Category Archives: Preprosthetic Surgery

Migraine

Migraine

Migrine is a common headache afflicting approximately 18% of woman and 8’M) of men. The first migraine

BOX 25-9

IHS Criteria for Migraine Headache without Aura

A. Two of the following:
I • ‘Unilateral headache pain location ..
• Headache pain has pullating q’uality .
• Moderate-ta-severe intensity
• Aggravation by routine physical activity
B. At least one ‘of the following:
• Nausea
• Photophobia and phonophobia’
C.Headache, untreated, lasting” to 72 hours
D. Both of the following:
• Similar pain in.the past
• No evidence of organic disease

BOX 29-6

IHS Criteria for Migraine Headache with Aura

A. Headache pain is preceded by fully reversible neurologic
symptoms, occurring over 5 to 60 minutes,
such ·as the following:
• Visual
• S.cintillating scotoma
• Fortific’ation spectra
• Photopsia •
sensory
• Paresthesia
• Numbness
• Unilateral weakness
• Speech disturbance
1 Common migraine characteristics:
I 1 Duration-usually 12 to 72 hours i :’! Sex-female/male ratio is > 2: 1
Neurologic aura40%

disorders ITM[)~IIThe mechanism for migraine headache: although not completely understood, appears to involve neurogenic Inflammation of intracranial blood vessels seeondarv to neurotransmitter imbalance iri certain brain stem centers. It is a referred pain process, and the intracranial
vessel involved determines the site of perceived pain ‘(e.g., the orbit, temple, jaw, vertex of the head). Preventive’ treatment is directed at normalizing neurotransmitter imbalance with antidepressants, anticonvulsants, .betablockers, and other drugs. Biofeedback and other therapies are also helpful. Treatment of acute attacks is with the – “triptans” (e.g., sumatriptan-Imitrex, zolmitriptan-Zomig, rizatriptan-Maxalt, naratriptan-Amerge, almotrtptan- Axert), ergots, nonsteroidal antiinflammatory drugs (NSAIDs), opioid analgesics, anti emetics, and other agents. For the dentist knowledge of migralne, is important,
because temporomandibular disorders may precipitate a migraine attack in a migraine-prone patient. Likewise, cervical spine and cervical muscular disorders may precipitate mlgraine. It is also important for the dentist to
recognize that cervical and mastjcatory muscle hyperactivity often occurs during a.migraine headache. Migraine may therefore be a perpetuating factor in-some TMDs or a reason for misdiagnosis.Although toothache and jaw, pains are. not a common expression of migraine, a number
of cases have been reported in the literature and are seen with some frequency by pain specialists. When migraine is a cause of jaw or face pain, the key to the diagnosis is recognizing that nausea,soriophobia, and
photophobia are not accompaniments of masticatory musculoskeletal disorders or jaw and tooth pain, of dental orign

Correction of Skeletal Abnormalities in the Totally Edentulous Patient

Correction of Skeletal Abnormalities in the Totally Edentulous Patient

After the appropriate clinical and radiographic evaluation, casts should be mounted on an articulator for  determination of the ideal ridge .relationship. The dentist responsible for prosthetic construction should be responsible for determining the final desired position of the maxilla and mandible after surgery. In the case of the totally edentulous patient in whom the maxilla,
mandible, or both are to be repositioned, the esthetic facial result must also be considered with the functional result of ridge repositioning. Casts with simulated surgical changes, cephalometric prediction tracings and experienced clinical judgment are required to determine

FIG. 13-4S-cont'd I ana J, Postoperative photograph showing result after proper construction of upper partial and lower full denture. K, Dashed lines (preoperative) and solid lines (postoperative) superimposed cephalometric tracings.

FIG. 13-4S-cont’d I ana J, Postoperative photograph showing result after proper
construction of upper partial and lower full denture. K, Dashed lines (preoperative) and
solid lines (postoperative) superimposed cephalometric tracings.

