Preprosthetic Surgery - Chapter 13 PDF

13 Preprosthetic Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ MYRON R. TUCKER AND RICHARD E. BAUER CHAPTER OUTLINE...

13 Preprosthetic Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ MYRON R. TUCKER AND RICHARD E. BAUER CHAPTER OUTLINE After the loss of natural teeth, bony changes in the jaws begin to Objectives of Preprosthetic Surgery, 217 take place immediately. Because the alveolar bone no longer responds Principles of Patient Evaluation and Treatment Planning, 219 to stresses placed in this area by teeth and the periodontal ligament, Evaluation of Supporting Bony Tissue, 219 bone begins to resorb. The specific pattern of resorption is unpredict- Evaluation of Supporting Soft Tissue, 220 able in a given patient because great variation exists among individu- Treatment Planning, 221 als. In many patients, this resorption process tends to stabilize after a period, whereas in others a continuation of the process Recontouring of Alveolar Ridges, 221 eventually results in total loss of alveolar bone and underlying Simple Alveoloplasty Associated With Removal of Multiple basal bone (Fig. 13.1). The results of this resorption are accelerated Teeth, 221 by wearing dentures and tend to affect the mandible more severely Intraseptal Alveoloplasty, 222 than the maxilla because of the decreased surface area and less Maxillary Tuberosity Reduction (Hard Tissue), 223 favorable distribution of occlusal forces.1 Buccal Exostosis and Excessive Undercuts, 223 The increasing use of implants for the restoration of missing Lateral Palatal Exostosis, 225 dentition has changed the treatment planning paradigm. The Mylohyoid Ridge Reduction, 225 practitioner must identify, prior to the extraction of teeth, if the Genial Tubercle Reduction, 226 patient is going to have implant placement immediately or in the Tori Removal, 227 future. The planned or immediate placement of implants following Maxillary Tori, 227 the extraction of teeth necessitates different treatment planning Mandibular Tori, 230 in regard to preprosthetic surgical procedures. The focus of the Soft Tissue Abnormalities, 230 practitioner still remains maximal preservation of hard and soft Maxillary Tuberosity Reduction (Soft Tissue), 231 tissue to maintain alveolar and jaw height and width. Traditional Mandibular Retromolar Pad Reduction, 231 preprosthetic surgery focuses on maintaining alveolar ridge form Lateral Palatal Soft Tissue Excess, 233 in addition to maintaining ideal edentulous jaw relationships, Unsupported Hypermobile Tissue, 233 palatal and vestibular depth, tuberosity form, and keratinized gingiva and avoiding damage or compression of the neurovascular bundle. https: / / t.me / LibraryEDent Inflammatory Fibrous Hyperplasia, 233 Labial Frenectomy, 235 The practitioner must address the treatment option regarding Lingual Frenectomy, 239 the placement of implants prior to the surgical procedure. The maximal preservation of alveolar ridge form for implant placement, Immediate Dentures, 240 especially with the use of grafting procedures, is ideally performed Alveolar Ridge Preservation, 242 at the time of the initial surgery. The surgical planning for the immediate or delayed placement of implants is addressed in the Overdenture Surgery, 242 corresponding chapter on contemporary implant dentistry. Despite Advanced Preprosthetic Surgical Procedures, 243 the increasing use of implants, many of the preprosthetic surgical Soft Tissue Surgery for Ridge Extension of the Mandible, 243 techniques or variations of these techniques remain applicable to Transpositional Flap Vestibuloplasty (Lip Switch), 244 achieve an ideal bony ridge form for successful implant placement Vestibule and Floor-of-Mouth Extension Procedures, 244 or if the patient has medical or financial limitations and will be treated with removable partial or complete dentures. Soft Tissue Surgery for Maxillary Ridge Extension, 246 Submucosal Vestibuloplasty, 246 Maxillary Vestibuloplasty With Tissue Grafting, 247 Objectives of Preprosthetic Surgery Correction of Abnormal Ridge Relationships, 247 Despite the enormous progress in the technology available to Segmental Alveolar Surgery in the Partially Edentulous preserve the dentition, prosthetic restoration and rehabilitation of Patient, 247 the masticatory system are still needed in patients who are edentulous Correction of Skeletal Abnormalities in the Totally Edentulous or partially edentulous. General systemic and local factors are Patient, 248 responsible for the variation in the amount and pattern of alveolar Summary, 250 bone resorption.2 Systemic factors include the presence of nutritional abnormalities and systemic bone diseases such as osteoporosis, 217 218 PART I I I Preprosthetic and Implant Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ A B C D E https: / / t.me / LibraryEDent Fig. 13.1 (A) Ideal shape of the alveolar process in the denture-bearing area. (B–E) Progression of bone resorption in the mandible after tooth extraction. endocrine dysfunction, or any other systemic condition that may resorption, a significant increase in the risk of spontaneous man- affect bone metabolism. Local factors affecting alveolar ridge dibular fracture exists. resorption include alveoloplasty techniques used at the time of The prosthetic replacement of lost or congenitally absent teeth tooth removal and localized trauma associated with loss of alveolar frequently involves surgical preparation of the remaining oral tissues bone. Denture wearing also may contribute to alveolar ridge to support the best possible prosthetic replacement. Often, oral resorption because of improper ridge adaptation of the denture structures such as frenal attachments and exostoses have no sig- or inadequate distribution of occlusal forces. Variations in facial nificance when teeth are present but become obstacles to proper structure may contribute to resorption patterns in two ways: (1) prosthetic appliance construction after tooth loss. The challenge The actual volume of bone present in the alveolar ridges varies of prosthetic rehabilitation of the patient includes restoration of with facial form3; and (2) individuals with low mandibular plane the best masticatory function possible, combined with restoration angles and more acute gonial angles are capable of generating or improvement of dental and facial esthetics. Maximal preservation higher bite force, thereby placing greater pressure on the alveolar of hard and soft tissue during preprosthetic surgical preparation ridge areas. The long-term result of combined general and local is also mandatory. The oral tissues are difficult to replace after they factors is the loss of the bony alveolar ridge, increased interarch are lost. space, increased influence of surrounding soft tissue, decreased The objective of preprosthetic surgery is to create proper sup- stability and retention of the prosthesis, and increased discomfort porting structures for subsequent placement of prosthetic appliances. from improper prosthesis adaptation. In the most severe cases of The best denture support has the following 11 characteristics4:  CHAPTER 13 Preprosthetic Surgery 219 1. No evidence of intraoral or extraoral pathologic conditions evaluation of models. Abnormalities of the remaining bone can 2. Proper interarch jaw relationship in the anteroposterior, often be assessed during the visual inspection; however, because transverse, and vertical dimensions of bony resorption and location of muscle or soft tissue attachments, 3. Alveolar processes that are as large as possible and of the proper many bony abnormalities may be obscured. Palpation of all areas configuration (The ideal shape of the alveolar process is a of the maxilla and mandible, including the primary denture-bearing broad U-shaped ridge, with the vertical components as parallel area and vestibular area, is necessary. as possible; see Fig. 13.1.) Evaluation of the denture-bearing area of the maxilla includes 4. No bony or soft tissue protuberances or undercuts an overall evaluation of the bony ridge form. No bony undercuts 5. Adequate palatal vault form or gross bony