Pre-Prosthetic Oral Surgery Flashcards
population that is edentulous
10% of american population
35% of those are above 65 years old
loss of dentition consequences
irregular alveolar ridge
undercuts
scarring
muscle interferes with denture stability
general goal of pre-prosthetic surgery
prepare the mouth to relieve a functional dental prosthesis
preserve hard and soft tissue
maxillary resorptionproblems
anteriorly - many times there is a concavity
posterior – problem with maxillary sinuse
mandibular resorption
knife edge ridge
- cortical bone - cant place implants there direcrtly without grafting
or grind down and place - but sacrifice knife edge
classification of edentulous jaws – general
I– VI
class I edentulous jaw description
dentate - still teeth
class II edentulous jaw description
immediately post-extraction
like good enough ridge to place something on right away
class III edentulous jaw description
convex ridge form, adequate in height and width
class IV edentulous jaw description
knife-edge form, adequate in height but INADEQUATE in width
class V edentulous jaw description
flat ridge form - inadequate height AND width
class VI edentulous jaw description
loss of basal bone which may be extensive but follows NO PREDICTABLE pattern
specific goals for pre-prosthetic intervention
- ridge should have adequate width, height, and U shape
- mucosa should have adequate UNIFORM thickness
- ridge without undercuts or sharpness
- no bony or soft tissue protruberence
- adequate buccal and lingual sulci depth
three broad overview of intra-oral examination
anatomical structures
- VISUAL
- PALPATE
- RADIOGRAPHIC EXAMINATION
visual inspection look at
ridge contour
undercuts
muscle atachment
soft tissue health
palpate?
denture bearing areas might reveal sharp bony areas
radiographic examination
need to rule out any bony pathologies
- if decided to leave retained roots, should be notified to patietn
retained roots usually are noticeable to the patient?
NO – 73-84% of the retained root fragments are seen on radiographic examination of edentulous patients, and majority of theem are present WITH NO ASSOCIATED SYMPTOMS
prevelence of retained roots
11-37%
maxilla intra oral exam
evaluate for undercuts or bony protruberences
palatal tori
tuberosity
labial and buccal frenum
hyperpladstic tissue
inter arch distance
mandible intra oral exam
ridge form
contour
irregularities
buccal extoses
tori
muscle attachment
overclosure of the mandible?
might give the impression of a pseudo class III
normal resting position?
must evaluate patient in this as well to get the antero-posterior vertical relationship
also
- assymetries
- inter-arch distance
lateral ceph can
help determine anteroposteiror relation of the jaws
one of the most important determinants of success with complete dentures
soft tissue —health and quality
characterstics you want in soft tissue
healthy keratinized
firmly attached to the underlying bone
vestibule FREE of iflammation
muscle attachment low/ high to the alveolar crest
specific thing poited out that makes the denture base unstable?
hyperplastic tissue over the maxillary ridge — tissue will make the denture base unstable
implicationof labial frenum?
plasty
- reposition it if in way
treatment planning after?
intra and extra oral exams
tx planning outline
- medical and dx history
- concerns of the patient
- benefits and possible complications - intra/extra oral exam
- radiographi exam
- alternative treatment
- surgical procedures involving bone contouring or augmentatino should be addressed first, followed by soft tissue proceudres
surgical blades noted in armamentarium
15 and 11
bard parker scalpal handle and molt periosteal elevator
step 1 for immediate denture treatment
w/ notes
prophylaxis PRIOR to extractions
to MINIMIZE BLEEDING AND INFECTION PROBABILITIES
Step 2 for immediate denture treatment
w/ notes
complicated extractions
as bony changes may effect final impressions and denture fit
step 3 for immediate denture treatment
w/ notes
extractions of maxillary and mandibular molars
after extractions – allow 6 weeks for healing before making final impressoins
after extractions of molars wait?
