening, wound closure is done.

❖ Excision of Tori
Torus is bony exostosis/overgrowth of cortical/cortico-cancellous bone, which is localized to
particular area, usually benign and asymptomatic and slow growing. Origin is unknown.
In maxilla; it is usually seen in midline of the palate. Incidence is 20 % in females, 10% in
male patients. Multiple shapes and configurations can be seen. It will vary from single smooth
elevation to multi-lobulated, pedunculated bony masses.
In mandible; found in 8% of population, with same incidence in males and females. Usually
bilateral tori in the premolar region on the lingual aspect are seen. May be single or multiple
or multilobulated.
Indications for reduction/removal/excision of tori:
[Link] extremely large torus, the upper or lower partial/complete denture construction is not
possible, unless tori are excised.
2. A large torus that may extend beyond the post-dam area.
3. Ulceration, traumatization, and hyperkeratinization of the overlying mucosa.
4. Deep bony undercuts.
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 5. Interference with the function (speech or deglutition)
6. Psychological consideration (cancer phobia).
7. Food lodgment under the folds and projection of the tori.
Technique for Excision of Palatal Torus:
• Local anesthesia, bilateral greater palatine and incisive nerve block
• Anteroposterior linear incision is made in the midline of the palate
• Y-shaped releasing incisions at one or both the ends of incision
• Thin lobulated mucosa should be carefully handled
• Two mucoperiosteal flaps are raised with periosteal elevator, from the midline, sideways.
• Retraction sutures can be placed on both the flaps to maximize the exposure.
• The torus should never be excised in mass, because of the proximity to the nasal floor,
perforation into the nose (oronasal communication).
• Division of the torus into multiple segments should be done with the bur (vertical and
horizontal multiple cuts).
• The small pieces removed with the chisel and mallet.
• Large round bur is used gently to final finish.
• Excess soft tissue should be trimmed
• Prefabricated acrylic stent/splint wears to prevent haematoma.
Possible complications:
[Link]-injury to greater palatine vessels.
[Link] of the palatal shelf.
[Link]/oroantral communication.
[Link] haematoma, sloughing/necrosis of the palatal mucosa.
Technique for excision of Mandibular Tori:
• Local anesthesia, inferior alveolar nerve block anesthesia.
• Incision over alveolar ridge in lower premolar region.
• Mucoperiosteal flap is raised, only on the lingual aspect of the mandible, without perforation
over the torus area.
• Make groove with the bur, on the medial aspect of the torus, parallel to the medial surface of
the mandible from the base to the superior margin.
• Gentle tapping to excise the entire torus with the osteotome placed in the groove and
smoothening with round bur/bone file.
• Irrigation and suturing.
Possible complications
[Link] to submandibular salivary gland duct.
[Link] bleeding.
[Link] of the mylohyoid muscle.
[Link] of the flap.
[Link]: Life-threatening hemorrhage in the floor of the mouth, infection and airway
obstruction (injury to sublingual artery).

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❖ Maxillary tuberosity reduction and exostosis removal
• Excess horizontal and vertical bony/soft tissue in the maxillary tuberosity region may
interfere with denture construction.
• Excessive bony undercut/mobile or hyperplastic fibrous tissue may be present.
• Radiographs are often necessary: periapical and OPG. To determine the extent of the bone
and soft tissue in the enlarged tuberosity region and to locate the level of the floor of the
maxillary sinus.
Technique
•Local anesthesia, infiltration of posterior superior alveolar and greater palatine blocks.
•A crestal elliptical incisions from tuberosity to premolar area.
•The mucoperiosteum is undermined and the section of the tissue between the elliptical
incisions is removed.
• If the excess soft tissue is fibrous, hyperplastic, then the medial margins of the incisions on
both sides are thinned out tangentially to remove the wedge of excess fibrous tissue till the
bony crest.
• If the excess tissue is primarily bone, then rest of the mucoperiosteum is reflected till the
vestibular depth.
• Excess bone/buccal exostosis is then removed from the crest of the ridge and from the
buccal plate (if excessive undercut exists). This can be accomplished with chisel and mallet
or burs.
• After the desired contour is achieved, the excess soft tissue is trimmed along the incision
edges to correct the excess tissue.
• The flap is sutured and a stent is placed.
• In case of sinus perforation, a collagen matrix, platelets rich fibrin or barrier membrane can
be placed prior to suturing.