protuberances that block the path of denture insertion @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ 6. Proper posterior tuberosity notching should be allowed to remain in the area of the alveolar ridge, 7. Adequate attached keratinized mucosa in the primary denture- buccal vestibule, or palatal vault. Palatal tori that require modifica- bearing area tion should be noted. Adequate posttuberosity notching is necessary 8. Adequate vestibular depth for prosthesis extension for stabilization of the posterior denture and peripheral seal. 9. Added strength where mandibular fracture may occur The remaining mandibular ridge should be evaluated visually 10. Protection of the neurovascular bundle for overall ridge form and contour, gross ridge irregularities, tori, 11. Adequate bony support and attached soft tissue covering to and buccal exostosis. In cases of moderate to severe resorption of facilitate implant placement when necessary alveolar bone, ridge contour cannot be adequately assessed by visual inspection alone. Muscular and mucosal attachments near the crest of the ridge may obscure underlying bony anatomy, Principles of Patient Evaluation and particularly in the area of the posterior mandible, where a depression Treatment Planning can frequently be palpated between the external oblique line and mylohyoid ridge areas. The location of the mental foramen and Before any surgical or prosthetic treatment, a thorough evaluation mental neurovascular bundle can be palpated in relation to the outlining the problems to be solved and a detailed treatment plan superior aspect of the mandible, and neurosensory disturbances should be developed for each patient. It is imperative that no can be noted. preparatory surgical procedure be undertaken without a clear Evaluation of the interarch relationship of the maxilla and the understanding of the desired design of the final prosthesis. mandible is important and includes an examination of the antero- Preprosthetic surgical treatment must begin with a thorough posterior and vertical relationships, as well as any possible skeletal history and physical examination of the patient. An important asymmetries that may exist between the maxilla and the mandible. aspect of the history is to obtain a clear idea of the patient’s chief In partially edentulous patients, the presence of supraerupted or complaint and expectations of surgical and prosthetic treatment. malpositioned teeth should also be noted. The anteroposterior Esthetic and functional goals of the patient must be assessed carefully relationship must be evaluated with the patient in the proper and a determination made as to whether these expectations can vertical dimension. Overclosure of the mandible may result in a be met. A thorough assessment of overall general health is especially class III skeletal relationship but may appear normal if evaluated important when considering more advanced preprosthetic surgical with the mandible in the proper postural position. Lateral and techniques because many of the approaches described require general posteroanterior cephalometric radiographs with the jaws in proper anesthesia, donor site surgery to harvest autogenous graft material, postural position may be helpful in confirming a skeletal discrepancy. and multiple surgical procedures. Specific attention should also Careful attention must be paid to the interarch distance, particularly be given to possible systemic diseases that may be responsible for in the posterior areas, where vertical excess of the tuberosity, either the severe degree of bone resorption. Laboratory tests such as bony tissue or soft tissue, may impinge on space necessary for https: / / t.me / LibraryEDent serum levels of calcium, phosphate, parathyroid hormone, and placement of a prosthesis that is properly constructed (Fig. 13.2). alkaline phosphatase may be useful in pinpointing potential meta- bolic problems that may affect bone resorption. Psychological factors and the adaptability of patients are important determinants of their ability to function adequately with full or partial dentures. Information on success or failure with previous prosthetic appliances may be helpful in determining the patient’s attitude toward and adaptability to prosthetic treatment. The history should include important information such as the patient’s risk status for surgery, with particular emphasis on systemic diseases that may affect bone or soft tissue healing. An intraoral and extraoral examination of the patient should include an assessment of the existing occlusal relationships (if any remain), the amount and contour of remaining bone, the quality of overlying soft tissue, the vestibular depth, location of muscle attachments, the jaw relationships, and the presence of soft tissue or bony pathologic condition. Evaluation of Supporting Bony Tissue Fig. 13.2 Examination of interarch relationships in proper vertical dimen- sion often reveals lack of adequate space for prosthetic reconstruction. In Examination of the supporting bone should include visual inspec- this case, bony and fibrous tissue excess in the tuberosity area must be tion, palpation, radiographic examination, and, in some cases, reduced to provide adequate space for partial denture construction. 220 PART I I I Preprosthetic and Implant Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ A Fig. 13.3 Radiograph demonstrating atrophic mandibular and maxillary alveolar ridges. Pneumatization of the maxillary sinus is demonstrated. Proper radiographs are an important part of the initial diagnosis and treatment plan. Panoramic radiographic techniques provide an excellent overview assessment of underlying bony structure and pathologic conditions.5 Radiographs should disclose bony pathologic lesions, impacted teeth or portions of remaining roots, the bony pattern of the alveolar ridge, and pneumatization of the maxillary sinus (Fig. 13.3). Cephalometric radiographs may also be helpful in evaluating the cross-sectional configuration of the anterior mandibular ridge area and ridge relationships (Fig. 13.4). To evaluate the ridge relationship in the vertical and anteroposterior dimensions, it B may be necessary to obtain the cephalometric radiograph in the Fig.13.4 (A) Cephalometric radiograph illustrating cross-sectional appropriate vertical dimension. This often requires adjusting or anatomy of the anterior mandible (patient is overclosed, giving the relative reconstructing dentures to this position or making properly adjusted appearance of a class III jaw relationship). (B) Computed tomography scan bite rims to be used for positioning at the time the radiograph showing detailed cross-sectional anatomy of the mandible. is taken. https: / / t.me / LibraryEDent More sophisticated radiographic studies, such as computed tomography scans, may provide further information. Computed tomography scans are particularly helpful in evaluating the cross-sectional anatomy of the maxilla, including ridge form and sinus anatomy. The cross-sectional anatomy of the mandible, including the configuration of basal bone, the alveolar ridge, and the location of the inferior alveolar nerve, can be evaluated more precisely. Evaluation of Supporting Soft Tissue Assessment of the quality of tissue of the primary denture-bearing area overlying the alveolar ridge is of utmost importance. The amount of keratinized tissue firmly attached to the underlying bone in the denture-bearing area should be distinguished from poorly keratinized or freely movable tissue. Palpation discloses hypermobile fibrous tissue that is inadequate for a stable denture base (Fig. 13.5). The vestibular areas should be free of inflammatory changes such as scarred or ulcerated areas caused by denture pressure or hyperplastic tissue resulting from an ill-fitting denture. Tissue at Fig. 13.5 Palpation reveals hypermobile tissue that will not provide an the depth of the vestibule should be supple and without irregularities adequate base in the denture-bearing area.  