6 weeks before final impressions
final impressions when
after the posterior extractions
step 5 for immediate denture treatment
w/ notes
model surgery
remove the teeth that are visible above the gingiva, contour gingival tissue, and remove undercuts
step 6 for immediate denture treatment
w/ notes
construction of clear surgical stent
will guide the surgeon during the preocedure for alveolar recontouring
- must make sure it is seated completely
post op instructions for immediate
antibiotics are usually UNNECESSARY
do NOT remove denture until follow-up with dentist (24 hours)
follow up with surgeon in 1 week
soft-tissue reline if needed
elliptical incision?
looked at the mandibular anterior
- raise a flap and eliminate tissue and bone
grind down with pinapple bur
be careful with pineapple bur?
yes – around cancellous bone – this is soft bone and this bur can remove too much if not careful
remove inter-proximal papilla?
is an option – then can remove the bone in the inter-ridge areas and smooth down
remove mandibular lingual extoses
make incision in bone towards buccal
full flap
so not too worried about lingual nerve
because incisoin on bone towards buccal and full buccal periosteal flapp - so lingual nerve on the other side
most alveolopplasty are done
on the maxilla and anterior mandible
alveoplasty definiotn
contouring the alveolar ridge to remove irregularities and under-cuts
goals of alveoplasty
provide stable base for prosthesis
preserve alveolar bone
pitfalls of alveoplasty
poor evaluation of the patient
- does the patient need bone reduction or augmentation?
poor communication with the dentist
- dentists goals and expectaions met?
tip of elevator has to be?
POINTED EDGE CONTACTING BONE
could damage tissue and nerves in area if dont
surgical technique for alveoplasty with incision?
crestal incision over the area with VERTICAL RELEASE INCISION
- FULL thickness flap
- be careful with anatomical structures
periostal elevator?
MUST USE – pointed edge of the elevator must be AGAINST BONE
reflect with?
a seldin or minnesota retractor
start reflection?
where the vertical and crestal incision join
contour bone with?
bone file, rongeurs and/ or round bur
- ELIMINATE UNDERCUTS AND SHARP EDGES
eliminate the undercuts and sharp edges
bone file, rongeurs and round bur
irrigate with?
NNS and suture to original position
implication of lone standing tooth
the tooth super-erupts and brings bone with it - so if just remove the tooth - left with a bony protuberance
envelope flap has?
NO releasing incisions
isolated teeth in maxilla posterior make sure to check
x-ray
dont use elevator – maxillary sinus may come with the tooth
indication for maxillary tuberosity reduction
not enough space, vertically or horizontally for denture base
severe undercut
mobile tissue
radiograph with max tuberosity reduction?
panorex – to determine the proximity of the maxillary sinus
helps to determien if it is fibrous or bony in nature
fibrous tuberosity technique?
wedge resection
wedge resection used in
fibrous tuberosity reduction on maxilla
surgical techniwue for wedge resection
incision type? with?
ELLIPTICAL INCISION
- #15 BLADE
wedge resection incision starts?
elliptical incision
STARTSON CREST or AT JUNCTION of the normal and fibrotic tissue
wedge resection incisoin extends?
POSTERIORLY towards hamular notch
submucous lateral resection?
yes used in the wedge resection technique with fibrous tuberosity reuction
uses #15 blade
make sure to preserve ___ with wedge resection
the vestibule and attached gingiva
suture with wedge resection
approximate flaps and suture with CONTINUOUS 3.0 suture
fibrous vs bony identified by?
x ray normally
bony tuberosity maxillary reduction incision?
we do 3 - corner flap - have to reflect more to work in the bone
single crestal incision
release incision ***
flap with bony tuberoisty
similar procedure to an alveloplasty
FULL THICKNESS with periosteal elevator
place seldin retractor - tip in bone
contour bone in bony tuberosity removal?
YES – with rongeur, oval bur, bone file
suture in bony tuberosity?
suture 3.0
most tori…
do not need to be removed
- but if interfere - must remove
solid cortical bone
indications for removal of maxillary torus
constant trauma
prevent good post dam seal
large undercuts
speech impediment
psychological phobia
radiograph with max tori?
yes – to evaluate and determine the proximity of nasal cavity and maxillary sinus
technique for max tori removal
maxillary impression
torus removed from the cast and clear stent is made
stent will protect the area andprevent hematom
stent can prevent
a hematoma
LA for max tori removal?
15 blade used to make an incision in the for of a Y
LA with VASOCONSTRICTOR for greater palatine and nasopalatine
incision form for max tori removal?
reflection?
