Category Archives: Preprosthetic Surgery

IMMEDIATE DENTURES

The decision may be _lWde to insert dentures at the time of tooth removal and bony recontouring. Hartwelll-‘ cites several advantages of an immediate denture technique. The insertion of a denture after extraction offers immedi-ate psychologic and esthetic benefits to patients, whereas alternatively they may De edentulous for some time. The immedia-te insertion of a denture after surgery also functions to splint the surgical site, which results in the reduction of postoperative ‘bleedirrg and edema and improved tissue adaptation to the alveolar rige. Another advantage
is that the vertical dimension can be most -easily reproduced with an immediate denture technique. Disadvantages include the need for frequent alteration of the denture postoperatively and the construction of a new
denture after initial healing has taken place. . Surgical- treatment for immediate denture insertion can be accomplished in stages, with extraction of the posterior dentition in the maxilla and the mandible done before anterior extraction. This allows for initial healing of the posterior areas and facilitates the denture con- struction. After the initial healing period of the posterior segments, new records are taken and models are mount- r
ed on a serniadjustable articulator. After replacement of the model teeth with prosthetic teeth, the cast of the alveolar ridge area is then carefully recontoured (Fig. 13-29). Immediate denture surgery generally involves the most conservative technique possible in removal of the remaining teeth. An intraseptal alveoloplasty, preserving as much vertical height and cortical bone as possible, is generally indicated. (Fig. 13-30). After the- bony recontouring and elimination of gross irregularities is completed,
the tissue is approximated with digital pressure, and the clear acrylic surgical guide constructed on the presurgical casts is inserted. Any areas of tissue blanching or gross irregularities are then reduced until the clear surgical guide is ‘adapted to the alveolar ridge in all areas. Incisions are closed with continuous or interrupted sutures. The immediate denture with a soft liner is inserted. Care should be taken not to extrude any reline material into the fresh wound. The occlusal relationships are .checked and adjusted as necessary. The patient is instructed to wear the denture continuously for 24 hours and to return the next day for a postoperative check. Bupivacaine or another similar long-acting local anesthetic injected at the conclusion of the surgical procedure greatly improves comfort in the first 24-hour postoperative period. At that time the denture is gently
removed, and the underlying mucosa and alveolar ridge areas are inspected for any areas of excessive pressure.   The denture is cleaned and reinserted, and the patient is instructed to wear the denture for 5 to 7 days and to remove it only for oral saline rinses. Sutures are generally taken out 7 days postoperatively.

labial Frenectomy

Labial frenal attachments consi t of thin bands of fibrou tissue covered with mucosa, extending from the lip and cheek to the alveolar periosteum. The level of frenal attachments may vary. from the height of the vestibule to
the crest of the alveolar ridge and evert to the Incisal papilla area in the anterior maxilla. With the exception of the midline labial frenumr association with a diastemat

frenal attachments generally do not present problems when the dentition is intact. However, the construction of a denture may be complicated .when it is necessary to accommodate a frenal attachment. Movement of the soft
tissue adjacent to the frenum may create discomfort and ulceration and may interfere with the peripheral seal and dislodge the denture. ‘ Three surgical techniques are effective in removal of frenal attachments: (1) the simple excision technique, (2) the Z-plasty technique, and (3) a localized vestibulepIa sty with secondary epithelialization, The first two tech-,
niques (simple excision and Z-plasty) are effective when the mucosal and fibrous tissue band is relatively narrow; the third {a localized  estibuloplasty with secondary epithelialization) is often preferred when the frenal attachment bas a wide base. ‘ Local anesthetic infiltration is sufficient for surgical treatment of frenal attachments, Care must be taken to avoid excessive anesthetic infiltration directly in the frenum area, because it may obscure the anatomy that must be visualized at the time of excision. In all cases it is helpful to have the surgical assistant elevate and evert the
iii) during this procedure, For the simple excision technique ‘a narrow elliptic incision around the fren’eI:area down to the periosteum is completed (Fig. l’:+”~5}Thefibrous frenum is then sharply dissected from the edger.

lying periosteum and soft tissue, and the margins of the wound are gently undermined and reapproximated. Placement of the first uture should be at the maximal depth of the vestibule and should include both edges of
mucosa and underlying’periosteum at the height of the vestibule beneath the anterior nasal spine (see Fig. 13-25). This will reduce hematoma formation and allow for adaptation of the tissue to the maximal height of the
vestibule. The remaindef of the incision should then be closed with interrupted sutures. Occasionally, it is not possible to approximate the portion ofthe excision closest to the alveolar ridge crest; this wili~ndetgo secondary epithelialization without difficulty. In the Z-plasty technique an excision of  the fibrousconnective tissue is done, similar to that in the simple excision procedure just described, After excision of the fibrous tissue, two oblLque incisions are made in a Z fashion, one at each end of the previous area of excision (Fig, 13-26), The two pointed naps are then gently undermined and rotated to close the initial vertical incision “horizontally. The two small oblique extensions also require closure, This technique may d~crease the amount ‘of vestibular ablation sometimes seen after linear exctsron of a frenum.A third technique.for removal of the frenum involves
a localized vestibuloplasty with secondary epit)lelializal