CHAPTER 13 Preprosthetic Surgery 221 for maximal peripheral seal of the denture. Assessment of vestibular Recontouring of Alveolar Ridges depth should include manual manipulation of the adjacent muscle attachments. By tensing the soft tissue adjacent to the area of the Irregularities of the alveolar bone found at the time of tooth alveolar ridge, the dentist can note muscle or soft tissue attachments extraction or after a period of initial healing require recontouring (including frena) that approximate the crest of the alveolar ridge before final prosthetic construction. This chapter focuses primarily and are often responsible for the loss of peripheral seal of the on preparation of ridges for removable prostheses, but some emphasis denture during speech and mastication. is placed on the possibility of future implant placement and the The lingual aspect of the mandible should be inspected to obvious need to conserve as much bone and soft tissue as determine the level of attachment of the mylohyoid muscle in possible. @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ relation to the crest of the mandibular ridge and the attachment of the genioglossus muscle in the anterior mandible. The linguoves- Simple Alveoloplasty Associated With Removal tibular depth should be evaluated with the tongue in several positions because movement of the tongue accompanied by elevation of the of Multiple Teeth mylohyoid and genioglossus muscles is a common cause of move- The simplest form of alveoloplasty consists of the compression of ment and displacement of the lower denture. the lateral walls of the extraction socket after simple tooth removal. In many cases of single tooth extraction, digital compression of the extraction site adequately contours the underlying bone, provided Treatment Planning no gross irregularities of bone contour are found in the area after Before any surgical intervention, a treatment plan addressing the extraction. When multiple irregularities exist, more extensive patient’s identified oral problems should be formulated. The dentist recontouring often is necessary. A conservative alveoloplasty in responsible for prosthesis construction should assume responsibil- combination with multiple extractions is carried out after all of ity for seeking surgical consultation, when necessary. Long-term the teeth in the arch have been removed (see Chapter 8). The maintenance of the underlying bone, soft tissue, and prosthetic specific areas requiring alveolar recontouring are obvious if this appliances should be kept in mind at all times. When severe bony sequence is followed. Whether alveolar ridge recontouring is atrophy exists, treatment must be directed at correction of the performed at the time of tooth extraction or after a period of bony deficiency and alteration of the associated soft tissue. When healing, the technique is essentially the same. Bony areas requiring some degree of bony support remains despite alveolar atrophy, recontouring should be exposed using an envelope type of flap. A improvement of the denture-bearing area may be accomplished mucoperiosteal incision along the crest of the ridge, with adequate by directly treating the bony deficiency or by compensating for extension anteroposterior to the area to be exposed, and flap it with soft tissue surgery. The most appropriate treatment plan reflection allow adequate visualization and access to the alveolar should consider ridge height, width, and contour. Several other ridge. Where adequate exposure is not possible, small vertical- factors should also be considered: in an older patient in whom releasing incisions may be necessary. moderate bony resorption has taken place, soft tissue surgery alone The primary objectives of mucoperiosteal flap reflection are to may be sufficient for improved prosthesis function. In an extremely allow for adequate visualization and access to the bony structures young patient who has undergone the same degree of atrophy, that require recontouring and to protect soft tissue adjacent to bony augmentation procedures may be indicated. The role of this area during the procedure. Although releasing incisions often implants may alter the need for surgical modification of bone or create more discomfort during the healing period, this technique soft tissue. is certainly preferred to the possibility of an unanticipated tear in Hasty treatment planning, without consideration for long-term the edges of a flap when inadequate exposure could not be achieved results, can often result in unnecessary loss of bone or soft tissue with an envelope flap. Regardless of flap design, the mucoperiosteum https: / / t.me / LibraryEDent and improper functioning of the prosthetic appliance. For example, should be reflected only to the extent that adequate exposure to when there appears to be redundant or loose soft tissue over the the area of bony irregularity can be achieved. Excessive flap reflection alveolar ridge area, the most appropriate long-term treatment may result in devitalized areas of bone, which will resorb more plan may involve grafting bone to improve the contour of the rapidly after surgery, and a diminished soft tissue adaptation to alveolar ridge or support endosteal implants. Maintenance of the the alveolar ridge area. redundant soft tissue may be necessary to improve the results Depending on the degree of irregularity of the alveolar ridge of the grafting procedure. If this tissue were removed without area, recontouring can be accomplished with a rongeur, a bone any consideration of the possible long-term benefits of a grafting file, or a bone burr in a handpiece, alone or in combination (Fig. procedure, the opportunity for improved immediate function and 13.6). Copious saline irrigation should be used throughout the the opportunity for long-term maintenance of bony tissue and soft recontouring procedure to avoid overheating and bone necrosis. tissue would be lost. If bony augmentation is indicated, maximum After recontouring, the flap should be reapproximated by digital augmentation frequently depends on availability of adjacent soft pressure and the ridge palpated to ensure that all irregularities have tissue to provide tension-free coverage of the graft. Soft tissue been removed (Fig. 13.7). After copious irrigation to ensure removal surgery should be delayed until hard tissue grafting and appropriate of debris, the tissue margins can be reapproximated with interrupted healing have occurred. This is especially true for conservation of or continuous sutures. Resorbable sutures are usually used to gingiva and keratinized soft tissues, which provide a better implant approximate tissue and add tensile strength across the wound environment. Therefore it is usually desirable to delay definitive margins. The resorbable material is broken down by salivary soft tissue procedures until underlying bony problems have been proteolytic enzymes or hydrolysis over several days to weeks, adequately resolved. However, when extensive grafting or other eliminating the need for removal.6 If an extensive incision has more complex treatment of bony abnormalities is not required, been made, continuous suturing tends to be less annoying to the bony and soft tissue preparation sometimes can be completed patient and provides for easier postoperative hygiene because of simultaneously. the elimination of knots and loose suture ends along the incision 222 PART I I I Preprosthetic and Implant Surgery A @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ B C Fig. 13.6 Simple alveoloplasty eliminates buccal irregularities and undercut areas by removing labiocorti- cal bone. (A) Elevation of mucoperiosteal flap, exposure of irregularities of the alveolar ridge, and removal of gross irregularity with a rongeur. (B) Bone burr in a rotating handpiece can also be used to remove bone and smooth labiocortical surface. (C) Use of a bone file to smooth irregularities and achieve the final desired contour. line. The initial soft tissue redundancy created with reduction of to the depth of the labial vestibule because of the configuration the bony irregularities often shrinks and readapts over the alveolus, of the alveolar ridge. The technique can be accomplished at the allowing preservation of attached gingiva. time of tooth removal or in