Y shape
and reflect with a periosteal elevator
score?
score the torus with a FISSURE BUR
fissure bur?
used to score the torus on the maxilla
technique for removal of max torus?
score torus with fisure bur
chisel and mallet or round bur
smooth with large oval burr with copious irrigation
suture with chromic 3.0
suture with max tosi removal?
with chromic 3.0
mandibular tori location?
usually bilateral and located on the lingual aspect
mandibular tori can interefere?
yes with the mandibualr partial or complete denture
LA technique for mandibular tori removal
IAN blocks
incision for mandibular tori
incision alongt he crest of the ridge extended equivalent of 2 teeth beyond torus
release incisions usually NOT needed
release incisions in mandibular tori?
usually NOT needed
flap in mandibular tori removal
detailed with anatomy included
FULL thickness flap
be careful because mucosa is THIN
the lingual ARTERY and NERVE are close to the surgical area
flap extended BELOW the torus and protected with selding retractor
groove in mandibular tori removal?
yes use a groove with fissure burr on the SUPERIOR MARGIN
- depth should not be more than halfway through the vertical dimension
monobevel chisel?
used to be placed into the groove created with fissure bur when removing a mandibular tori
mandibular tori removal
implication with chin?
needs to be supported when removing
- so support manually and then monobevel chisel in the groove
- tap with a mallet
- a bur could also be used
mandibular tori suture?
SILK 3.0
vs. maxillary tori was chromic 3.0
vestibuloplasty goal
remove unwanted muscle insertions into the alveolar ridge that prevents denture flange from extending adequate stability and retention
vestibuloplasty requires adequate?
HEIGHT OF ALVEOLAR BONE
vestibuloplasty surgical technique
LA
incision
- placed at the JUNCTION of attached and unatteched mucosa with a #15 blade
partial thickness flap is raised with the blade or deans scissors preserving the periosteum
periosteal has to be left
so PARTIAL THICKNESS FLAP
vestibuloplasty incision
incision
- placed at the JUNCTION of attached and unatteched mucosa with #15
flap in vestibuloplasty
partial thickness flap is raised with the blade or deans scissors preserving the periosteum
suture in vestibuloplasty
the mucosal edge is sutured to the bottom of dissected area
resulting denuded periosteum can be handled in different ways… name the two
- heal by SECONDARY INTENTION (50% will relapse)
- GRAFT the area
- palatal graft
- collagen membrane
- cadaveric mucoslal membrane
perforate graft?
YES – graft should be perforated with a #11 blade after suturing to prevent blood clots forming between the graft and periosteum
protect the graft?
yes – use patients denture or soft clear splint with soft tissue relining material to protect the graft
denture / splint removal after vestibuloplasty
should NOT be removed for a WEEK
removal of the splint after grafting?
graft will look WHITE - this is NORMAL
angiogensis and healing with graft?
angiogenesis occurs within 48 hours and healing takes up to 5-6 weeks
labial frenectomy
frenum consists of thin bands of connective tissue attached to the bone
can interfere with the extension of the denture flange if not altered
simple excision used in? effective when?
labial frenectomy
*EFFECTIVE WHEN MUCOSAL AND FIBROUS BAND IS RELATIVE NARROW
labial frenectomy surgical technique with incision?
simple incision is made
ELLIPTICAL
- is done around the frenum down to the periosteum
RHOMBOID IN SHAPE AROUND IT
incision margins undermined with___ in labial frenectomy
deans scissors
Z plasty?
technique to remove labial frenum
z plasty effetive when
when mucosal and fibrous band is relatively narrow
incisoin with z plasty
with #15 blade – do incision ALONG the frenum
at edge of the incisions - two small incisions are made in a Z fashion
flaps in labial frenectomy with z plasty technique
flaps are undermined with deans scissors and rotated to close the original vertical incision in a horizontal manner
you actually lengthen the frenum
- do not see secondary intention healing
labial frenectomy when frenal attachment has a wide base with secondary epithelialization
incision?
flap?
suture?
healing?
SEMI-LUNAR SUPRA-periosteal incision is made at the JUNCTION free and attached gingiva
flap
- undermined
suture
- to the periosteum at the depth of the vestibule
helaing
- takes place by secondary epitheliazatoin
lingual frenectomy aka
need for TONGUE-TIE OR ANKYLOGLOSIA
can cause difficulty in denture contriction
surgical technique for lingual frenectomy
suture?
TRACTION SUTURE - at the tip of the tongue to retract the tongue SUPERIORLY
lingual frenectomy use of hemostat?
yes – clamp the hemostat at the BASE of the frenum at the same time you RETRACT the tongue
watch out for___ in lingual frenectomy?
SUBMANDIBULAR DUCTS
have to what in lingual frenectomy with tissue
have to UNDERMINE the tissue