B. Soft tissue surgeries

❖ Removal of excess crestal soft tissue:
• Presence of fibrous, hyperplastic tissue often gives rise to flabby ridge form, results in
unstable base for dentures.
•In maxilla - enlarged tuberosity.
•In mandible-enlarged retromolar pad.

❖ Ill fitting dentures

A. Denture granuloma or hyperplasia

It is seen in palatal region or at the vestibular depth, obliterates the sulcus or sometimes on
lingual aspect of the lower dentures. The tissue is inflamed, fibrous and hyperplastic.
Irrespective of the site, to reduce this hyperplastic issue, elliptical incisions are done on either
side of the issue and later on submucosal excision of the excess issue is carried out. The
patient is instructed to stop using the ill-fitting dentures.

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 B. Epulis fissurata
These are the benign, pedunculated lesions present as excessive tissue of the vestibule,
frequently associated with over extension of the denture border or ill-fitting dentures.
Treatment by excision, electrocauterization, and cryosurgery or laser excision can be done.

C. Palatal papillary hyperplasia

It is due to chronic denture irritation due to ill-fitting dentures. There can be superimposed by
candida infection. Denture should be relieved in this area and antifungal agents can be
prescribed prior to excision of the lesion. Supraperiosteal excision with electrocautery can be
done.

❖ Frenectomy
Frenal attachment is a thin band of fibrous tissue and a few muscle fibers covered by mucous
membrane.
Indications for surgical removal:
[Link] attachments of labial frenum or fibrous bands attached near the alveolar crest in the
buccal regions, often displace the dentures during function.
[Link] times ulceration can be seen at the frenal attachments due to impingement of the
denture peripheries. One option is to relieve the denture borders at these frenal attachments,
but for persistent problem, frenectomy should be considered.

❖ Maxillary midline frenum or labial frenum

It usually extends from the upper lip to the crest of the alveolar ridge and it extends toward
palate to the incisive papilla. Whenever there is a lot of tissue is available, and then a cross-
diamond excision is used. The base of the frenum at the alveolar crest is grasped with
hemostat and incision is taken below and above the hemostat. The surgical defect is created
by excision of fibrous band. The closure can be done by interrupted sutures. The small defect
at the alveolar crest can be healed by secondary intention.
The Z plasty procedure can be used, when the frenum is broad and the vestibule is short.
These types of procedures can be used for eliminating the frenum, as well as for deepening
the vestibule. V-Y type of incision can be used for lengthening localized area.
Broad frenum in premolar-molar area can be treated by semilunar incision at the
mucogingival junction and a supraperiosteal dissection is done. The superior edge of the
incision is sutured at the depth of the vestibule to the periosteum and the rest of the raw area
below is allowed to heal by secondary epithelialization. Use of prefabricated stent is
necessary.

❖ Lingual Frenectomy
Lingual frenum is attached to the crest of the alveolar ridge and it connects to the tongue,
below the tip of the tongue in edentulous patient. This condition is also known as tongue tie or
ankyloglossia.
Aim of surgery:
1. To correct speech
2. Prior to denture construction
[Link] improve the tongue mobility

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 Technique
• Local anesthesia; bilateral lingual nerve block with local infiltration.
• Tongue traction suture is done to improve visibility and stabilization of the tongue during
procedure.
• One hemostat can be placed at the anterior attachment of the frenum to the tongue and
another hemostat be placed at the inferior attachment to the ridge.
• A cross-diamond incision along the edge of both the hemostats is made.
• Submucosal dissection on either side to undermine lingual and sublingual mucosa is
carried out.
• Care is taken to avoid damage to the submandibular duct orifice.
Intraoperative possible complications:
1. Injury to sub lingual artery
2. Injury to Wharton's duct/papilla.
Postoperative complications:
1. Hematoma in the floor of the mouth
2. Pain and restricted tongue movements
3. Partial dysphasia