the early initial postoperative healing When a sharp knife-edge ridge exists in the mandible, the sharp period. https: / / t.me / LibraryEDent superior portion of the alveolus can be removed in a manner After exposure of the crest of the alveolar ridge by reflection similar to that described for simple alveoloplasty. After local of the mucoperiosteum, a small rongeur can be used to remove anesthesia is obtained, a crestal incision is made, extending along the intraseptal portion of the alveolar bone (Fig. 13.9). After the alveolar ridge approximately 1 cm beyond either end of the adequate bone removal has been accomplished, digital pressure area requiring recontouring (Fig. 13.8). After minimal reflection should be sufficient to fracture the labiocortical plate of the alveolar of the mucoperiosteum, a rongeur can be used to remove the ridge inward to approximate the palatal plate area more closely. major portion of the sharp area of the superior aspect of the Occasionally, small vertical cuts at either end of the labiocortical mandible. A bone file is used to smooth the superior aspect of the plate facilitate repositioning of the fractured segment. By using a mandible. After copious irrigation, this area is closed with continu- burr or osteotome inserted through the distal extraction area, the ous or interrupted sutures. Before removal of any bone, strong labial cortex is scored without perforation of the labial mucosa. consideration should be given to reconstruction of proper ridge Digital pressure on the labial aspect of the ridge is necessary to form using grafting procedures (discussed later in this chapter). determine when the bony cut is complete and to ensure that the mucosa is not damaged. After positioning of the labiocortical plate, Intraseptal Alveoloplasty any slight areas of bony irregularity can be contoured with a bone file, and the alveolar mucosa can be reapproximated with interrupted An alternative to the removal of alveolar ridge irregularities by or continuous suture techniques. A splint or an immediate denture the simple alveoloplasty technique is the use of an intraseptal lined with a soft lining material can then be inserted to maintain alveoloplasty, or Dean technique, involving the removal of intraseptal the bony position until initial healing has taken place. bone and the repositioning of the labial cortical bone, rather than This type of technique has several advantages: the labial promi- removal of excessive or irregular areas of the labial cortex.7 This nence of the alveolar ridge can be reduced without significantly technique is best used in an area where the ridge is of relatively reducing the height of the ridge in this area. The periosteal attach- regular contour and adequate height but presents an undercut ment to the underlying bone can also be maintained, thereby  CHAPTER 13 Preprosthetic Surgery 223 The main disadvantage of this technique is the decrease in ridge thickness that obviously occurs with this procedure. If the ridge form remaining after this type of alveoloplasty is excessively thin, it may preclude placement of implants in the future. For this reason the intraseptal alveoloplasty should reduce the thickness of the ridge in an amount sufficient only to reduce or eliminate undercuts in areas where a plan to place endosteal implants does not exist. Methods for preservation of alveolar width with simultane- ous grafting into the extraction site are addressed later in the @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ chapter. Maxillary Tuberosity Reduction (Hard Tissue) A Horizontal or vertical excess of the maxillary tuberosity area may be a result of excess bone, an increase in the thickness of soft tissue overlying the bone, or both. A preoperative radiograph or selective probing with a local anesthetic needle is often useful to determine the extent to which bone and soft tissue contribute to this excess and to locate the floor of the maxillary sinus. Recontouring of the maxillary tuberosity area may be necessary to remove bony ridge irregularities or to create adequate interarch space, which allows proper construction of prosthetic appliances in the posterior areas. Surgery can be accomplished using local anesthetic infiltration or posterosuperior alveolar and greater palatine blocks. Access to the tuberosity for bone removal is accomplished by making a crestal incision that extends up the posterior aspect of the tuberosity area. The most posterior aspect of this incision is often best made with a No. 12 scalpel blade. Reflection of a full-thickness mucoperiosteal flap is completed in the buccal and palatal directions to allow B adequate access to the entire tuberosity area (Fig. 13.10). Bone can be removed using a side-cutting rongeur or rotary instruments, with care taken to avoid perforation of the floor of the maxillary sinus. If the maxillary sinus is inadvertently perforated, no specific treatment is required, provided that the sinus membrane has not been violated. After the appropriate amount of bone has been removed, the area should be smoothed with a bone file and copiously irrigated with saline. The mucoperiosteal flaps can then be readapted. Excess, overlapping soft tissue resulting from the bone removal is excised in an elliptical fashion. A tension-free closure over this area is important, particularly if the floor of the sinus has been https: / / t.me / LibraryEDent perforated. Sutures should remain in place for approximately 7 days. Initial denture impressions can be completed approximately 4 weeks after surgery. C In the event of a gross sinus perforation involving an opening in the sinus membrane, the use of postoperative antibiotics and Fig. 13.7 (A) Clinical appearance of the maxillary ridge after removal of sinus decongestants is recommended. Amoxicillin is usually the teeth. (B) Minimal flap reflection for recontouring. (C) Proper alveolar ridge antibiotic of choice, unless contraindicated by allergy. Sinus form free of irregularities and bony undercuts after recontouring. decongestants such as pseudoephedrine, with or without an antihistamine, are adequate. The antibiotic and the decongestant should be given for 7 to 10 days postoperatively. The patient is reducing postoperative bone resorption and remodeling. Finally, informed of the potential complications and cautioned against the muscle attachments to the area of the alveolar ridge can be creating excessive sinus pressure such as nose blowing or sucking left undisturbed in this type of procedure. Michael and Barsoum with a straw for 10 to 14 days. reported the results of a study comparing the effects of postoperative bone resorption after three alveoloplasty techniques.8 In their study, nonsurgical extraction, labial alveoloplasty, and an intraseptal Buccal Exostosis and Excessive Undercuts alveoloplasty technique were compared with evaluate postoperative Excessive bony protuberances and resulting undercut areas are more bony resorption. The initial postoperative results were similar, but common in the maxilla than in the mandible. A local anesthetic the best long-term maintenance of alveolar ridge height was achieved should be infiltrated around the area requiring bony reduction. with nonsurgical extractions, and the intraseptal alveoloplasty For mandibular buccal exostosis, inferior alveolar blocks may also technique resulted in less resorption than did removal of labiocortical be required to anesthetize bony areas. A crestal incision extends bone for reduction of ridge irregularities. 