PRE PROSTHETIC SURGERY INTRODUCTION Definition: Pre Prosthetic Surgery (GPT 8): The surgical procedure designed to facilitate

fabrication of prosthesis or to improve the prognosis of prosthodontic care. The majority of patients who require prosthodontic treatment will not require surgical intervention prior to commencement of their prosthodontics. For many others, however, a thorough and comprehensive examination, diagnosis and treatment plan will reveal that surgical intervention can improve the prognosis for the case. Consideration of pre-prosthetic surgery is one of numerous methods by which a patients clinical presentation may be advantageously altered. As a general "rule of thumb" the best procedure to consider is the least invasive process that will produce clinical success. This may mean that it could be a disservice to the patient to perform surgery when a non-surgical method could be used. It is likewise a disservice to fail to consider and perform surgery when a non-surgical approach will produce a less than satisfactory result. REVIEW OF LITERATURE 1853: Willard stressed the importance of mouth preparation for complete dentures 1876: Beers advocated excision of alveolus after tooth extraction 1935: Kazanjian described a technique. for vestibular deepening 1944: Lisowski introduced tracing instrument to study the morphological changes following teeth extraction

 1951: Mathis & Cooley suggested surgical technique for lowering the mental foramen. 1957: Atwood radio graphically estimated the alveolar ridge resorption following teeth loss. 1960: Sobolik brought out the effects of constant and intermittent pressure over the residual ridge. 1965: Obweseger published contemporary review of indications of soft tissue reconstruction in the vestibule and floor of the mouth. 1976: Canzona experimented mandibular augmentation 1981: Samit et al described interpositional osteotomy and mandibular vestibuloplasty 1982: Kent advocated the use of hydroxyl apatite for ridge augmentation 1984: Indersano described a technique of open sub mucosal vestibuloplasty

OBJECTIVES The two main goals of Preprosthetic surgery for completely edentulous arch are: Provision of a comfortable tissue foundation to support the denture Enlargement of the denture bearing area in attempt to provide stability for a denture. The objectives of Pre Prosthetic surgery in partially edentulous arch are: Restoration of the best masticatory function possible Restoration or improvement of dental and facial esthetics.

INDICATIONS Correcting conditions that preclude optimal prosthetic function Localised/ generalised hyperplastic replacement of resorbed ridges Epulis fissuratum Papillomatosis Unfavorably located frenular attachments Pendulous maxillary tuberosities Bony prominences, undercuts, and ridges Discrepancies in jaw size relationships Pressure on mental foramen Enlargement of denture bearing area(s) Vestibuloplasty Ridge augmentation Ridge preservation procedures Supra mucosal vital root retention Sub mucosal vital root retention Root cone implants Essential features of a denture bearing area The denture bearing area should have following features: Alveolar processes should be as large as possible and of the proper configuration. Ideal ridge- Criteria for an ideal residual ridge (Goodsell- 1955) 1. Adequate bony support 2. Adequate soft tissue coverage 3. No undercuts & protuberances 4. No sharp ridges 5. Adequate vestibular depth

6. No scar bands 7. No high attachments of function 8. Satisfactory relationship of maxilla to mandible 9. No soft tissue folds, redundancies or hypertrophies 10. Free of neoplasm According to Heartwell: Characteristics of this ideal form which provide for maximum support and stability and minimum interference with function are: Ridges are broad and flat with vertical height (minimum of 5mm) provided by nearly parallel, non undercut, bony walls. A firm, resilient mucosal covering with nicely shaped buccal and lingual sulci which are uninterrupted by frenae,scars or redundant tissue folds. An inter-arch distance (minimum 16 to 18mm) and relationship which allows room for the denture and its components. Proper jaw relationship should occur in anteroposterior, lateral and vertical dimensions. Adequate attached keratinized mucosa should be in present in primary denture bearing area. Adequate bone support for denture. Adequate vestibular depth. No excessive muscle fibres or frena should be present , which can mobilize the periphery of prosthesis during function No evidence of intra- or extra- oral pathological conditions. No bony or soft tissue protuberances or undercuts should be present. PATIENTS EVALUATION Before any surgical or prosthetic treatment, a thorough evaluation outlining problems to be solved and a detailed treatment plan should be developed. muscle bands/Freni that dislodges denture during