Segmental Alveolar Surgery in the Partially Edentulous Patient

Segmental Alveolar Surgery in the Partially Edentulous Patient 

Supraeruption of teeth and bony segments into an.opposing  edentulous area may decrease interarch space and preclude the construction of an adequate fixed or removableprosthetic appli.mr« in this area. ‘1Ill’ Ims of teeth in one 0arch may increase till’ difficulty of (JiJtaining a functional
and esthetic prosthetic appliance with prosthetic teeth located properly over the underlying ridge. Several altema- .tives exist to restore the dentition in these patients, including extraction of teeth in the mal positioned segment or repositioning-of these teeth with segmental surgery.
Preoperative considerations should include facial esthetic quality, an intraoral occlusal examination, panoramic and cephalometric radiographs, and modelsproperly mounted on an articulator. If segmental surgery is to be considered, the models can .be cut and teeth . repositioned in’ their desired location. The dentist responsible for final prosthetic restoration of the patient must ‘make the final determination of the placement of the segments on the articulated models. Presurgical .orthodontic preparation may be necessary to align teeth properly and allow proper segmental ‘positioning. After model surgery, a splint is fabricated to locate placement
of segments precisely at tbe time of surgery and to pro-

FIG. 13 43 Segmental osteotomies. A and B, Posterior maxillary osteotomy for superior and anterior repositioning of posterior segment of maxilla. This improves interarch space for construction of removable partial mandibular denture. C and D, Example of mandibular seqrnental oste9tomy to reposition molar tooth to function <IS distal abutment for fixed prosthetic appliance or for improved support as partial denture abutment.

FIG. 13 43 Segmental osteotomies. A and B, Posterior maxillary osteotomy for superior and anterior
repositioning of posterior segment of maxilla. This improves interarch space for construction of
removable partial mandibular denture. C and D, Example of mandibular seqrnental oste9tomy to reposition
molar tooth to function as partial denture abutment.

vide stability during the postoperative healing period. When possible the splint should be stabilized by contacting other teeth rather than resting on soft tissue. Palatal and lingual flanges on the splint should be avoided,
because pressure from the splint may interfere with blood supply important for the viability of the bone and teeth that were repositioned with segmental surgery. In  construction of the splint must include contact
on the alveolar ridge tissue of the opposing arch to maintain the interridge distance. The patient’s deformity and the surgeon’s preference and experience dictate the specific surgical procedure performed. Segmental procedures for correction of abnormalities in the maxilla and the mandible are described in Chapter 25 and in other textbooks _(Fig. 13_43).35 A final fixed and removable prosthetic rehabilitation follows the surgical procedure and an adequate postoperative healing period

 

 

 

 

 

 

CORRECTION OF ABNORMAL RIDGE RELATIONSHIPS

CORRECTION OF ABNORMAL RIDGE RELATIONSHIPS

Approximately S(Yt, of the population has a severe skeletal vdiscrepancy between their upper _and lower jaws that results in a severe malocclusion. When the teeth are lost, an abnormal ridge. relationship results that complicates construction of prosthetic appliances .. When a preexisting
class III ridge relationship exists, loss of teeth and the pattern of bony resorption increase the severity of the class IJJ skeletal problem. In patients with partially missing dentition, the absence of opposing occlusal forces
may allow the supracruption of .teeth, which may complicate subsequent prosthetic restoration .

 Preoperative photograph. G, Postoperative result.

Preoperative photograph. G, Postoperative result.

The assessment of ridge relationships is an important, often overlooked aspect of the evaluation’ of patients for prosthetic treatment. In partially edentulous patients the evaluation should include an examination of the direction of the occlusal plane and’ a determination of interarch distances that may be affected by supraerupted teeth or segments, In totally edentulous patients, the interarch ‘space and the anteroposterior’ jind transverse relationships of the maxilla and mandible must b evaluated with the patient’s jaw at the proper occlusal vertical dimension. This determination in the diagnostic phase may require the construction of bite rims with proper lip support. Lateral cephalometric radio graphs are also necessary in this evaluation to confirm the clinical impression.

Maxillary Vestibuloplasty with Tissue Grafting

Maxillary Vestibuloplasty with Tissue Grafting

When insufficient labiovestibular mucosa exists and lip shortening would result from a submucosal vestibuloplasty technique, other vestibular extension techniques must be used. In-such cases a modification of Clark’s vestibuleplasty technique using mucosa pedicled from the upper  lip and sutured at the depth of the maxillary vestibule after a supraperiostcal dissection can be  Tne denuded periosteum over the alveolar ridge heals by secondary epithelialization, Moderate discomfort can occur in the postoperative period, and a longer time is required (6 to 8 weeks: before denture construction. Main-tenance of the maxillary vestibular depth is  unpredictable,The use of a labially pedicled mucosal flap combined with
tissue grafting  over the exposed periosteum of the maxilla provides the added benefits of more rapid healing OH’r the area of previously exposed periosteum and more  dictable long-term maintenance of vestibular depth.

