PREPROSTHETIC SURGERY

Dr. AKHILA K MDS

ASSISTANT PROFESSOR, DEPT OF OMFS

MES DENTAL COLLEGE AND HOSPITAL

INTRODUCTION

• A thorough examination of the mouth prior to the construction of complete denture prosthesis is necessary to identify potential problem areas.

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A determination of whether surgery is necessary is an essential part of that examination and plays an important role in successful patient management.

By Definition…

“ PREPROSTHETIC SURGERY is carried out to reform/redesign soft/hard tissues, by elimination of biological hindrances to receive comfortable and stable prosthesis”

According to Bruce Donoff, preprosthetic surgery is that part of the oral and maxillofacial surgery designed to establish the best hard and soft tissue bases for prosthetic appliances.

History

• Reverdin in 1867 reported the success of pinch grafts (skin)
• Carl thierch in 1870 gave the concept of thin grafts are easily vitalized
• Pichler and trauner in 1915 first to create a buccal vestibule with thiersch graft
• Later Gillies , Pickerill, Jackson,and Kazanjian published various techniques
• Wassmund introduced lowering of genioglossus attachment
• Obwegeser demonstrated a technique of lowering of mental foramen and mylohyoid.

Characteristics of this ideal form which provide for maximum support and stability and minimum interference with function are:

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Adequate bone support for dentures.

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Bone covered by adequate soft tissue.

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No undercuts or overhanging protuberances

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No sharp ridges

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Adequate buccal and lingual sulcus.

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No scar bands to prevent normal seating of

denture

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No muscle fibers or frenula to interfere with the periphery of

the prostheses

Satisfactory ridge relationship between the

maxilla and the

mandible

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No soft tissue folds or hypertrophies on the ridge or sulci

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A ridge free of neoplastic disease

Defining the problem

Post-extraction alveolar bone remodeling

Reduction of alveolar ridge height & width Reduction of denture bearing area Compromised denture retention & stability

Long-term use of ill-fitting denture

Accelerated shrinkage of alveolar ridge Muscle attachment closer to the crest of alveolar ridge

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Obliteration of labio-buccal & lingual sulcus & continued

ridge resorption

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Compromised speech, mastication & patient comfort

Need to increase ridge height & width

Classification of Edentulous alveolar ridge (Cawood & Howell )

• Stage I -- Dentate
• Stage II – Post extraction
• Stage III – Well-rounded ridge adequate in height and width.
• Stage IV – Knife-edge ridge adequate in height but inadequate in width.
• Stage V – Flat ridge inadequate in height & width.
• Stage VI – Depressed or concave ridge with many at times involvement of basal

bone.

Rate and pattern of resorption

Marked resorption : after 1yr of tooth loss and continued over 25yr

4 times more resorption in mandible than

maxilla

More in posterior area than anterior Severe atrophy: women > men

Changes associated with alveolar ridge resorption

Inter-arch changes

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Facial changes

Mucosal changes

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Vascularity changes

Classification

1. Alveolar ridge correction
2. Alveolar ridge extension
3. Alveolar ridge augmentation
4. Distraction osteogenesis

1.Alveolar ridge correction

2. ALVEOLAR RIDGE EXTENSION

Labial/Buccal vestibuloplasty

1. Mucosal advancement / submucous vestibuloplasty
1. Closed submucous vestibuloplasty
2. Open view submucous vestibuloplasty

2) Secondary epithelizatition/re-epithelization

vestibuloplasty

• Kazanjian’s technique
• Modification
• Goldwin’s technique
• Lipswitch technique

• Clark’s technique
• Modifications
• Obwegeser’s secondary

epithelization procedures

• Periosteal fenestration

Lingual vestibuloplasty

• Caldwell’s procedure
• Trauner’s procedure
• Obwegeser’s procedure

Classification of Vestibuloplasty procedures (Peterson)