2. Alveolar Ridge Extension

Whenever there is an inadequate vestibular depth present, (due to alveolar bone atrophy and
high muscle and soft tissue attachments). To increase the retention and stability of the
denture, deepening of the vestibule is considered. In extreme atrophy cases, where resorption
of the basal bone has taken place, this option is out of consideration.
Deepening of the vestibule without any addition of the bone is termed as vestibuloplasty or
sulcoplasty. Vestibuloplasty can be done in the maxilla or in the mandible or in both jaws.
Mandibular techniques are further divided into two categories:
➢ Labial vestibuloplasty
➢ Lingual vestibuloplasty.
❖ Labial vestibuloplasty
The procedure will be known as transpositional flap vestibuloplasty or lip switch procedure,
when the soft tissues from the inner aspect of the lip is shifted to a favorable zone on the
alveolar bone, so that the increase in the denture bearing area is achieved.
This method effectively increases the vestibular depth in the mandible, when the patient has a
bone height of 15 mm or more in the anterior region.

❖ Kazanjian Technique (1924): oldest Technique

Surgical procedure:
• An incision is made in the mucosa of the lip and a large flap of labial and vestibular
mucosa is reflected.
• Vestibule is deepened by a supraperiosteal dissection.
• Flap of mucosa is turned downward from its attachment on the alveolar ridge.
• The flap is placed directly against the periosteum to which it is sutured.

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 • A rubber catheter stent is placed into the deepened sulcus and fixed through the lip to the
outer surface with percutaneous sutures.
• The catheter helps to hold the flap in its new position and to maintain the depth of the
vestibule during the initial stages of healing.
• Catheter is removed after 7 days.
• The labial donor site is coated with tincture benzoin compound and left to heal by
secondary epithelization.
Complications:
Severe scarring of the lip mucosa may decrease the flexibility of the lower lip.

❖ Clark's Technique
Surgical procedure:
• An incision is started slightly labial to the crest along the alveolar ridge.
• Supraperiosteal dissection is done, along the labial surface of the alveolar bone till the desired
vestibular depth.
• Edge of the mobilized flap is pushed into the new vestibular depth area and held in position
by sutures passed through the chin area extraorally and tied around cotton roll or rubber
catheter placed below the chin.
• As the alveolar bone is covered by periosteal layer, it heals quickly by granulation.
• Success rate is better than Kazanjian method.
❖ Obwegeser's Modification (1959)
Similar to Clark's method, except the area of the alveolar bone with its periosteal attachment
is covered with a split thickness mucosal or skin graft and held in position by sutures or stent
constructed preoperatively.
The benefits of this technique:
[Link] the bone and ensures faster healing.
[Link] chances of postoperative infection
3. Less bone loss and scarring.

❖ Lingual vestibuloplasty
Floor of the mouth extension:
[Link] provide an adequate denture bearing area.
[Link] the muscle attachments that dislodge the prosthesis.
[Link] in the mandible, when the mylohyoid and genioglossus attachments are close to the
alveolar ridge crest.

Floor of the mouth extension can be done by following methods:

❖ Trauner's technique:
Used for increasing the depth of the floor of the mouth in the mylohyoid region.
Technique:
• Incision given over lingual side of the alveolar ridge bilaterally, in the posterior region or
from second molar to second molar region
• Supraperiosteal dissection is done to identify mylohyoid muscle