History: Patients chief complaint, expectations, esthetics, functional goals, psychological factors, patients surgical risk status must be reviewed. Physical Examination: Evaluation of supporting bone by Visual inspection Palpation Radiographic examination Articulated diagnostic casts Presence of inflammation Quality of tissues Depth of the vestibule Frenal & muscle attachments

Evaluation of supporting soft tissues for

Treatment plan Non surgical Surgical Combination of these NONSURGICAL METHODS: Rest for Denture Supporting Tissue Removal of old denture should be done from the mouth usually 4872hours before taking impression. Use the tissue conditioning material inside the old denture. Rinse the mouth daily with a saline solution frequently. Regular massage of denture bearing mucosa should be done with finger or soft tooth brush which stimulates the mucosa to improve blood circulation and enhances keratinisation. Correction of Vertical Dimension of Occlusion in Old Prosthesis

An attempt can be made to restore an optimal vertical dimension of This enables the dentist to know the amount of vertical facial

occlusion to the old denture by using an interim resilient lining material. support that patient can tolerate and brings back the displaced tissue to their original form. Nutritional Care of Patient Good nutritional program comprising of all essential nutrients must be emphasized for each edentulous patient, specially for geriatric patient because: - Metabolic and masticatory efficiency is decreased in edentulous patients due to decreased food intake. Oral signs of nutrient deficiencies: Protein: decreased salivary flow, enlarged parotid glands. Vitamin B Complex, Iron & Proteins: Lips show cheilosis, angular scars, angular stomatitis & inflammation. Conditioning the Patients Musculature Jaw exercises are used like: side to side movements protrusive and retrusive movements opening and closing of the mouth

to relax the muscles of the mastication and strengthen their coordination. These also prepare the patient psychologically for prosthetic service. SURGICAL METHODS Before surgery certain investigations are required such as: Routine blood examination like TLC, DLC, Hb%, ESR, BT,CT Blood sugar level Throat swab culture Allergic tests Chest X-ray

CLASSIFICATION Hard tissue surgery Resective Augmentation

Soft tissue surgery Resective Ridge extension

Miscellaneous Nerve relocation Sinus grafting Tissue relocation

SOFT TISSUE PROCEDURES: RESECTIVE SURGERIES HYPERPLASTIC RIDGE

Also known as flabby ridge, it is mobile. There is marked fibrosis, inflammation and resorption of underlying bones. Causes Inadequate rest to the denture bearing area. Various forces to which the supporting tissues are subjected e.g. natural lower teeth opposing the upper denture. Excessive force on limited segments of the dental arches, due to lack of balancing contacts in eccentric jaw position. Trauma from denture wearing Changes in the alveolar socket after extraction. Prevent the causative factor.

Treatment

If this type of ridge is present in the maxillary anterior region, it is generally removed surgically. A satisfactory denture can be made on flabby ridge by using special impression technique. Surgical excision of hyperplastic soft tissue can be done to improve the stability and support to denture and to minimize the alveolar ridge resorption. o Simple excision :If sulcus depth is adequate o Excision & alveoloplasty o Subsequent vestibuloplasty o Sclerosing (Laskin-1970) If excessive mobile tissues with acceptable ridge contour with sclerosing agent Sodium Mohurrate

If there is excessive alveolar ridge resorption, bone graft or alloplastic material such as hydroxyapatite can be used to improve the contour of the alveolar ridge.

Causes

EPULIS FISSURATUM Denture irritation due to o Allergy or reaction to dental material o Ill fitting denture o o Faulty denture construction Progressive resorption Continuous mucous fold b/w denture and alveolar process

It is irritational fibrous growth of mucosa around the borders of the denture.

Clinical features o o Lobulated / Bifid Treatment o o o Placement of soft liner Conventional surgery Keep the denture out from the patients mouth to provide rest to the irritated mucosa.

 o Electrosurgery

Single mass - Simple excision Multiple - Excision of the complete area

o o

Surgical splint : Application of surgical stent helps in margin fixation

at desired position Full thickness graft - Prevents relapse

FIBROUS HYPERPLASIA Fibrous hyperplasia of maxillary tuberosity Causes - Pre existing periodontal disease of molars Appears as avascular dense tissues at the tuberosity Bony enlargements can be seen in radiographs Treatment Surgical excision Elliptical incision Removal of the elliptic portion Sub mucosal undermining Suturing

Fibrous Hyperplasia: Retromolar pad Causes - Impingement of maxillary molars and long standing irritation over the pad Prevents posterior extension of mandibular denture Treatment Surgical excision Wedge incision Thinning of the flap Closure