Based on extent

• Full ridge vestibuloplasty
• Partial ridge vestibuloplasty

Based on dissection

• Open supraperiosteal vestibuloplasty
• Closed supraperiosteal vestibuloplasty

Based on healing

• Secondary re-epithelization vestibuloplasty
• Grafting vestibuloplasty

3. Alveolar ridge Augmentation

A. Mandibular augmentation

1. Superior border augmentation
2. Inferior border augmentation
3. Interpositional or sandwich bone grafts
4. Visor osteotomy
5. onlay grafting

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B. Maxillary augmentation

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1. Onlay bone grafting
2. Interpositional or sandwich bone grafts
3. Sinus lift procedure

1.

2.

3.

C. Augmentation in combination with orthognathic surgery Mandibular osteotomy procedure

Maxillary osteotomy procedure

Combination procedure

• Augmentation with grafts
• Autogenous bone
• Allogenic bone
• Alloplastic material

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• Augmentation with osteotomy procedures
• Horizontal osteotomy
• Vertical osteotomy
• Combined osteotomy
• Lefort I osteotomy with Onlay bone grafting

Pre operative evaluation

Clinical examination

• Assessment of existing tooth; if any tooth is

remaining.

• Amount and contour of the remaining bone.
• Quality of soft tissue overlying the primary denture bearing area.
• Vestibular depth.
• Location of muscle attachment.
• Jaw relationship and presence of soft tissue or bony pathologic condition.
• Patient’s age.
• Physical and mental health status.
• Financial constraint.

Examination of inter-arch relationships in proper vertical dimension

If lack of adequate space for prosthetic reconstruction

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Bony and fibrous tissue excess in tuberosity area must be reduced.

• Radiograph:

OPG

Lateral ceph Occlusal radiograph:

• Palpation reveals hypermobile tissue that will not provide adequate base in denture-bearing area.

Basic Pre-Prosthetic Surgeries

1. ALVEOLOPLASTY

• Surgical procedure which intends to recontour the alveolar ridge.
• Alveolotomy : Partial removal of alveolar bone
• Alveolectomy : Complete removal of alveolar bone.
• Alveoloplasty : Shaping of the alveolar bone.
• Indications :

INDICATIONS:

• Presence of sharp bony margins
• Knife edge ridge
• Sever undercuts
• Maxillary protrusion alveoloplasty.
• Reduction of Mylohyoid ridge and

lingual alveolar crest.

• Elimination of labial mandibular undercut

Types of alveoloplasty :

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1. Simple alveoloplasty
2. Labial and buccal cortical alveoloplasty
3. Dean’s interseptal or Thoma’s intracorticular
4. Obwegeser technique

2) Simple Alveoloplasty

Indications:

-Reduction of buccal/labial plate

-Extraction of

single/multiple teeth

2 . Labial & Buccal Cortical Alveoloplasty

• Simple alveoloplasty eliminates buccal irregularities and undercut areas by

removing labiocortical bone

3. Dean’s Intraseptal /Intercortical/Crush Technique

Principles:

1. Reduction of labial/alveolar prominences
2. Muscle attachments are undisturbed
3. Intact periosteum
4. Preserve cortical bone
5. Less post-op resorption

4. Obwegeser’s modification

In case of extreme protrusion both cortical plates are fractured inwards

2. MAXILLARY TUBEROSITY REDUCTION

• Indications:
• Reduced inter ridge distance
• To prevent displacement of denture.
• To reduce severe bilateral undercuts.
• Incision placed on the lateral side rather on the crest.
• In case of thick fibrous tissue - excised.
• Care should be taken not to perforate into the sinus.

Bony tuberosity

reduction.

A, Incision extended along crest of alveolar ridge distally to superior extent of 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 continuous suture technique

a. Buccal exostosis and excessive undercuts

A, Gross irregularities of buccal aspect of alveolar ridge. After tooth removal, incision is completed over crest of alveolar ridge. (Vertical-releasing incision in cuspid area is demonstrated.)