Submucosal Vestibuloplasty

Submucosal Vestibuloplasty

The submucosal vestibuloplasty as described by Obwegeser may be the procedure of choice for correction of soft tissue attachment on or near the crest of the alveolar ridge of the maxilla. This technique is particularly
useful when maxillary alveolar ridge resorption has occurred but the residual bony maxilla is adequate for proper denture support. In this technique, underlying submucosal tissue is either excised or, repositioned to allow direct apposition of the labiovestibular mucosa to the periosteum of the remaining maxilla. To provide adequate vestibular depth without producing an abnormal appearance of the upper lip, adequate . mucosal length must be available in this area. A sunple test to. determine whether adequate lablovestibular mucosa is present is performed by placing a dental mouth mirror under the upper lip and elevating the superior
aspect of the vestibule to the desired postoperative depth (Fig. 13-41). If no inversion or shortening of the lip occurs, then adequate mucosa is present- to perform a proper submucosal vestibuloplasty,  The submucosal vestibuloplasty can generally be performed with local anesthetic and intravenous (IV) seda  tion in an outpatient setting. A midline incision is made in the anterior maxilla, and the mucosa is undermined and separated from the underlying submucosal tissue (see Fig. 13-41). A supraperiosteal tunnel is then developed by dissecting the muscular and submucosal attachments from the periosteum. The intermediate layer of tissue created
by the two tunneling dissections is incised at its attachment area near the crest of the alveolar ridge. This submucosal and muscular tissue can be repositioned superiorly or excised. After closure of the midline incision,
a preexisting denture or prefabricated splint is modified to extend into the vestibular areas and is secured  with palatal screws for 7 to 10 .days to hold the mucosa over the ridge in close apposition to the’ periosteum. When healing takes place, usually within 3 weeks, the mucosa is closely adapted to the anterior and lateral walls of the maxilla at the required depth of the vestibule. The maxillary submucosal vestibuloplasty can also be combined with HA augmentation of the alveolar ridgearea. subperiosteal tunnelcan be created using a technique similar to standard maxillary HA augmentation
procedures.V By incising the periosteum high on the Iateral aspect of the mandible, the periosteal envelope can be enlarged to allow greater HA augmentation in this area

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·FIG. 13-41-cont'd B, Anterior vertical incision is used to create submucosal and then supraperiosteal tunnel along lateral aspects of maxilla. C, Cross-sectional view showing submucosal tissue .layer, D, Excision of submucosal soft tissue layer. E, Splint in place holding mucosa against periosteum at depth of vestibule until healing occurs

·FIG. 13-41-cont’d B, Anterior vertical incision is used to create submucosal and then supraperiosteal
tunnel along lateral aspects of maxilla. C, Cross-sectional view showing submucosal tissue
.layer, D, Excision of submucosal soft tissue layer. E, Splint in place holding mucosa against periosteum
at depth of vestibule until healing occurs

These techniques provide a predictable increase in vestibular depth and attachment of mucosa over the denture-bearing area. A properly relined denture can often be worn immediately after the surgery or after removal of the splint.. and Impress+. is for final denture relining or construction can be completed 2 to 3 weeks after surgery. .

 

 

 

 

 

 

 

 

 

SOFT TISSUE SURGERY FOR MAXILLARY RIDGE EXTENSION

SOFT TISSUE SURGERY FOR MAXILLARY RIDGE EXTENSION

Maxillary alveolar bone resorption frequently results in  mucosal and muscleattachments that interfere with denture construction, stability, and retention. Because of the large denture-bearing area of the maxilla, adequate
denture construction and -stabillty can often be achieved after extensive bone loss. However, excess soft tissue may accompany bony resorption, or soft tissue may require modification as an adjunct to previous augmentation surgery. Several techniques provide additional fixed mucosa and vestibular depth in the maxillary denture-bearing area.