 

 

 

 

 

 

 

 

 

 

 

 

 

Inflammatory Papiilary Hyperplasia of the Palate

Inflammatory papillary hyperplastic tissue formation in the palate is  frequently a result of mechanical irritation and is seen most often in patients who wear prosthetic appliances. Other potential contributing factors to thispsocess include poor hygiene, fungal infections, and the associated  nflamrr.ation. This condition usually appears as multiple nodula projections in the palatal tissue. Although it was onve thought to represent a  recancerous condition, this 1′, ‘S not been substantiated.l” Because theprocess appears to be primarily inflammatory rather than neoplastic, total full-thickness incision is not necessary. In fact, in the very early stages, onsurgical treatment,such as proper denture adjustment combined with a tissue conditioner, may eliminate or reduce this problem. If rem oval is required, a mucosal excision superficial to the periosteum is recommended and can generally be performed with local anesthetic infiltration in the palatal area. Regardless of the technique used for removal of this tissue, a specimen should be obtained and submitted for histopathologic  examination. Guernsey’!! described a technique using electrosurgical loops for excision of the 0palatal mucosa. When electrosurgical techniques are
used, it is important  to maintain a split-thickness excision so that palatal bone is not cauterized. An alternative technique that elimmates this possibility is split-thickness. excision done sharply with a scalpel.V However, palatal form and access to the area of excision may limit
the use of this scalpel technique in certain situations. Techniques to abrade the superficial layer of palatal mucosa are also effective for treatment. A coarsely fluted acrylic or bone bur or dermabrasion brush in a rotating
handpiece can be used for this purpose (Fig. 13-24). Other techniques that can be considered for superficial tissue removal include cryosurgery and the use of lasers. After tissue incision, insertion of a splint or denture containing soft tissue liner provides impro ‘cd patient comfort during
the healing period. Secondary epithelialization usually takes place in approximately 4 weeks.

Inflammatory Fibrous Hyperplasia

Inflammatory fibrous hyperplasia, also called epulis fissuratum  or denture fibrosis, is a generalized hyperplastic enlargement of mucosa and fibrous tissue in the alveolar ridge and vestibular area, which most often results from
ill-fitting dentures.’ In the early stages of fibrous hyperplasia, when fibrosis is minimal, nonsurgical treatment with a denture in combination with a soft liner is frequentIy sufficient for reduction or elimination ‘of this tissue. When the condition has been present for some time, significant fibrosis exists within the hyperplastic tissue. This will not respond to nonsurgical treatment’ (Fig, 13-22); excision of the hyperplastic tissue is the treatment of choice. 273

Three- techniques can be used for successful treatment o f inflammatory fibrdus hyperplasia. Local anesthetic infiltration in the area of the redundant tissue is sufficient for anesthesia. When the area to be excised is minimallyenlarged. electrosurgical or laser techniques provide good results for tissue excision. If the tissue mass is xtensive, large areas of excis.ion using electrosurgical techniques may result in excessice  estibular  carring. Simple excision and reappr0::imat;on of the remaining tissue is preferred. The redundant areas of tissue are grasped with ti.ssue  pickups, a sharp mcislon is made at the base of the excessive fibrous tissue down to the periosteum, and the hyperplastic tissue is removed (Fig. 13-23). The adjacent tissue is gently undermined and reapproximated using interrupted or continuous sutures. When areas of gross tissue redundancy are found, excision frequently results in total elimination of the vestibule. In such cases excisicn of the epulae, with peripheral mucosal repositioning and secondary epithelialization, is preferable (see Fig. 13-23). In this  procedure the !lyperplastic soft tissue is excised superficial to the periosteulll from the alveolar ridge area. A clean supra periosteal bed is created over the  lveolar ridge area. and the unaffected margin of the tissue excision is sutured to the most superior aspect ot’the vestibular periosteum with all interrupted suture technique. A surgical splir or denture lined with soft tissue conditioner is inserted and worn continuously for the first 5 to
7 days, with removal only for oral saline rinses. Secondary epithelialization usually takes place, and denture impressions can be made within 4 weeks. Laser excision of large epulis allows complete removal without excessive
scarring or bleeding. A soft relined denture can provide for additional postoperative comfort from a procedure that initially creates minimal pain, but the pain peaks several days later. .  The hyperplastic tissue usually represents only the result of an inflammatory process; however, other pathologic conditions may exist. It is therefore imperative that
representa  tive tissue samples always’ be submitted for pathologic examination after removal.