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B, Exposure and removal of buccal exostosis with rongeur.

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C, Soft tissue closure using continuous suture technique.

b. Lateral palatal exostosis

• 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 bone file to remove bony excess. D, Soft tissue closure.

3.MYLOHYOID RIDGE REDUCTION :

A, Cross-sectional view of posterior aspect of mandible, showing concave contour of the superior aspect of ridge from resorption. Mylohyoid ridge and external oblique lines form highest portions of ridge. (This can generally best be treated by alloplastic augmentation of mandible but, in rare cases, may also require mylohyoid

ridge reduction.)

B, Crestal incision and exposure of lingual aspect of mandible for removal of sharp bone in mylohyoid ridge area. Rongeur or bur in rotating handpiece can be used to remove bone.

C, Bone file used to

complete recontouring of mylohyoid ridge

4. GENIAL TUBERCLE REDCUTION

• Neither exostoses nor tori.
• Often prominent following advanced alveolar ridge resorption in the anterior area of the mandible.
• Covered by thin tissue which will not bear the pressure of a denture flange

located in this area.

Complete removal- AVOIDED

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IMPAIRED TONGUE FUNCTION due to

attatchment loss of GENIOHYOID & GENIOGLOSSUS.

5. TORI REMOVAL

a:Typical appearance of maxillary torus

b: Mucoperiosteal flaps retracted with silk sutures to improve access to all areas of torus. Removal of palatal torus.

MAXILLARY TORI REMOVAL

D and E, Sectioning of torus using fissure bur. F, Small osteotome used to remove sections of torus. G and H, Large bone bur used to produce the final desired contour. I, Soft tissue closure

MANDIBULAR TORI REMOVAL

Use of bone bur and bone file to eliminate minor irregularities.

Tissue closure

6.INFLAMMATORY FIBROUS DYSPLASIA

• In the early stages, when fibrosis is minimal nonsurgical treatment with a denture in combination with a soft liner is frequently sufficient for reduction or elimination of this tissue.

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• When this condition has existed for some time, significant fibrosis occurs and then this will not respond to non surgical treatment and excision is the treatment of choice.

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• If tissue mass minimal- Electrosurgical technique
• If tissue mass extensive- Simple

excision.

7. LABIAL FRENECTOMY

• Indication :
• Frenum is close to crest of the ridge
• Irritated by the flange of the ridge.
• Diastema in the midline (in dentulous)

• Method of Frenectomy :
1. Diamond type
2. Z plasty
3. V-Y plasty

V-Y Technique

The V-Y type of incision can be used for lengthening localized area.

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Broad frenum in premolar molar area can be treated by taking semilunar incision at the mucogingival junction and a supraperiosteal dissection is done.

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The superior edge of the incision is sutured at the depth of the vestibule to the periosteum and the rest of the raw area is allowed to heal by secondary

epithelialization

8.LINGUAL FRENECTOMY

VESTIBULOPLASTY

• Is a surgical procedure whereby the oral vestibule is deepened by changing the soft tissue attachments.

Increases the size of denture

bearing area

Increases the height of residual ridge.

TYPES OF VESTIBULOPLASTY

• 1. MUCOSAL ADVANCEMENT VESTIBULOPLASTY
• 2.CLOSED MUCOSAL VESTIBULOPLASTY
• 3. OPEN VIEW SUBMUCOUS VESTIBULOPLASTY
• 4.SECONDARY EPITHELIALIZATION VESTIBULOPLASTY
1. Kazanjian’s Technique
2. Clark’s technique

Others :

1. Godwins technique
2. Lip switch Vestibuloplasty
3. Obwegeser’s technique

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2

3

SECONDARY EPITHELIALIZATION VESTIBULOPLASTY

Indications:

When sufficient bone is present but the mucosa is either insufficient in quantity or of a poor quality.

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Basically two techniques of vestibuloplasty:

I. Kazanjian (1935)

2. Clarks (1953)

a. KAZANJIAN’S TECHNIQUE

• Kazanjian in 1935.