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 • Instrument is passed below mylohyoid muscle and separated from the bony attachment
• Care is taken to avoid lingual nerve damage.
• Fixation of incised edge of the mylohyoid muscle to a new desired vestibular depth on
lingual side by:
a. Sutures passed extraorally over the skin at the inferior border of the mandible
b. Placement of the skin graft and preformed denture/stent.
❖ Obwegeser's Technique (Combination of Buccal and Lingual vestibuloplasty)
Technique:
• Incision is done on the alveolar ridge
• Supraperiosteal flap raised buccally and lingually
• Mylohyoid muscle attachment and only superficial fibers of genioglossus muscle are
separated on the lingual side.
• Edges of buccal and lingual flaps sutured to each other below inferior border of the mandible.
• Skin graft is placed over entire alveolar ridge. Preformed acrylic stent/denture placed and
fixed to the mandible, with circummandibular wiring.

❖ Mental Nerve Transposition

Patients with severe mandibular atrophic ridge, complain of pain after wearing the denture.
The cause is the superior position of the mental neurovascular bundle. Repositioning of the
nerve can relieve the pain. Level of the mental foramen is ascertained with the X-rays. A
crestal incision is done with buccal releasing incisions in the region of premolars.
Mucoperiosteal flap is reflected inferiorly to locate the nerve. Dissection below the foramen
till the inferior border of the mandible, should be done and the nerve is freed lightly and held
with the hook upward. A bony groove is cut below the mental foramen, only in the buccal
cortex. Then the nerve is positioned inferiorly and secured in place with gelfoam and the flap
is then sutured.

3. Alveolar Ridge Augmentation

Implant or bone grafts should be considered in the patient having less than 15 mm of bone
height in the anterior region. The mucosa must be healthy and exhibit no fibrosis, scarring or
hyperplasia. Also indicated when the alveolar ridge resorption is so extreme, that the alveolar
bone has completely disappeared. In maxilla, the height has been reduced to the point that a
nearly flat surface exists between the vestibule and palate and the piriform aperture lies just
beneath the gingiva. In the mandible, the basal bone has shown considerable amount of
resorption with the mental nerve positioned almost at the crest and very thin mandibular
alveolar ridge exists, which can end up in fracture easily. Vestibuloplasty is out of
consideration in such cases, until the replacement of necessary supportive bone is done.
Many techniques have been described for management of the maxilla and/or the mandible
atrophy.
Two approaches are available:
[Link] of alveolar bone
[Link] of implants.

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 Limitations:
Medical condition of the patient, healing capacity of the patient, nutritional deficiencies,
availability of adequate soft tissue coverage, and compliance of the patient for major surgery.
Materials used for augmentation of alveolar ridge
➢ Autogenous bone graft – iliac crest, rib grafts.
➢ Allogenic bone grafts – freeze dried cadaver bone
➢ Alloplastic material – hydroxyapatite.
➢ Metal mesh with autogenous cancellous bone.
➢ Metal mesh with hydroxyapatite.
None of the grafting materials have been considered as ideal or perfect. Various studies have
suggested that autogenous bone grafts either from iliac crest or rib show 28 % resorption at
the end of 6 months, 45 % at the end of one year, 78 % at the end of 2 years, and 89 % at the
end of 3 to 5 years, it is mainly vertical bone loss.

❖ Mandibular Augmentation
A. Superior border grafting/augmentation:
Davis in 1970 has described a technique for ridge augmentation that uses two 15 cm
autogenous rib grafts. One rib is secured at the cortex, followed by contouring the same rib in
the shape of the mandible. The rib graft is fixed to the mandible, either with transosseous
wiring or circummandibular wiring or bone plate. The other rib graft is made into
corticocancellous particles and moulded around the first rib graft. The surgical area is then
closed. Iliac crest grafting to the superior border also can be used. Hydroxyapatite blocks can
be used (pre carved in a horse shoe-shaped manner blocks are available).