1 to 1.5 cm beyond each end of the area requiring contouring, 224 PART I I I Preprosthetic and Implant Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ B A C D https: / / t.me / LibraryEDent E Fig. 13.8 Recontouring of a knife-edge ridge. (A) Lateral view of the mandible, with resorption resulting in a knife-edge alveolar ridge. (B) Crestal incision extends 1 cm beyond each end of area to be recontoured (vertical-releasing incisions are occasionally necessary at the posterior ends of the initial incision). (C) Rongeur used to eliminate bulk of a sharp bony projection. (D) Bone file used to eliminate any minor irregularities (bone burr and handpiece can also be used for this purpose). (E) Continuous suture technique for mucosal closure. and a full-thickness mucoperiosteal flap is reflected to expose the with autogenous or allogeneic bone material. Such a situation areas of bony exostosis. If adequate exposure cannot be obtained, might occur in the anterior maxilla or mandible, where removal vertical-releasing incisions are necessary to provide access and prevent of the bony buccal protuberance results in a narrowed crest in the trauma to the soft tissue flap. If the areas of irregularity are small, alveolar ridge area and a less desirable area of support for the recontouring with a bone file may be all that is required; larger denture, as well as an area that may resorb more rapidly. areas may necessitate use of a rongeur or rotary instrument (Fig. Local anesthetic infiltration is generally sufficient when filling 13.11). After completion of the bone recontouring, soft tissue in buccal undercut areas. The undercut portion of the ridge is is readapted, and visual inspection and palpation ensure that no exposed with a crestal incision and standard dissection, or the irregularities or bony undercuts exist. Interrupted or continuous undercut area can be accessed with a vertical incision made in suturing techniques are used to close the soft tissue incision. Denture the anterior maxillary or mandibular areas (Fig. 13.12). A small impressions can be completed 4 weeks postoperatively. periosteal elevator is then used to create a subperiosteal tunnel Although extremely large areas of bony exostosis generally require extending the length of the area to be filled in with bone graft. removal, small undercut areas are often best treated by being filled Autogenous or allogeneic material can then be placed in the  CHAPTER 13 Preprosthetic Surgery 225 @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ B A C D F E Fig. 13.9 Intraseptal alveoloplasty. (A) Oblique view of the alveolar ridge, demonstrating a slight facial undercut. (B) Minimal elevation of the mucoperiosteal flap followed by removal of intraseptal bone using a fissure burr and handpiece. (C) Rongeur used to remove intraseptal bone. (D) Digital pressure used to https: / / t.me / LibraryEDent fracture the labiocortex in a palatal direction. (E) Cross-sectional view of alveolar process. (F) Cross- sectional view of alveolar process after tooth removal and intraseptal alveoloplasty. By fracturing the labiocortex of the alveolar process in a palatal direction, labial undercut can be eliminated without reducing vertical height of the alveolar ridge. defect and covered with a resorbable membrane. Impressions for recontouring (Fig. 13.13). Reflection of the mucoperiosteum in denture fabrication can be taken after tissue healing 3 to 4 weeks the palatal direction should be accomplished with careful attention after surgery. A modification of this technique is also discussed in to the area of the palatine foramen to avoid damage to the blood Chapter 15. vessels as they leave the foramen and extend forward. After adequate exposure, a rotary instrument or bone file can be used to remove Lateral Palatal Exostosis the excess bony projection in this area. The area is irrigated with sterile saline and closed with continuous or interrupted sutures. No The lateral aspect of the palatal vault may be irregular because of surgical splint or packing is generally required, and the apparent the presence of lateral palatal exostosis. This presents problems in redundant soft tissues will adapt after this procedure. denture construction because of the undercut created by the exostosis and the narrowing of the palatal vault. Occasionally these exostoses are large enough that the mucosa covering the area becomes Mylohyoid Ridge Reduction ulcerated. One of the more common areas interfering with proper denture Local anesthetic in the area of the greater palatine foramen and construction in the mandible is the mylohyoid ridge area. In addition infiltration in the area of the incision are necessary. A crestal incision to the actual bony ridge, with its easily damaged thin covering of is made from the posterior aspect of the tuberosity, extending mucosa, the muscular attachment to this area often is responsible slightly beyond the anterior area of the exostosis, which requires for dislodging the denture. When this ridge is extremely sharp, 226 PART I I I Preprosthetic and Implant Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ A B D C E Fig. 13.10 Bony tuberosity reduction. (A) Incision extended along the crest of the alveolar ridge distally to the superior extent of the tuberosity area. (B) Elevated mucoperiosteal flap provides adequate exposure to all areas of bony excess. (C) Rongeur used to eliminate bony excess. (D) Tissue reapproximated with a continuous suture technique. (E) Cross-sectional view of the posterior tuberosity area, showing vertical https: / / t.me / LibraryEDent reduction of bone and reapposition of the mucoperiosteal flap. (In some cases removal of large amounts of bone produces excessive soft tissue, which can be excised before closure to prevent overlapping.) denture pressure may produce significant pain in this area. (Reloca- by sharply incising the muscle attachment at the area of bony tion of the mylohyoid muscle to improve this condition is discussed origin. When the muscle is released, the underlying fat is visible later in this chapter.) In cases of severe resorption, the external in the surgical field. After reflection of the muscle, a rotary instru- oblique line and the mylohyoid ridge area may actually form the ment with careful soft tissue protection or bone file can be used most prominent areas of the posterior mandible, with the midpor- to remove the sharp prominence of the mylohyoid ridge. Immediate tion of the mandibular ridge existing as a concave structure. In replacement of the denture is desirable because it may help to such cases, augmentation of the posterior aspect of the mandible, facilitate a more inferior relocation of the muscular attachment; rather than removal of the mylohyoid ridge, may be beneficial. however, this is unpredictable and may actually be best managed However, some cases can be improved by reduction of the mylohyoid by a procedure to lower the floor of the mouth. ridge area. Inferior alveolar, buccal, and lingual nerve blocks are required for mylohyoid ridge reduction. A linear incision is made over the Genial Tubercle Reduction crest of the ridge in the posterior aspect of the mandible. Extension As the mandible begins to undergo resorption, the area of the of the incision too far to the lingual aspect should be avoided attachment of the genioglossus muscle in the anterior portion of because this may cause potential trauma to the lingual nerve. A the mandible may become increasingly prominent. In some cases full-thickness mucoperiosteal flap is reflected, which exposes the the tubercle may actually function as a shelf against which the mylohyoid ridge area and mylohyoid muscle attachments (Fig. denture can be constructed, but it usually requires reduction to 13.14). The mylohyoid muscle fibers are removed from the ridge construct the prosthesis properly. Before a decision to remove this  CHAPTER 13 Preprosthetic Surgery 227 Smoothing with a burr or a rongeur followed by a bone file removes the genial tubercle. The genioglossus muscle is left to reattach in a random fashion. As with the mylohyoid muscle and mylohyoid ridge reduction, a procedure to lower the floor of the mouth may also benefit the anterior mandible. Tori Removal Maxillary Tori @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ Maxillary tori consist of bony exostosis formation in the area of the palate. The origin of maxillary tori is unclear. Tori are found in 20% of the female population, which is approximately twice the prevalence rate in males.9 Tori may have multiple shapes and A configurations, ranging from a single smooth elevation to a multiloculated pedunculated bony mass. Tori present few problems when the maxillary dentition is present and only occasionally interfere with speech or become ulcerated from