Complication

Lingual nerve paresthesia

Hyperplastic palatal mucosa Usually seen on the palatal aspect of maxillary molars Appears as firm, non tender with undercuts Causes mechanical interference in denture construction and insertion. speech Treatment Simple excision o Sub mucosal dissection o Sloughing due to severing of palatal blood supply Patient comfort Better dietary intake o Stent to be placed for: It also results into the narrowing of palatal vault and interferes with

Avoid damage to the greater palatine nerve and vessels. Papillary palatal hyperplasia (Palatal papillomatosis) Hyperplastic papillary enlargement of tissues Caused due to: Poor oral hygiene Continuous wearing of ill fitting dentures Candida infection Electrosurgical excision Impaired healing Islands of epithelium acts at growth centre Papilla removed by: Sharp bony files Muco abrasion technique

Treatment

Dermabrasion brushes Relining of dentures by soft liners

HYPERTROPHIC LABIAL FRENUM Irritation by frenal notch in the denture flange Treatment Relieving the frenal notch Unesthetic appearance Mid line fracture of denture Inadequate border seal during impression making May dislodge the denture May create discomfort and ulceration Frenectomy Excision of frenum Frenoplasty Z-plasty Localized vestibuloplasty with secondary epithelialization, Localized attachment. Other frenal conditions affecting denture performance: Abnormal lingual frenum High / Prominent buccal frenum Affects stability of denture Tongue tie & speech impairment Poor border seal Simple excision supraperiosteal dissection removing the fibrous

Surgical excision

Treatment

PAPILLOMATOSIS It is chronic inflammation of denture bearing area. It is characterized by finger like projections which are aggravated by microbial plaque and yeast on the fitting surface of denture base due to poor oral hygiene. Cause It occurs if patient wears denture throughout 24hrs. Treatment o Maintenance of oral hygiene and rest to tissues. o Antifungal therapy o Surgical removal of papillary projections. PENDULOUS MAXILLARY TUBEROSITIES

They may occur unilaterally or bilaterally and obliterate the inter-arch space. They interfere with the denture construction.

Causes o Formation of excessive soft tissues overlying the bone or o Due to the excessive bone formation at the site of tuberosity Determined by Radiograph Sharp probe under LA arch space. (Majority of the tissue reduction should be done on the buccal aspect instead of lingual aspect to reduce the risk of damaging the lingual nerve and artery).

Treatment Surgical excision of excessive soft tissue is required to provide adequate inter-

RIDGE EXTENSION SURGERIES Compensates for alveolar atrophy Vestibuloplasty Secondary epithelialization procedures Zygomaticoplasty & Tuberoplasty Overlying mucosa Frenal attachments Muscle attachments

Repositions:

Advantages: Large denture base area More retention & stability

VESTIBULOPLASTY

This exposes the bone still present. Healing is by secondary epithelialization. Skin or mucosal graft can be used. Complications are loss of sensation, sagging of chin and hypotonia of circumoral muscles Sub mucosal vestibuloplasty (Obwegeser-1951) Indications Small clinical ridge Sufficient healthy overlying mucosa Infiltration anesthesia Midline vertical incision from nasal spine to incisive papilla Sub mucosal dissection & tunneling Closure & stabilization with stent

Procedure

Secondary epithelialization procedures Indications Excessive scarring of tissues Epulis fissuratum Insufficient height of bone with adequate mucosa Incision through mucosa of inner surface of lip Dissection of mucosa back to the crest of the ridge Supra periosteal dissection Suturing of flap to the periosteum Circumferential suturing of the rubber tube Secondary epithelialization of labial mucosa Secondary epithelialization of alveolar ridge Procedure Incision slightly labial to the ridge crest Supra periosteal dissection & sulcus deepening Undermining the lip mucosa till vermillion border

Kazanjians method

Clarkes technique

 Disadvantages

Mucosal flap held by circumferential sutures

50% relapse in maxilla within 3 years 80-90% in mandible sufficient alveolar height sufficient vestibular depth especially indicated in mandibular arch

Transpositional flap vestibuloplasty (Lip switch) Indication

Procedure - a split thickness mucosal flap is dissected from a periosteal flap. The periosteal flap is used to cover the raw soft tissue surface and the mucosal flap to cover the raw bony surface. Epithelial graft vestibuloplasty Uses grafts over exposed tissues Skin Mucosa Support Stability Retention of denture