Vestibule and Floor-of-Mouth Extension Procedures

Vestibule and Floor-of-Mouth Extension Procedures

In addition to the attachment of labial muscles and soft tissues to the denture-bearing area, the mylohyoid and genioglossus muscles in the floor of the mouth present similar problems on the lingual aspect of the mandible. Trauner-” described detaching the mylohyoid muscles from the ‘mylohyoid ridge area and repositioning them inferiorly, effectively .deepentng the floor of the mouth, area and relieving theinfluence of the mylohyoid musde on the d enture. MacIntosh and Obwegeser-? later
described the effective use of a labial extension proce- • dure combined with <[rauner’s procedure to provide maximal vestibular extension to both the buccal and lingual aspects of the mandible. The technique for extension of the labial vestibule is a modification of a labially pedicled supraperiosteal flap described by Clark.v” After the two vestibular extension techniques, a skin graft can be used to cover the area of denuded periosteum – (rig. 13-39), The combination procedure effectively eliminates the dislodging forces of the mucosa and muscle attachments and provides a broad base of fixed keratinized tissue on the primary denture-bearing area (Fig, 13-40). Split-thickness skin grafting with the buccal

vestibuloplasty and floor-of-mouth procedure is indicated when adequate alveolar ridge for a denture;bearing area is lost but at least 15 rnm of mandibular bone height remains. The remaining bone must have adequate contour so that the form of the alveolar ridge exposed after the procedure is adequate for dentr- c construction. Endosteal implants are generally a much more suitable treatment and therefore vcstibuloplasty with skin grafting is not commonly performed. If gross bony irregularities exist, such as large concavities in the superior aspect of the posterior mandible, they should. be corrected through grafting or minor alveoloplasty procedures
before the soft tissue procedure. . The technique has the advantage of early covering of the exposed periosteal bed, which improves patient comfort
and allows earlier denture construction. In addition, the long-term results of ,;csHbular extension are predictable. The need for hospitalization and donor-site surgery combined with the moderate swelling and discernfort discernfort experienced by the patient postoperatively are the
primary disadvantages . Patients rarely complain about, the appearance or function of skin in the oral cavity. If the skin graft is too thick at the time of harvesting, hair  follicles may not totally degenerate, and hair growth may
occasionally be s een in isolated areas of the graft.Tissue other than skin has been used effectively for grafting over the alveolar ridge. Palatal tissue offers the potential advantages of providing a firm, resilient tissue. with minimal contraction of the grafted area.” Although palatal tissue is relatively easy to obtain at the time of surgery, the limited amount of tissue
and the discomfort associated ‘with donor-site harvesting are the primary drawbacks. In areas where mil)’ a smallloQlized graft is required, palatal tissue is usually adequate. Full-thickness buccal mucosa harvested from the’ inner aspect of the cheek provides advantages similar to those of palatal tissue. However. the need for specialized

FIG. 13-39 Labial vestibuloplasty, floor-of-mouth lowering procedure, and skin grafting (i.e., Obwegeser's technique). A, Preoperative muscle and soft tissue attachments near crest of rernaininq mandible. B, A crestal incision is made. Buccal and lingual flaps are created by a supraperiosteal dissection. C, Flaps are sutured near inferior border of mandible, with sutures passed under inferior border of mandible, tethering labial and lingual tissues near inferior border of mandible. D, Skin graft held in place with splint. E; Postoperative view of newly created vestibular depth and floor-of-mouth area

FIG. 13-39 Labial vestibuloplasty, floor-of-mouth lowering procedure, and skin grafting (i.e.,
Obwegeser’s technique). A, Preoperative muscle and soft tissue attachments near crest of rernaininq
mandible. B, A crestal incision is made. Buccal and lingual flaps are created by a supraperiosteal dissection.
C, Flaps are sutured near inferior border of mandible, with sutures passed under inferior border
of mandible, tethering labial and lingual tissues near inferior border of mandible. D, Skin graft held
in place with splint. E; Postoperative view of newly created vestibular depth and floor-of-mouth area

mucotornes to harvest huccal mucosa and extensive buccal  mucosa carring after harvesting LJf a full-thickness graft are disadvantages. This mucosa does not become kera tinized, is generally mobile, and often results in an inadequate denture-bearing surface,

Transpositional Flap Vetibuloplasty (Lip Switch)