frequent trauma to the palate. However, when the loss of teeth necessitates full or partial denture construction, tori often interfere with proper design and function of the prosthesis. Nearly all large maxillary tori should be removed before full or partial denture construction. Smaller tori may often be left because they do not interfere with prosthetic construction or function. Even small tori necessitate removal when they are irregular, extremely undercut, or in the area where a posterior palatal seal would be expected. Bilateral greater palatine and incisive blocks and local infiltration provide the necessary anesthesia for tori removal. A linear incision in the midline of the torus with oblique vertical-releasing incisions B at one or both ends is generally necessary (Fig. 13.15). Because the mucosa over this area is extremely thin, care must be taken in reflecting the tissue from underlying bone, a particularly difficult task when the tori are multiloculated. A full palatal flap can sometimes be used for exposure of the tori. An incision is made along the crest of the ridge when the patient is edentulous or a palatal sulcular incision is used when teeth are present. Tissue reflection with this type of incision is often difficult if the tori have large undercuts where the bony exostosis is fused with the palate. When tori with a small pedunculated base are present, an osteotome and mallet may be used to remove the bony mass. For https: / / t.me / LibraryEDent larger tori, it is usually best to section the tori into multiple frag- ments with a burr in a rotary handpiece. Careful attention must be paid to the depth of the cuts to avoid perforation of the floor of the nose. After sectioning, individual portions of the tori can C be removed with a mallet and osteotome or a rongeur; then the Fig. 13.11 Removal of buccal exostosis. (A) Gross irregularities of the area can be smoothed with a large bone burr. The entire bony buccal aspect of the alveolar ridge. After tooth removal, incision is com- projection does not necessarily require removal, but a smooth pleted over the crest of the alveolar ridge. (Vertical-releasing incision in regular area without undercuts should be created, without extension the cuspid area is demonstrated.) (B) Exposure and removal of buccal into the area where a posterior palatal seal would be placed. Tissue exostosis with a rongeur. (C) Soft tissue closure using a continuous suture is readapted by finger pressure and is inspected to determine the technique. amount of excess mucosa that may require removal. Retention of enough tissue to allow a tension-free closure over the entire area prominence is made, consideration should be given to possible of exposed bone is important. The mucosa is reapproximated and augmentation of the anterior portion of the mandible rather than sutured; an interrupted suture technique is often required because reduction of the genial tubercle. If augmentation is the preferred the thin mucosa may not retain sutures well. To prevent hematoma treatment, the tubercle should be left to add support to the graft formation, some form of pressure dressing must be placed over in this area. Local anesthetic infiltration and bilateral lingual nerve the area of the palatal vault. A temporary denture or prefabricated blocks should provide adequate anesthesia. A crestal incision is splint with a soft liner placed in the center of the palate to prevent made from each premolar area to the midline of the mandible. A pressure necrosis can also be used to support the thin mucosa and full-thickness mucoperiosteal flap is dissected lingually to expose prevent hematoma formation. the genial tubercle. The genioglossus muscle attachment can be The major complications of maxillary tori removal include removed by a sharp incision. postoperative hematoma formation, fracture or perforation of the 228 PART I I I Preprosthetic and Implant Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ A B C Fig. 13.12 Removal of mandibular buccal undercut. (A) Cross-sectional view of the anterior portion of the mandible, which, if corrected by removal of labiocortical bone, would result in knife-edge ridge. (B) Vertical incision is made and a subperiosteal tunnel developed in the depth of the undercut area. (C) Cross-sectional view after filling the defect with graft material. The material is contained within the bound- aries of the subperiosteal tunnel. https: / / t.me / LibraryEDent A B C D Fig. 13.13 Removal of palatal bony exostosis. (A) Small palatal exostosis that interferes with proper denture construction in this area. (B) Crestal incision and mucoperiosteal flap reflection to expose palatal exostosis. (C) Use of a bone file to remove bony excess. (D) Soft tissue closure.  CHAPTER 13 Preprosthetic Surgery 229 @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ A B C Fig. 13.14 Mylohyoid ridge reduction. (A) Cross-sectional view of the posterior aspect of the mandible, showing concave contour of the superior aspect of the ridge from resorption. Mylohyoid ridge and external oblique lines form the highest portions of the ridge. (This can generally best be treated by alloplastic augmentation of the mandible but, in rare cases, may also require mylohyoid ridge reduction.) (B) Crestal incision and exposure of the lingual aspect of the mandible for removal of sharp bone in the mylohyoid ridge area. Rongeur or burr in a rotating handpiece can be used to remove bone. (C) Bone file used to complete recontouring of the mylohyoid ridge. https: / / t.me / LibraryEDent A B C Fig. 13.15 Removal of a palatal torus. (A) Typical appearance of a maxillary torus. (B) Midline incision with the anteroposterior oblique releasing incisions. (C) Mucoperiosteal flaps retracted with silk sutures to improve access to all areas of the torus. Removal of palatal torus. Continued 230 PART I I I Preprosthetic and Implant Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ D E F G H I Fig. 13.15, cont’d(D–E) Sectioning of the torus using a fissure burr. (F) Small osteotome used to remove sections of the torus. (G–H) Large bone burr used to produce the final desired contour. (I) Soft tissue closure. floor of the nose, and necrosis of the flap. Local care, including of the mandible. The line of cleavage can be directed by creating vigorous irrigation, good hygiene, and support with soft tissue a small trough with a burr and a handpiece before using an conditioners in the splint or denture, usually provides adequate osteotome. It is important to ensure that the direction of the initial treatment. burr trough (or the osteotome, 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 use of a burr and handpiece Mandibular Tori can be a more controlled technique versus the use of a mallet and Mandibular tori are bony protuberances on the lingual aspect of osteotome, due to potential trauma to anatomic structures within https: / / t.me / LibraryEDent the mandible that usually occur in the premolar area. The origins the floor of the mouth. This is especially so when the practitioner of this bony exostosis are uncertain, and the growths may slowly has little experience with an osteotome. The tongue and mucosa increase in size. Occasionally, extremely large tori interfere with of the floor of the mouth must be retracted and protected with a normal speech or tongue function during eating, but these tori smaller contoured retractor such as a Seldin retractor. The burr rarely require removal when teeth are present. After the removal can also be used to deepen the trough so that a small instrument, of lower teeth and before the construction of partial or complete such as a #81 straight dental elevator, can be levered against the dentures, it may be necessary to remove mandibular tori to facilitate mandible to fracture the lingual tori to allow its removal. A bone denture construction. burr or file can then be used to smooth the lingual cortex. The Bilateral lingual and inferior alveolar injections provide adequate tissue should be readapted and palpated to evaluate contour and anesthesia for tori removal. A crest of the ridge incision should be elimination of undercuts. An