Unsupported Hypermobile Tissue

Excessive hypermobile tissue without inflammation on  he. alveolar ridge is generally the result of resorption of the underlying bone, ill-fitting dentures, or both. Before the excision of this tissue,·a determin tion must be made
of whether the underlying bone sho~ld be augmented with a graft. If a bony deficiency is the primary cause of. soft tissue excess, then. augmentation of the underlying bo~ is the treatment of choice. If adequate alveolar
height remains after reduction of the hypermobile soft . tissue, then excision may be indicated.Alocal anesthetic is injected adjacent to the area requiring tissue excision. Removal of llypermobile tissue in thealveolar
ridge area consists of two. parallel full-thickness incisions on the buccal and Itngual-sspects of the tissue tobe excised’ (Fig. 13-20). A periosteal elevator is used fo, remove the excess soft tissue from the underlying bone. A-u
tangential excision of small amounts of tissue in the adjacent areas may be necessary to allow for adequate soft tissue adaptation during closure. These additional excisions should.be kept to a minimum whenever possible to avoid removing too much softtissue and to prevent detachment of periosteum from underlying bone. Continuous or interrupted sutures are used to approximate the remaining tissue and are removed 7 days after surgery, Denture impressions can usually be taken 3 to 4 weeks after surgery’ possible complication of this type of procedus.

obliteranon of the buccal vestibule as a result of tissue undermining necessary to obtain tissue closure. . Hyperinobile tissue in the crestal area of the mandibular alveolar ridge frequently consists of a small cordlike
band of tissue. If n o underlying sharp bony projection is present, this tissue can best be removed by a supraperiosteal soft tissue excision. Local. anesthetrc is injected adjacent to the area requiring tissue removal. The cordlike band of fibrous connective tissue caa be elevated by using pickups and scissors, and the scissors”<:an be used to excise the fibrous tissue at the attachment. to the alveolar ridge (Fig. 13-21), Generally, no suturlrrgts necessary for this terhrrique, and a denture with a soft liner can be
re:nserted immediately,

 

 

 

 

Lateral.Palatal Soft Tissue Excess

Soft tissue excess on- the lateral aspect of the palatal vault
often interferes with proper construction of the denture

As with bony abnormalities of this area, soft tissue hypertrophy often narrows the palatal vault and creates slight undercuts, which interfere with denture. construction and insertion. One technique suggested for removal of-lateral palatal soft tissue involves submucosal resection of the excess tissue in a manner similar to the previously described  oft tissue berosity reduction. However, the amount and  exte nSlhn of soft tissue removal under the mucosa is much more extensive andcreates the risk of damage to
the greater palatine vessels, -with possible hemorrhaging or sloughing of the lateral palatal soft tissue area. The preferred technique requires uperficial excision of the soft tissue excess. Local anesthetic infiltrated in thegreater palatine area and anterior to the soft tissue mass is sufficient. With-a sharp scalpe -blade in the tangential fashion, the superficial layers of mucosa and underlying. fibrous tissue can be removed to the extent necessary to

undercuts in soft tissue bulk (Fi;’-13-19). After removel of this tissue, a surgical splint lined with a tissue conditioner can be inserted for 5 to 7 clays to aid in healing.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mandibular Retromolar Pad Reduction

The need for removal of mandibular retromolar hypertrophic tissue israre. It is important to determine that thepatient is not posturing the  andible forward or vertlcal- Iy ovcrcloscd during clinical evaluation and with treat-: mcnt recor ds and mounted .casts. Local anesthetic infiltration in the area requiring excision is sufficient. An elliptic incision is made to excise the greatest area of tissue  thickness i;~ the posterior ‘mandibular area. Slight thinnillg of the adjacent areas is carried out with the majority of the tissue reduction on’ the labial aspect. Excess removal of tissue in the submucosal area of the lingual
flap may resut in damage to the lingual nerve and artery. The tissue is approximated with continuous or  interrupted sutures.