Increases

Tissue graft vestibuloplasty A. Partial thickness skin graft Indications: Insufficient bone height Correction of relapse following epithelialization procedures Decreased wound contracture Rapid healing & early construction of dentures Grafted area will become dry & non-resilient

Advantages:

Disadvantages:

Requires special instruments

B. Buccal mucosa graft Advantages: Smooth transition b/w attached & free mucosa Vestibule remains displaceable and enhances denture retention Contracture Difficult to work with Chances of relapse is greater

Disadvantages:

C. Free palatal graft Used in mandible Tough, resistant & resists forces Easy to obtain Undergoes less contracture Disadvantages: Healing of donor site is delayed and extremely painful ZYGOMATICOPLASTY & TUBEROPLASTY

For increasing vestibular height in atrophic maxilla Increases lateral stability of denture Prevents anterior displacement of denture

LOWERING THE FLOOR OF THE MOUTH As the alveolar bone is resorbed, the attachments of the mylohyoid and

genioglossus muscles may interfere with the lingual aspect of the denture.

HARD TISSUES SURGERIES RESECTIVE SURGERIES BONY SPICULES, PROMINENCES, UNDERCUTS & SHARP SPINY RIDGES Meyers classification Treatment Cortical alveoloplasty Localized spicules & prominences Incision Trimming of bone & soft tissues Irrigation & linear closure Prominent & irregular alveolar process Removes undesirable undercuts Removal of septa Collapsing of labial / buccal cortical plates Saw tooth like Razor like Discrete spiny projections

Inter cortical alveoloplasty

ENLARGED TUBEROSITY (BONY ENLARGEMENT) Enlargement may be: Buccal Palatal Vertical Combination Molar impaction Pneumatized tuberosity -- Unilateral -- Bilateral

Radiographs to rule out:

Other bony lesions

Treatment Surgical excision Crestal incision behind the tuberosity Removal of excess bone Sub mucosal dissection Irrigation & closure

Alveoloplasty Posterior maxillary osteotomy Entrance into the sinus

PROMINENT / SHARP MYLOHYOID RIDGE Maximum lingual extension of denture Counteract loss of tonicity of mylohyoid muscle Enhances stability & denture retention

Severe undercuts due to alveolar atrophy Treatment Surgical excision Lingual sulcus deepening Transposition of mylohyoid ridge ligature wiring PROMINENT GENIAL TUBERCLE Constant source of mucosal irritation under the flange & securing by circum mandibular

 Treatment Surgical reduction Removal of tubercles and allowing reattachment Removal of tubercles and repositioning of muscles by percutaneous sutures Sectioning of tubercles and trans positioning it along with the muscles to the inferior border & securing it with ligature wiring

EXOSTOSES

Mandibular tori Single Unilateral -- Multiple -- Bilateral

Indications for removal: Interference in denture fabrication Constant ulceration under flanges Interferences in speech & deglutition

 Treatment Surgical excision Indications for removal Interference in the placement of PPS Inadequate posterior extension of denture Undercuts that trap food Chronic inflammation of overlying mucosa Palatal Torus

Treatment Surgical removal Oro-nasal fistula (Traumatic cleft palate) Complication

CYSTS AND TUMORS Odontogenic or Non odontogenic Enucleation and marsupalisation Excision or hemimandilectomy & RND

RIDGE AUGMENTATION PROCEDURES Corrects the atrophic residues ridges surgically Seiberts classification of ridge defects Class-I defect Facio lingual loss of tissue width with normal ridge height Loss of ridge height with normal ridge width Combination of loss in both directions Class-II defect Class-III defect

ONLAY BONE GRAFTING Maxilla - Rib Mandibular superior border - Rib or iliac crest Mandibular inferior border - Rib

Direct Augmentation of Superior Border of Mandible Procedure Infiltration anesthesia Incision from one retro molar pad to other

Releasing incision for greater mobilization Lowering of mental nerve to prevent stretching 2 ribs of 15cm long Vertical scoring adaptation 1st rib 4-6 mm pieces 2nd rib Closure by continuous mattress suture 3 8 cm block removed Cut into 1-1.5 cm pieces, contoured & adapted Fastening with circum mandibular wiring Packing of cancellous bone into the dead spaces Closure with continuous mattress suture Extensive surgical procedure Lip paresthesia 67-70% relapse in 3 years