interrupted or continuous suture made, extending 1 to 1.5 cm beyond each end of the tori to be technique is used to close the incisions. Gauze packs placed in the reduced. When bilateral tori are to be removed simultaneously, it floor of the mouth and retained for several hours are generally is best to leave a small band of tissue attached at the midline helpful in reducing postoperative edema and hematoma formation. between the anterior extent of the two incisions. Leaving this tissue In the event of wound dehiscence or exposed bone in the area of attached helps to eliminate potential hematoma formation in the a mucosal perforation, treatment with local care, including frequent anterior floor of the mouth and maintains as much of the lingual vigorous saline irrigation, is usually sufficient. vestibule as possible in the anterior mandibular area. As with maxillary tori, the mucosa over the lingual tori is generally very Soft Tissue Abnormalities thin and should be reflected carefully to expose the entire area of bone to be recontoured (Fig. 13.16). Abnormalities of the soft tissue in the denture-bearing and peripheral When the torus has a small pedunculated base, a mallet and tissue areas include excessive fibrous or hypermobile tissue, inflam- osteotome may be used to cleave the tori from the medial aspect matory lesions such as inflammatory fibrous hyperplasia of the  CHAPTER 13 Preprosthetic Surgery 231 vestibule and inflammatory papillary hyperplasia of the palate, with a sharp probe after local anesthesia is obtained at the time and abnormal muscular and frenal attachments. With the exception of surgery. of pathologic and inflammatory lesions, many of the other condi- Local anesthetic infiltration in the posterior maxillary area is tions do not present problems when the patient has a full dentition. sufficient for a tuberosity reduction. An initial elliptical incision However, when loss of teeth necessitates prosthetic reconstruction, is made over the tuberosity in the area requiring reduction, and alteration of the soft tissue is often necessary. Immediately after this section of tissue is removed (Fig. 13.17). After tissue removal, tooth removal, muscular and frenal attachments initially do not the medial and lateral margins of the excision must be thinned present problems but may eventually interfere with proper denture to remove excess soft tissue, which allows further soft tissue construction as bony resorption takes place. reduction and provides a tension-free soft tissue closure. This can @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ Long-term treatment planning before any soft tissue surgery is be accomplished by digital pressure on the mucosal surface of mandatory. Soft tissue that initially appears to be flabby and excessive the adjacent tissue while sharply excising tissue tangential to the may be useful if future ridge augmentation or grafting procedures mucosal surface (Fig. 13.18). After the flaps are thinned, digital are necessary. Oral mucosa is difficult to replace once it is removed. pressure can be used to approximate the tissue to evaluate the The only exception to this usefulness of excess tissue is when vertical reduction that has been accomplished. If adequate tissue pathologic soft tissue lesions require removal. has been removed, the area is sutured with interrupted or continu- ous suturing techniques. If too much tissue has been removed, no attempt should be made to close the wound primarily. A Maxillary Tuberosity Reduction (Soft Tissue) tension-free approximation of the tissue to bone should be accom- The primary objective of soft tissue maxillary tuberosity reduction plished, which allows the open wound area to heal by secondary is to provide adequate interarch space for proper denture construc- intention. tion in the posterior area and a firm mucosal base of consistent thickness over the alveolar ridge denture-bearing area. Maxillary tuberosity reduction may require the removal of soft tissue and Mandibular Retromolar Pad Reduction bone to achieve the desired result. The amount of soft tissue available The need for removal of mandibular retromolar hypertrophic tissue for reduction can often be determined by evaluating a presurgical is rare. It is important to verify that the patient is not posturing panoramic radiograph. If a radiograph is not of the quality necessary the mandible forward or vertically overclosed during clinical to determine soft tissue thickness, this depth can be measured evaluation and with treatment records and mounted casts. Local https: / / t.me / LibraryEDent A B C Fig. 13.16 Removal of mandibular tori. (A) After block, local anesthetic is administered; ballooning of thin mucoperiosteum over the area of the tori can be accomplished by placing the bevel of a local anes- thetic needle against the torus and injecting local anesthetic subperiosteally. (This greatly facilitates reflec- tion of the mucoperiosteal flap.) (B) Outline of crestal incision. (C) Exposure of torus. Removal of mandibular tori. 232 PART I I I Preprosthetic and Implant Surgery anesthetic infiltration in the area requiring excision is sufficient. interrupted sutures. Another option for tissue removal in this area An elliptical incision is made to excise the greatest area of tissue is with the use of a laser. Laser-assisted recontouring of the retro- thickness in the posterior mandibular area. Slight thinning of the molar area allows reduction of the tissue excess without incisions adjacent areas is carried out with the majority of the tissue reduction and limits the postoperative healing period.10 The most common on the labial aspect. Excess removal of tissue in the submucosal laser used in oral surgery is the carbon dioxide laser.11 Tissue ablation area of the lingual flap may result in damage to the lingual nerve allows for controlled removal of tissue in layers based on intensity and artery. The tissue is approximated with continuous or and depth of penetration.12 @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ D E https: / / t.me / LibraryEDent F G H I Fig. 13.16, cont’d(D) Exposure of torus. (E) and (F) Fissure burr and handpiece used to create a small trough between the mandibular ridge and torus. (G) Use of a small osteotome to complete removal of torus from the mandible. (H–I) Use of a bone burr and a bone file to eliminate minor irregularities. Removal of mandibular tori.  CHAPTER 13 Preprosthetic Surgery 233 the mucosa are much more extensive and creates 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 superficial excision of the soft tissue excess. Local anesthetic infiltrated in the greater palatine area and anterior to the soft tissue mass is sufficient. With a sharp scalpel blade in the tangential fashion, the superficial layers of mucosa and underlying fibrous tissue can be removed to the extent necessary to eliminate undercuts in soft tissue bulk (Fig. 13.19). @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ After removal of this tissue, a surgical splint lined with a tissue conditioner can be inserted for 5 to 7 days to aid in healing. Unsupported Hypermobile Tissue Excessive hypermobile tissue without inflammation on the alveolar J ridge is generally the result of resorption of the underlying bone, ill-fitting dentures, or both. Before the excision of this tissue, a determination must be made whether the underlying bone should be augmented with a graft. If a bony deficiency is the primary cause of soft tissue excess, then augmentation of the underlying bone is the treatment of choice. If adequate alveolar height remains after reduction of the hypermobile soft tissue, then excision may be indicated. A local anesthetic is injected adjacent to the area requiring tissue excision. Removal of hypermobile tissue in the alveolar ridge area consists of two parallel full-thickness incisions on the buccal and lingual aspects of the tissue to be excised (Fig. 13.20). A K periosteal elevator is used to remove excess soft tissue from underly- ing bone. A 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 soft tissue and to prevent detachment of periosteum from underlying bone. Continuous