An incision is made in the mucosa of the lip and a large flap of labial and vestibular mucosa is reflected.

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Vestibule is deepened by a supra periosteal dissection

Flap of mucosa is turned downwards from its attachment on the alveolar ridge and

is placed directly against the periosteum to which it was sutured.

Rubber catheter stem is placed into the deepened sulcus and fixed through the lip to the outer surface with percutaneous sutures.

Catheter is removed after seven days.

The labial donor site is coated with tincture of benzoin compound and left to granulate and heal by secondary epitheliazation and contracture of the wound margin.

b. Godwin's Technique

• Similar to Kazanjian.
• The periosteum and the attached connective tissue are either excised or pushed downwards and the flap of labial and vestibular mucosa is placed directly against the bone and sutured to the connective tissue beyond to the deepened vestibule with absorbable suture.

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• Rubber catheter is placed along the deepened vestibule and fixed with percutaneous sutures for eleven days.

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• Zinc oxide eugenol dressing is placed against the raw donor site on the lip for 3 days.

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• The raw tissues heal by granulation and secondary epithelization with a contracture line on the labial side of the vestibule.

Both Kazanjian and Godwin's procedures have the disadvantage of scar contracture on the labial side of the sulcus with a loss in sulcular depth.

c. Lip Switch Vesibuloplasty

Transpositional flap (lip-switch) vestibuloplasty

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A, Mucosal flap elevated , the periosteum incised at the crest of the alveolar ridge and a subperiosteal dissection is completed on the anterior aspect of the mandible.

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B, The periosteum sutured to the anterior aspect of the labial vestibule & the mucosal flap is sutured to the vestibular depth at the area of the periosteal attachment.

Suggested by Kethley and Gamble, in 1961.

Advantages:

It is simple

Does not require hospitalization No donor site surgery

No prolonged period without denture

No scarring at depth of vestibule

Disadvantages:

Unpredictability of amount of relapse of vestibular depth

Problem with the adaptation of the peripheral flange of denture to depth of vestibule

B. CLARK’S PROCEDURE

Clark's vestibular extension procedure (1953) can be considered the reverse of Kazanjian's technique and is based on four principles of plastic surgery:

• The soft tissue side of the vestibule is covered by mucosa, whereas on the osseous side the raw periosteal surface is left to granulate and epithelize.

1. Raw surfaces on connective tissue contract, whereas the same

surfaces undergo minimal contraction when lined by an epithelium:

2. Raw surface overlying bone cannot contract.

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• Epithelial flaps must be undermined sufficiently to facilitate repositioning and fixation without tension.

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• Soft tissues undergoing plastic revision have a tendency to return to their former position, so over correction and firm fixation are necessary.

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• In this technique:
• An incision is made on the alveolar ridge and a supraperiosteal dissection is made to the desired depth. The mucosa of the lip is undermined to the vermilion border.

(Clark's technique with Tortorelli’s periraosteal fenestration modification)

• A)Horizontal incision is made at the mucogingival junction on the residual ridge extending from the right to the left molar areas.
• A large mucosal lap is undermined well out onto the lip.
• The supraperiosteal -dissection deepens the vestibule.
• The right and left mental neurovascular bundles should be preserved.
• At the base of the deepened vestibule the periosteum is incised horizontally from the right to the left premolar areas, and the inferior periosteal margin is elevated slightly

• B and C, Mucosal flap is transposed and sutured to the infe-rior periosteal margin with 4-0 gut sutures. Healing of the bare bone at the base of the vestibule is 2- 3 weeks slower than healing and re- epithelization of the periosteum-covered part of the ridge. Relapse stops at the line of the periosteal fenestration.

Labial-palatal advancement vestibuloplasty

• Maxillary labial-palatal advancement vestibuloplasty (Double flap technique)

A, Residual alveolar ridge is composed primarily of movable gingiva with little supporting bone.