Transpositional Flap Vetibuloplasty (Lip Switch)

A lingually based flap vestibuloplasty was ‘first described by Kazanjian.24 In this procedure a mucosal flap pedicled from the alveolar ridge is elevated from ‘the’ underlying an.l sutured to the depth of the .vestibule (Fig. U-‘~~ Till’ inner portion of the lip is allowed to heal by , t:wndal y epithelialization. This ptocedure has beenmo dified, and the use of a technique transposing a linguallylingually based mucosal flap and a labially based periosteal flap (transpositional flap) has become popular.zs
. When adequate mandibular height exists, this procedure increases the anterior vestibular area, which improves denture retention and stablliry. The primary indications for the pLOcedure include adequate anterior mandibular ‘height (at least IS rnrn), inadequate facial vestibular depth
from mucosal and muscular attachments in the anterior mandible, ,and’ the presence of an adequate vestibular  depth on the lingual aspect of the mandible.  These techniques provide adequate results in many cases and generally do not require hospitalization, donor-site surgery, or prolonged periods without a denture. Disadvantages include unpredictability of the amount of relapse of the vestibular depth, scarring in the depth of

FIG, 13-38 Transpositional flap vestibuloplasty (i.e. lip switch), A, Incision is made in labial mucosa, and thin mucosal flap is dissected from underlying tissue, Sl,Jpraperiosteal dissection is also performed on anterior aspect of the mandible, B, Flap of labial mucosa is sutured to depth of vestibule, Exposed labial tissue heals by secondary lntention. C, Modification of technique by incising periosteum at crest of alveolar ridge and,suturing free periosteal edge to denuded area of labial mucosa, 0, Muco.sal flap is then sutured over denuded: bone to periosteal junction at depth of vestibule.

FIG, 13-38 Transpositional flap vestibuloplasty (i.e. lip switch), A, Incision is made in labial mucosa,
and thin mucosal flap is dissected from underlying tissue, Sl,Jpraperiosteal dissection is also performed
on anterior aspect of the mandible, B, Flap of labial mucosa is sutured to depth of vestibule, Exposed
labial tissue heals by secondary lntention. C, Modification of technique by incising periosteum at crest
of alveolar ridge and,suturing free periosteal edge to denuded area of labial mucosa, 0, Muco.sal flap
is then sutured over denuded: bone to periosteal junction at depth of vestibule.

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the vestibuleand problems with adaptation, of the  peripheral flange area of the denture to the depth of the vestibule.26,27

SOFT TISSUES INJURES EXTENSTION OF MANDIBLE

SOFT TISSUES INJURES EXTENSTION OF MANDIBLE

As alveolar ridge resorption takes place, the attachment of Jl1UCOS<1and muscles near the denture-bearing area – exerts a ‘gre<1ter influence on the retention and stabiltry of dentures. In addition, the amount and quality of fixed tissue over the denture-bearing area may be decreased. Soft tissue” surgery performed to improve denture stability  may be carried out alone or may be done after” bony augmentation. In either case the primary goals of soft tisssues.

FIG. '13-37 Si~us lift procedure. A, Cross-sectional diagram of maxilla demonstrating bone grafting to the sinus floor. On the Left side of the diagram, the sinus extending into the alveolar ridge area, which results in sufficient bone for implant placement. On the right side the lateral wall of the maxilla has been fractured inward, bone grafted in the inferior portion of the sinus, and an implant placed into the sinus floor graft. B to 0, Clinical photographs showing sinus opening, placement of implants, and bone graft to fill inferior portion of sinus

FIG. ’13-37 Si~us lift procedure. A, Cross-sectional diagram of maxilla demonstrating bone grafting
to the sinus floor. On the Left side of the diagram, the sinus extending into the alveolar ridge area,
which results in sufficient bone for implant placement. On the right side the lateral wall of the maxilla
has been fractured inward, bone grafted in the inferior portion of the sinus, and an implant placed
into the sinus floor graft. B to 0, Clinical photographs showing sinus opening, placement of implants,
and bone graft to fill inferior portion of sinus

sue preprosthetic surgery are to provide an enlarged area of fixed tissue in the primary denture-bearing or implant area and to improve extension in the area of the denture flanges by removing the dislodging effects of muscle
attachments in the denture-bearing or vestibular areas.