or interrupted sutures are used to approximate the remaining tissue. Denture impressions can usually be taken 3 to 4 weeks after surgery. One possible complication of this type of procedure is the obliteration of the buccal vestibule as a result of tissue undermining necessary-to-obtain tissue closure. Hypermobile tissue in the crestal area of the mandibular alveolar ridge frequently consists of a small cordlike band of tissue. If no https: / / t.me / LibraryEDent underlying sharp bony projection is present, this tissue can best be removed by a supraperiosteal soft tissue excision. Local anesthetic is injected adjacent to the area requiring tissue removal. The cordlike L band of fibrous connective tissue can be elevated by using pickups and scissors, and the scissors can be used to excise the fibrous Fig. 13.16, cont’d (J) Use of a bone burr and bone file to eliminate minor tissue at the attachment to the alveolar ridge (Fig. 13.21). In irregularities. (K–L) Tissue closure. general, no suturing is necessary for this technique, and a denture with a soft liner can be reinserted immediately. Inflammatory Fibrous Hyperplasia Lateral Palatal Soft Tissue Excess Inflammatory fibrous hyperplasia, also called epulis fissurata or denture fibrosis, is a generalized hyperplastic enlargement of mucosa Soft tissue excess on the lateral aspect of the palatal vault often and fibrous tissue in the alveolar ridge and vestibular area, which interferes with proper construction of the denture. As with bony most often results from ill-fitting dentures. In the early stages of abnormalities of this area, soft tissue hypertrophy often narrows fibrous hyperplasia, when fibrosis is minimal, nonsurgical treatment the palatal vault and creates slight undercuts, which interfere with with a denture in combination with a soft liner is frequently denture construction and insertion. sufficient for reduction or elimination of this tissue. When the One technique suggested for removal of lateral palatal soft tissue condition has been present for some time, significant fibrosis exists involves submucosal resection of the excess tissue in a manner within the hyperplastic tissue. This tissue does not respond to similar to the previously described soft tissue tuberosity reduction. nonsurgical treatment (Fig. 13.22); excision of the hyperplastic However, the amount and extension of soft tissue removal under tissue is the treatment of choice. 234 PART I I I Preprosthetic and Implant Surgery @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ B A C D https: / / t.me / LibraryEDent E F Fig. 13.17 Maxillary soft tissue tuberosity reduction. (A) Elliptical incision around soft tissue to be excised in the tuberosity area. (B) Soft tissue area excised with the initial incision. (C) Undermining of buccal and palatal flaps to provide adequate soft tissue contour and tension-free closure. (D) View of final tissue removal. (E–F) Soft tissue closure. Three techniques can be used for successful treatment of inflam- the hyperplastic tissue is removed (Fig. 13.23). The adjacent tissue matory fibrous hyperplasia. Local anesthetic infiltration in the area is gently undermined and reapproximated using interrupted or of the redundant tissue is sufficient for anesthesia. When the area continuous sutures. to be excised is minimally enlarged, electrosurgical or laser techniques When areas of gross tissue redundancy are found, excision provide good results for tissue excision. If the tissue mass is extensive, frequently results in total elimination of the vestibule. In such large areas of excision using electrosurgical techniques may result cases excision of the epulides, with peripheral mucosal repositioning in excessive vestibular scarring. Simple excision and reapproximation and secondary epithelialization, is preferable. of the remaining tissue is preferred. The redundant areas of tissue In this procedure the hyperplastic soft tissue is excised superficial are grasped with tissue pickups, a sharp incision is made at the to the periosteum from the alveolar ridge area. A clean supraperi- base of the excessive fibrous tissue down to the periosteum, and osteal bed is created over the alveolar ridge area, and the unaffected  CHAPTER 13 Preprosthetic Surgery 235 The hyperplastic tissue usually represents only the result of an inflammatory process; however, other pathologic conditions may exist. Therefore it is imperative that representative tissue samples always be submitted for pathologic examination after removal. Labial Frenectomy Labial frenal attachments consist of thin bands of fibrous tissue covered with mucosa, extending from the lip and cheek to the @LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬ alveolar periosteum. The level of frenal attachments may vary from the height of the vestibule to the crest of the alveolar ridge and even to the incisal papilla area in the anterior maxilla. With the exception of the midline labial frenum in association with a diastema, frenal attachments generally do not present problems when the A dentition is intact. In cases of frenal attachment in the area of a diastema in a patient undergoing orthodontic treatment, there is some debate about the timing of frenum removal. Many surgeons and orthodontists prefer to remove or reposition the frenum prior to closure of the diastema, believing the elimination of the soft tissue barrier will facilitate alignment of the teeth. There are some practitioners who advocate removing the frenal attachment after the space closure because they believe surgery first will create dense scar tissue in the area of the diastema, making space closure more difficult.13 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. B Multiple surgical techniques are effective in removal of frenal attachments: (1) the simple excision technique, (2) the Z-plasty technique, (3) localized vestibuloplasty with secondary epithelializa- tion, and (4) the laser-assisted frenectomy. The simple excision and Z-plasty are effective when the mucosal and fibrous tissue band is relatively narrow. A localized vestibuloplasty with secondary epithelialization is often preferred when the frenal attachment has a wide base. Laser- assisted techniques are versatile in creating local excision and ablation of excessive mucosal tissue and fibrous tissue attachments, allowing secondary epithelialization. https: / / t.me / LibraryEDent Local anesthetic infiltration is often sufficient for surgical treat- ment 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. C In all cases it is helpful to have the surgical assistant elevate and Fig. 13.18 Maxillary soft tissue tuberosity reduction. (A) Elliptical incision. evert the lip during this procedure. For the simple excision tech- (B) Thinning of mucosal flaps by removal of underlying soft tissue. Digital nique, a narrow elliptical incision around the frenal area down to pressure used to stabilize the tissue flaps during submucosal excision. (C) the periosteum is completed (Fig. 13.24). The fibrous frenum is Tension-free readaptation of flaps. then sharply dissected from the underlying periosteum and soft tissue, and the margins of the wound are gently undermined and reapproximated. Placement of the first suture should be at the margin of the tissue excision is sutured to the most superior aspect maximal depth of the vestibule and should include both edges of of the vestibular periosteum with an interrupted suture technique. mucosa and underlying periosteum at the height of the vestibule A surgical splint or denture lined with soft tissue conditioner is beneath the anterior nasal spine. This technique reduces hematoma inserted and worn continuously for the first 5 to 7 days, with formation and allows for adaptation of the tissue to the maximal removal only for oral saline rinses. Secondary epithelialization height of the vestibule. The remainder of the incision should then usually takes place, and denture impressions can be made within be closed with interrupted sutures. Occasionally it is not possible 4 weeks. Laser excision of large epulis allows complete removal to approximate the portion of the excision closest to th