B, Mucosal flap has been reflected, and the vestibule has been deepened by supraperiosteal dissection

C, Labial and vestibular mucosal flap has been sutured high in the

vestibule with 4-0 gut.

D, Palatal flaps are adapted over the crest and the anterior surface of the maxillary alveolar ridge and sutured high in the vestibule with 4-0 gut.

E, Denture with a labial flange is relined and inserted to give added support to the labial and the palatal flaps.

d. Obwegeser’s technique

Incisions made at the mucogingival Junction on the facial and lingual surfaces of the mandible. These incisions are made through the mucosa only from one third molar area to the same position on the opposite side.

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Supraperiosteal dissections performed .

The mylohyoid and part of the genioglossus muscles are severed from the mandible. The labiobuccal mucosa is undermined.

Labiobuccal mucosa flap is sutured to the lingual mucosa and mylohyoid muscles with eight inframandibular chromic-gut mattress sutures.

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An awl is used to pass the sutures around the inferior border of the mandible. A strip of gingiva remains on the crest of the ridge.

Acrylic stent lined with impressions compound is adapted to the mandible.

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• A split-thickness skin graft is secured to the stent with an adhesive. The stent and the skin graft

are ligated to the mandible with two or three circumferential wires or heavy nylon sutures.

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• The sutures or wires should hold the graft firmly but without excessive pressure,

Skin adheres to the raw periosteal surfaces but not to the gingiva.

The stent is replaced and is worn by the patient until the new denture hit been constructed so that the depth of the sulci may be maintained

Vestibuloplasty, floor of the mouth lowering, and palatal soft tissue grafting.

A, Preoperative photograph showing lack of facial

and lingual vestibular depth and absent keratinized tissue adjacent to implant abutments.

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B, Improved vestibular depth with sound attached tissue over the alveolar ridge

Mandibular anterior ridge extension: a modification of the

Kazanjian vestibuloplasty technique, Al-Mahdy Al-Belasy F

J Oral Maxillofac Surg. 1997 Oct;55(10):1057-9

• Modification of the secondary epithelization vestibuloplasty technique described by kazanjian that eliminates the sharp V in the depth of the extended vestibule and counteracts shallowing of the sulcus is presented
• Elimination of the sharp V in the extended vestibular depth enables denture fabrication with better flange extension and improved oral hygiene.

Mucosal graft

Palatal graft

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Indications:

• In areas where only a small localized graft is needed. Advantages:
• Provide firm resilient tissues with minimal contracture of grafted material
• It is easy to obtain Disadvantage:
• Only limited amount of tissue can be obtained
• Patient discomfort.

Buccal mucosal graft

Harvested from the inner aspect of the cheek.

Advantages:

• Provide firm resilient tissues with minimal contracture of grafted material.
• It is easy to obtain Disadvantages:
• Need for specialized mucotomes to harvest buccal mucosa.
• Extensive buccal mucosa scarring.
• Does not get keratinized

Int J Oral Surg. 1982 Apr;11(2):81-8

Preprosthetic mandibular vestibuloplasty with buccal mucosal graft. A 2-year follow-up study. Hillerup S

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• 18% of the sulcus extension is lost during the first post-operative month, but regained by the time of the 6-month control, leaving 99% of the surgically created sulcus extension as a permanent gain.

1.Acellular dermal grafts 2.Amniotic membrane

NEWER GRAFT MATERIALS

Acellular dermal grafts

AMNIOTIC MEMBRANE

Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2004 May;97(5):574-8

Use of amnion as a graft material in vestibuloplasty: a

preliminary report.

Samandari MH¹, Yaghmaei M, Ejlali M, Moshref M, Saffar AS

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• Amnion might be used as a potential graft material for vestibuloplasty

Surgical defect

Amniotic Membrane

J Oral Maxillofac Surg. 2001 Feb;59(2):169-75

• Tissue-engineered mucosa graft for reconstruction of the intraoral lining after freeing of the tongue: a clinical and immunohistologic study , Lauer G, Schimming R et al.