Disadvantages
[Link] site morbidity.
[Link] surgical site necessary.
[Link] resorption of the grafted sites.
[Link] tissue dehiscence

B. Inferior border grafting:

This surgical procedure is indicated when the bony ridge is less than 5 to 8 mm in height and
is at risk of pathological fracture.
First described by Marx and Saunders in 1986 for construction of the mandible following
resection. Modified by Quinn in 1991 used for augmentation of atrophic ridge and subsequent
placement of implants.
Technique:
A supraclavicular incision similar to the incision used in bilateral neck dissection is made,
from mastoid-to-mastoid region. Subplatysmal dissection, till the inferior border of the
mandible is done. Incision through the periosteum is completed from angle to angle. A freeze-
dried allogenic graft will be used as a tray. A cancellous bone graft is harvested from the iliac
crest. The graft is then filled with autogenous cancellous graft particles and is fixed to the
inferior border by circummandibular fixation or by bone plates. The neck flap is closed in

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 tension free manner. Dental implants can be placed approximately 4-6 months following
surgery.
Advantages:
1. Since no surgery is done intraorally, patient's old dentures can be used as transitional
dentures
2. By using this technique 11 to 17 mm of bone augmentation can be achieved with a
resorption rate of only 5% over the first several years
3. Increased bone height to accommodate implant surgery
4. Also, lower one-third of the facial height is increased. Esthetically better results.
Disadvantages: Extraoral scar

C. Interpositional bone grafts (sandwich grafting)

During this procedure, a horizontal osteotomy is performed; splitting of the residual maxilla
or mandible and bone is grafted into this osteotomy gap.
In mandible, sandwich technique is mainly used for augmentation of the anterior mandible,
between the mental foramina. The autogenous or allogenic bone or hydroxyapatite grafts can
be used successfully. Delivery of the prosthetic appliance is delayed 3 to 5 months for
allowing the remodeling of the bone. Secondary vestibuloplasty procedures may be necessary.
Advantages:
1. Less resorption rate than onlay grafting.
2. Decreased incidence of nerve paresthesia than the visor osteotomy.
3. Can be used in conjunction with dental implants. Implants are placed through the superior
free segment of the bone and through the interpositional bone and secured inferiorly
within the remaining segment of the mandible. Implant success rate is reported as high as
98% with low resorption rate.

D. Onlay Grafting
When adequate height is present, but width is inadequate for prosthesis in the maxilla or
mandible, the option of onlay grafting should be considered. Oldest technique for onlay
augmentation with allograft, hydroxyapatite is advocated by Obwegeser via submucosal
vestibuloplasty technique. After creating a tunnel via midline, a putty is formed of
hydroxyapatite crystals, mixed with saline/blood, and is injected via syringe into the
submucosal tunnel.
Solid or porous blocks of hydroxyapatite have been used as onlay to improve the bony defect.
The hydroxyapatite crystal can be mixed with autogenous bone graft particles. Rib graft/iliac
crest bone graft can be used, as an onlay graft in the maxilla or mandible.
Dental implants can be used in conjunction with onlay bone grafting procedure.
Advantages:
[Link] the height and width of the maxillary alveolar bone
[Link] be used both in the anterior and posterior region.
Technique:
A high vestibular incision is taken to facilitate good water tight closure and to achieve good
undermining of the tissues for relaxation. Mucoperiosteal flap is reflected to expose the
defect. Small perforations are made in the external cortex by using small round bur to create
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 bleeding and promotion of clot formation and neovascularization. The grafting material is
placed over the external cortex. Placement of barrier membrane helps in regeneration and
preservation of the graft.

❖ Visor Osteotomy
The goal of Visor osteotomy is to increase the height of the mandibular ridge for denture
support. The Visor osteotomy consists of central splitting of the mandible buccolingually and
the superior positioning of the lingual section of the mandible, which is wired in position.
Cancellous bone graft material is placed at the outer cortex over the superior labial junction
for improving the contour.