Autogenous rib

Iliac crest

Disadvantage:

Direct Augmentation of Atrophic Maxilla Crestal incision from tuberosity to tuberosity Autogenous rib contoured and fastened by intra osseous wiring Cancellous chips filled in the dead space Closure by continuous mattress suture Advantages: Resorption less than that in mandible Postoperative sequestration Infection Disadvantages:

Augmentation of Inferior Border of Mandible First attempted by Canzona in 1975 Procedure: Continuous sub mandibular incision from angle to angle Autogenous rib 15-20 cm long Removal of inner cortex, scoring & contouring Fastening by transosseous wiring Dead space filled with inner cortical pieces Closure of wound in layers Advantages: Non obliteration of vestibule Interim denture can be worn No changes in vertical dimension of occlusion Graft not subjected to direct masticatory stress. Extra oral scar Possibility of altering the facial appearance (lower 3rd)

Disadvantages:

INTERPOSITIONAL BONE GRAFTS Augmentation with Interpositional Bone Grafts Indication:

Reasonable bone above the mandibular canal Horizontal osteotomy above the mandibular canal Corticocancellous struts placed in canine & molar region Cancellous chips placed in b/w the struts Closure Resorption less than 2mm in 1-5 years

Procedure:

Advantages:

OSTEOTOMY Mandibular "visor" Osteotomy Segmental Osteotomy for partially edentulous arch Maxillary Osteotomy with advancement with classic Lefort I osteotomy

Horizontal osteotomy : An adequate vertical height of mandible must exist so that the mandible can be cut horizontally. This cut is placed below the level of the mandibular canal and mental foramen to avoid injury to the mandibular nerve. Vertical or Visor Osteotomy Advocated by Harle & modified by Peterson & Slade Indications: Insufficient vertical height of bone in mandible Scope of performing horizontal osteotomy & interpositional graft is limited Minimum of 10mm width of bone is present

Procedure: Mandible split vertically Lingual section is elevated ( because the lingual section can be raised so it is called as visor)& secured by trans osseous wiring Closure

AUGMENTATION WITH SYNTHETIC GRAFTS Ceramic bone grafts Resorbable tri calcium phosphate Porous hydroxyl apatite Bony defects in periodontal pockets Non porous hydroxyl apatite Alveolar ridge atrophy Hydroxyl apatite Calcium phosphate identical to: Enamel

Indications: Non resorbable Indications:

Prototype of non resorbable ceramic bone substitute

Cortical bone Granular form Application done after mixing with: Normal saline Venous blood

Available in 2 gm vial

Placed via syringe Vertical incision lateral to the labial frenum in maxilla Bilateral vertical incision anterior to mental foramen in mandible. Sub periosteal tunneling Placement of hydroxyl apatite slurry by a syringe Closure Dehiscence & extrusion of particles Migration Abrasion of mucosa during tunneling causes extrusion of particles Infection Abnormal colour Mental nerve neuropathy Highly biocompatible Local augmentation possible Metallic implants can be inserted later Simple office procedure under LA

Procedure:

Complications

Advantages:

RIDGE PRESERVATION PROCEDURES SUPRA MUCOSAL VITAL ROOT RETENTION For over denture construction Increased Proprioception Masticatory efficiency Retention & stability No risk for rejection Psychological benefits to patient Caries & periodontal disease Increased treatment costs

Disadvantages

SUB MUCOSAL VITAL ROOT RETENTION Reduction of roots 2 mm below crestal bone Water tight closure of mucosa Teeth should have / be Not more than 1 mm horizontal mobility No infrabony pockets

Criteria of teeth selection (Garver)

 Advantages

Healthy circum muco gingival tissues Vital & asymptomatic

Preservation of alveolar bone height Preservation of bony contour Enhanced denture retention Proprioception Decrease in loss of vertical face height Immediate: Tissue dehiscence due to closure under tension Immediate post surgical exposure of root requires RCT Pressure pain Small dehiscence over individual roots Fistula

Complications

Delayed:

ROOT CONE IMPLANTS Calcium phosphate group of biomaterials Nonporous hydroxyl apatite

Tooth root analogues made of calcium phosphate group of biomaterials Non porous hydroxyl apatite frequently used Procedure: Prophylactic removal of teeth to maintain alveolar height Solid cones of non porous HA implanted Elevation of muco periosteum & covering the implants Healing by secondary intention No inflammatory response induced