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• Tissue-engineered mucosal cells can serve as a graft for large intraoral wounds. Complete intraoral lining is quickly reestablished, and normal epithelial differentiation is seen in the graft area within a 6-month postoperative period.

Evaluation of Autogenous Grafts used in Vestibuloplasty, Metin, M.; Dolanmaz, D.; Alkan, A.

The Journal of International Medical Research, 2003 july ; 31(4) 335-339

• The best results were obtained with palatal mucosal grafts, but graft size is limited. Meshed skin grafts were shown to be the best alternative.

Ridge augmentation procedure

Indications

Absence of clinical alveolar ridge (class IV

& V ridge )

Potential risk of ridge fracture Improper arch relationship

Techniques:

Direct augmentation with a bone graft Augmentation with pedicle & interpositional graft Augmentation with synthetic graft material

Graft materials :

Autogenous bone

• Allogenic bone
• Alloplastic material

Direct augmentation with a bone graft

Mandibular superior border augmentation

Davis (1970)

Indications:

Severely atrophic mandible resulting in

• Inadequate ridge height & contour
• Increased inter arch distance
• Neurosensory disturbance

Disadvantages:

• Need for secondary soft tissue surgery
• Delay in wearing denture for 6-8 months

1. Crestal incision
2. Periosteal releasing incision
3. Lingually placed groove

Final configuration with graft in place & the wound

sutured

Mandibular inferior border augmentation

Sander & Cox (1976)

Severely atrophic mandible with potential risk of fracture

Inferior Border Augmentation using composite cadaveric mandible combined with Autogenous cancellous bone

Advantages:

• Doesn’t change the vertical dimension
• Doesn't obliterates he sulcus
• Doesn't subjects the graft to direct masticatory forces, therefore reduces resorption of graft
• Denture can be worn immediately
• Increases the height of the lower 1/3 rd of face & improves esthetics

Disadvantages:

• Doesn’t improve ridge contour, interarch relation or nerve position
• May affect facial appearance adversely
• Extra oral scar

Augmentation of atrophic maxilla

Terry(1974)

Indications :

Severe resorption of maxillary alveolus with absence of clinical alv. Ridge & loss of adequate palatal vault form

Disadvantages:

• Need or secondary soft tissue surgery
• Delay in wearing denture for 6-8 months

WIDTH AUGMENTATION

Augmentation with synthetic graft material

Hydroxyapatite

Proposed by Kent (1983)

Disadvantages

Advantages

• Simple procedure ( can be done

in outpatients)

• Improve ridge contour fit and comfort of denture

• Difficulty in maintaining HA in a tunnel
• Nerve dysthesias
• Difficulty in achieving the desirable height augmentation
• Ridge flattening

Vicryl tubeTechnique

IJOMFS 1991,20:144

International Journal of Implant Dentistry 2017

• Sandwich bone graft for vertical augmentation of the posterior maxillary region: a case report with 9-year follow-up : Kenko Tanaka, Irena Sailer et al

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• Describes the outcome of treatment after alveolar ridge augmentation in the atrophic posterior maxillary region via segmental sandwich osteotomy combined with placement of an interpositional autograft prior to placement of endosseous implants.

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• The technique was successfully used to treat a deficiency in the vertical dimension

of the posterior maxillary region.

Vertical Ridge Augmentation of the Atrophic Posterior Mandible with Sandwich Technique: Bone Block from the Chin Area versus Corticocancellous Bone Block Allograft—Clinical and Histological Prospective Randomized Controlled Study : LuigiLaino, GiovannaIezzi et al

BioMed Research International Volume 2014, Article ID 982104, 7

• Both procedures supported good results, although the use of bone blocks allograft was less invasive and pre ferable than harvesting bone from the mental symphysis

Osteotomy procedures

1. Horizontal osteotomy with interpositional bone grafting ( sandwich osteotomy)

2. Vertical (visor) osteotomy

Harley , Slade & Peterson (1975)

Indicated when amount of bone over mandibular canal is insufficient

3. Three piece osteotomy

Stoelinga (1983)

4. Lefort I osteotomy with Onlay bone grafting

IMPLANT PREPROSTHETIC SURGERY

Relocation of the mental nerve

In cases of severe atrophy of the alveolar bone and superior aspect of underlying basal bone, the mental neurovascular bundle may occupy a position at the superior aspect of the mandible resulting in pain as a result of trauma from the denture on the superior portion of the remaining alveolar ridge.