❖ Modified Visor osteotomy

Consist of splitting the mandible buccolingually by vertical osteotomy only in the posterior
regions and a horizontal osteotomy in the anterior region. The posterior lingual segments are
then pushed superiorly on both sides and the anterior fragment is also pushed superiorly and
fixed by wires to the posterior newly mobilized lingual segments. Corticocancellous bone
graft particles with hydroxyapatite granules is placed in the gap between the superior and
inferior anterior segments. Rest of the graft material can be moulded on the buccal aspect of
the posterior segments.
Disadvantages:
[Link] paresthesia and dysaesthesia.
[Link] for hospitalization.
[Link] site morbidity.
[Link] to wear the dentures for 3 to 5 months following surgery.

❖ Maxillary augmentation
1. Sinus lift procedure:
It is mainly used to assist the placement of dental implants in the posterior maxilla. Due to
pneumatization of the maxillary sinus and atrophy of the ridge, the sinus floor is lowered
almost to the crest of the alveolar ridge in the posterior region. In order to improve the
implant support, the sinus lining at the floor is lifted up surgically and the bone graft is placed
between the sinus lining and the inner aspect of the alveolar crest.
Tatum (1986) was the first surgeon to perform the sinus grafts. A variety of materials have
been used with varying degree of success (autogenous bone, allogenic, tricalcium phosphate,
and hydroxyapatite).
Technique:
Intraoral incision is done on the maxillary crest or slightly on the palatal aspect with vertical
releasing incision from canine to tuberosity area. The anterolateral wall of the maxilla is
exposed by reflecting the mucoperiosteal flap. A bony window is made with a trap door type
osteotomy, just lateral and posterior to the canine fossa.
15 to 20 mm long inferior horizontal osteotomy cut is placed 3 mm above the sinus floor. The
anterior vertical osteotomy cut is placed perpendicular to horizontal osteotomy; the posterior
vertical cut is placed just at the maxillary buttress. The vertical cuts are joined superiorly by
placing small bur holes placed at small intervals without completing the superior cut. The trap

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 door type of bony window is then gently lifted up superiorly to expose the Schneiderian
membrane, which is then lifted up gently from the sinus floor and walls. The gap between the
lifted sinus membrane and the floor is filled with the graft material. Also there is another
technique which called Transcrestal or transalveolar technique, which lift the Schneiderian
membrane through the entrance via the crest of the alveolar ridge. For one stage surgery;
implant is inserted simultaneously with a corticocancellous iliac crest bone block. Otherwise a
waiting period of 6 to 9 months is advocated before implant placement.

2. Augmentation in combination with orthognathic surgeries

➢ Mandibular osteotomy
➢ Maxillary osteotomy
➢ Combination
Many osteotomies have been performed for reconstruction of edentulous atrophied
maxilla/mandible, as anterior maxillary osteotomy and LeFort I osteotomy, can be used along
with interpositioning of the grafts. Total maxillary osteotomy with palatal vault osteotomy
also can be used for deepening the palatal vault.
Problems encountered with augmentation technique
1. Inadequate soft tissue cover.
2. Rejection of grafts (failure of union with the host bone).
3. Dehiscence of overlying mucosa
4. Migration of the graft material
5. Resorption of the graft

Distraction osteogenesis
A new approach was performed for a patient with an extremely atrophic mandibular or
maxillary alveolar ridge by horizontal alveolar distraction to expand the ridge for implant
placement. Distraction osteogenesis (DO) performed by separating segments of bone by
osteotomy and the insertion of distraction device which provide gradual separation of bone
segments, and in its role produce continuous bone formation. There are several phases in DO
including; osteotomy, latency, distraction activation, consolidation, appliance removal, and
remodeling phases.
After surgical osteotomy, the distraction device was inserted and wait 7 days (latency period),
then activate the distraction device 0.25-0.5 mm twice daily, once the appropriate amount of
distraction is achieved and immature bone formed, the appliance remain in place not activated
during the consolidation phase allowing for mineralization of the regenerate bone, then the
appliance is removed, and the period from the application of functional load to the complete
maturation of the bone is termed remodeling phase.
Advantages; no need for bone graft, mucosal or skin graft and decreased neurological deficit.
Disadvantages; two surgical operations for the insertion and removal of the distraction device,
long treatment time and cost.

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