Maxillary Tuberosity Reduction (Soft Tissue)

The primary objective of soft tissue maxillary tuberosity  reduction is to provide adequate interarch space for proper denture construction in the posterior area and a firm mucosal base of consistent thickness over the alveolar ridge denture-bearing area. Maxillary tuberosity reduc-‘ tion may require the removal of soft tissue and bone to achieve the desired result. The amount of soft tissue available for reduction can often be determined by evaluating a presurgical panoramic radiograph. If a radiograph is not
. of the quality necessary to determine soft’ tissue thickness, this depth can be measured with a sharp probe after local anesthesia is obtained at the time of surgery. Local anesthetic infiltration in the posterior maxillary
area is sufficient for a tuberosity reduction. An initial elliptic incision is made over the tuberosity in the area requiring reduction, and this section of tissue is removed (Fig. 13-17). _ After tissue removal the medial and lateral margins of the excision must be thinned to remove exce’ss. soft tissue, which allows further soft tissue reduction and provide  a tension-free soft tissue closure. This can be accomplished by digital pressure on the mucosal surface of the adjacent tiss.

suewhlle sharply excising tissue tangential to the mucosal surface (fig. 13-18). After the flaps are thinned, digital pressure can be used to approximate the tissue to evaluate the vertical reduction that has been accomplished. If adequate tissue has been removed, the area is sutured with interrupt. ed or continuous suturing techniques. If too much tissue
has been removed, no attempt should be made to close the wound primarily. A tension-free approximation of the tissue to bone should be accomplished. which all’5 the open wound area to heal by secondary intention. Sutures are removed in 5 to 7 days, and impressions can generally e taken 3 to 4 weeks post operatively.

 

 

 

 

 

 

SOFT TISSUE ABNORMALlTIES

Abnormalities of the soft tissue in the denture-bearing and peripheral tissue areas include excessive fibrous or hypermobile tissue; inflammatory lesions; such as inflammatory fibrous hyperplasia of the vestibule and inflammatory papillary hyperplasia of the palate; and abnormal muscular and frenal attachments. With the exception of pathologic and inflammatory lesions, many of the other – conditions do not present problems when the patient has   full dentition. However, when loss of teeth  ecessitates
prosthetic reconstruction, alteration of the soft tissue is often necessary. Immediately after tooth removal; muscular and frenal attachments initially do not present problems but may eventually  nterfere with proper denture
construction as bony res orption takes place. Long-term treatment planning before any soft tissue surgery is mandatory. Soft tissue that initially appears to be flabby and excessive may be quite useful if future ridge augmentation or grafting procedures are necessary. Oral mucosa is difficult to replace once it is removed. The only exception’ to this usefulness of excess tlssue is when pathologic soft tissue lesions require removal.

Mandibular Tori

Mandibular tori are bony protuberances on the lingual  spect of the  andible that usually occur in the premolar area. The orlgtns of this bony exostosis are uncertain, and the growths may slowly increase in size. Occasionally,
extremely large tori interfere with normal speech or tongue function during eating, but, these tori rarely require removal when teeth are present: Afterthe removal, of Iower teeth and before the construction of partial or
complete dentures, it may be necessary to remove mandibular tori.to facilitate denture construction. , Bilateral lingual and inferior alveolar injections provide adequate anesthesia tor tori removal. A-cr~ the
ridge incision should be made, extending 1 & 1.., f.~.beyond each end of the  ori to be reduced. When bilateral t ori are to be removed simultaneously, it is best to leave a small band of tissue attached at the midline between
the anterior extent of the two incisions. Leaving this tiss.sue attached helps eliminate potential hematoma formation. In the anterior floor of the mouth and wilkmalntaln as much of the lingual vestibule a\ possible in the anterior
mandibular area. As with maxillary tori, the mucosa over the lmgua! tori is generally very thin and should be reflected carefully to expose the entire area of bone to be recontoured (Pig. 13-16)  When the torus ha s a small pedunculated base, a mallet and osteotome may be used tocleave the tori from the medial aspect of the mandible. The line of cleavage can . be directed by creating a small trough with a bur and a handpiece before using an osteotome. It is extremely . important to ensure that the direction of the initial burtrough (or the osteo ome if it is used alone) is parallel with the medial aspect of the mandible ‘to avoid an unfavorable fracture of the lingual or inferior cortex. The bur can alsobe used to deepen the trough so that. a small instrument can be levered against the mandible to fracture
the lingual tori to allow its removal, A bone bur or file can then be used to smooth the lingual cortex. The tissue should be readapted and palpated to evaluate contour and elimination of undercuts. An interrupted or continuous suture technique is used to close the incisions. Gauze .packs placed in the floor of the mouth and retained for 12 hours are generally helpful in reducing  postoperative edema and hematoma formation. In the
event of wound dehiscence or exposed bone in the area of a mucosal perforation, treatment with local care, including frequent vigorous saltne irrigation, is usually sufficient. . AFIG. ’13-15 .Removal of palatal torus. A, Typical appearance of maxillary torus. B, Midline. incision will.  nteroposterior oblique releasing incisions. C, Mucpperiosteal  laps retracted with silk sutures to improve access to all areas of torus.
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