• The cortical bone and underlying medullary bone can be removed with curettes and the NV bundle relocated to a more inferior position.
• After the bone is exposed inferior to the mental foramen, a groove is cut with a bur through the lateral cortex inferior to the mental foramen area.
• Resorbable material, such as Gel foam, can be packed around the bundle to help stabilize it at the inferior portion of the newly created groove.
• Soft tissue closure with interrupted or continuous suturing technique completes the procedure.

BONE GRAFTING PROCEDURES & VARIOUS ADJUNCTS

A brief idea about bone graft placement….

1. ONLAY GRAFTING PROCEDURE

• GRAFT is placed subperiosteally across the fragments without mobilizing the fragments.
• CORTICAL GRAFT was segmented with CANCELLOUS bone for

osteogenesis.

2. DUAL ONLAY GRAFTING

• TWO CORTICAL ONLAY GRAFTS are placed opposite each other on the host bone

across the non union and are fixed with the same set of screws.

• They grip the fragments like a vise.

3. SANDWICH OSTEOTOMY

• INTERPOSITIONAL OSTEOTOMY.
• It is used for INCREASING THE VERTICAL HEIGHT in severly atrophic maxilla & mandible.
• ADVANTAGE : Minimal bone resorption.

More Stability.

Minimal soft tissue exposure.

4.RIDGE SPLIT OSTEOTOMY

• Ridge splitting with bone expansion is a technique of manipulation of bone to form receptor site for implant without removing any bone from the implant site.
• Maxillary bone has inherent quality of flexibility which can bemolded to desire location by using series of instrument namely chisels and osteotome.This further improves quality of bone all around implant, at the crest and apex both.
• Ridge augmentation using autograft and block graft,GBR using membrane have proved to be successful in highly resorbed ridges to achieve result in horizontal and vertical dimension

Ridge split osteotomy procedure

5. SINUS LIFT PROCEDURES

• M

Line diagrams illustrating direct sinus lift with simultaneous implant placement,

(a) Atrophic posterior maxilla with residual bone height between sinus floor and alveolar crest inadequate for placement of dental implant, (b) Lateral wall of sinus in-fractured and membrane is elevated, (c) Grafted bone is densely packed in space created after lifting the membrane, (d) Augmented maxillary sinus with implant placed.

Sequential steps in indirect sinus augmentation technique; implant site prepared starting from small diameter to large diameter drills, sinus floor fractured, elevated, and bone graft placed in the resultant space and immediate implant placement

DISTRACTION OSTEOGENESIS – A

better alternative to bone grafting ?

Developed by ILIZARO in 1956.

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DISTRACTION OSTEOGENESIS is a biologic process of bone formation between the surfaces of bone segments that are graducally separated by incremental traction.

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Indications :

Bone grafting nonunion

Deformity Bone defects

Trauma infection/tumor.

Alveolar height distraction

Alveolar width distraction

ADVANTAGES OF DISTRACTION OSTEOGENESIS OVER BONE GRAFTING

• Reduces donor site morbidity
• Autograft is limited
• No fear of transmission of any antigen,bacteria,virus or dead foreign bodies.
• In infected wounds
• Risk of # is less

5 Sequential Periods of DISTRACTION OSTEOGENESIS – [Callotasis]

OSTEOTOMY

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LATENCY

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DISTRACTION

CONSOLIDATION

REMODELLING