Advantages:

Acts as a nidus for new bone growth Osseo integration occurs Height & width of ridge preserved

Excellent biocompatibility Undergoes no resorption Principle: Application of stress / tension induces osteogenesis Lead R system by Chin Robinson inter Oss alveolar device ACE distraction device Horizontal osteotomy Insertion of distraction rod from crestal direction Fastening of transport plate on transport segment with bone screws No donor site morbidity involved Quality of bone formed ideal for implant placement Increased vascularity & cellularity Vertical graft stability Shorter treatment time ( 1 mm bone regenerated/day) VD compromised Unesthetic appearance Sufficient width for bone placement Frequent post op visits Devices Binds chemically to bone DISTRACTION OSTEOGENESIS

Procedure:

Advantages:

Disadvantages:

MISCELLANEOUS Nerve relocation Problem is persistent discomfort under denture Sinus grafting or Maxillary sinus lift Success rate ranging from 75-100% Indicated in atrophic maxilla for the placement of endosseous implants Procedure: Incision parallel to alveolar crest and creation of a 2-3 mm window above the sinus floor. In fracture of window , Dissection of sinus membrane ,Creation of space for graft placement (Cancellous chips) ,Tears in membrane sealed with collagen tape and Closure Tissue sclerosing with sclerosing agent Sodium morrhuate can produce fibrosis in soft hyperplastic tissue PRE PROSTHETIC SURGERY FOR SPECIFIC PROSTHESES Over denture: Selection of teeth that should be retained that offers broad support Thorough oral prophylaxis Endodontic therapy For lowering crown not ratio (1:5) Periodontal therapy

To attain optimal level of attachment of attached gingiva

Amalgam plugs / cast copings with studs / bar attachments for increased retention Immediate dentures Thorough oral prophylaxis reduces post surgical edema and infection Teeth modification Implants CAT scans (Simplant software) Detailed evaluation of: Alveolar contour Neurovascular positions Sinus anatomy Path of insertion of Zygomatic implants To avoid interferences in determining VD Restorations Crowns RPD Endodontic treatment (immediate over denture) Other hard & soft tissues procedures Patient planned for single immediate denture requires:

Information regarding bone volume & quality Fabrication of surgical stent

PREPROSTHETIC SURGERY FOR PARTIALLY EDENTULOUS ARCH Extraction with alveolectomy Removal of residual roots Impacted & malposed teeth Cysts and tumours

Exostoses & tori Hyperplastic tissue Muscle and freni attachments Bony spines & knife edge ridges Polyps, papillomas & traumatic hemangioma Hyperkeratoses, Erythroplasia, and Ulcerations Dentofacial deformity Osseointegrated devices Augmentation of alveolar bone Periodontal surgeries Crown lengthening surgeries

PREPROSTHETIC CONSIDERATIONS IN MAXILLOFACIAL SURGERIES Team approach Never cut interdentally , it can jeopardize adjacent tooth rather cut intradentally. More conservative Modification of prosthesis design Ridge relationship discrepancies by orthognathic surgeries. For maxillary advancement Lefort I osteotomy and for mandibular advancement and retrusion sagittal split osteotomy is performed. POST OPERATIVE VISIT Diet Soft diet wherever indicated, nutrient rich diet must be advocated. Medication- analgesics and antibiotics Oral irrigation during checkups Rest Splint and oral fixation wherever indicated

CONCLUSION When severe bony atrophy exists, treatment must be directed at correction of the bony deficiency and alteration of the associated soft tissue. When adequate bony tissue remains, improvement of the denture-bearing area may be accomplished either by directly treating the bony deficiency or by compensating for it with soft tissue surgery. The patient's health status must be carefully evaluated, along with the ability and willingness to undergo these procedures including possible long periods without dentures during healing phases.

REFERENCES: 1. 2. 3. 4. Mandibular Cortical Bone Graft Part 2: Surgical Technique, Applications, and Morbidity; Williamson RA. Rehabilitation of the resorbed maxilla and mandible using autogenous Atwood DA. Bone loss of edentulous alveolar ridges. J Prosthet Dent 1971; 26: 266-271. Wise M D. Stability of gingival crest after surgery and before anterior crown placement. J

Compendium May 2007;28(5):274-281 bone grafts and osseointegrated implants. Int J Oral Maxillofac Implants. 1996;11:476-488.

Prosthet Dent 1985; 53: 20-23.