Prosto lec 3

This is the self-study lec

It will be 2 parts the first will include the slides and the second will include book
summary but for 2009 scripts I didnt find one about this lecture
Part 1
**When you want to look at any denture you must know that it is consists mainly
of three surfaces which are: 1 the teeth surface 2 the polished surface 3 the fitting
surface.
**As we mentioned before the successful denture is made by taking care of many
things like: 1extraoral examination 2 intraoral examination 3 soft and hard tissue
examinations 4 histology examination
** the major reason of why some cases are not ready for denture is that there is
some cases that may affect the retention of the denture and these cases are :
Aging, variation of anatomical structures, loss of tissue due to any cause and
difference of any anatomical structure
**as we mentioned before the PDI classification of the CD cases are 4 (class1,
class2, class3, class4) = (ideal case, moderately compromised, subetantialy
compromised, sever compromised) all of this depending on theses criteria's:
(1) bone height mandibular (2) (mandibular maxillary relationship ) (3)
muscle attachment ( 4) residual ridge morphology- maxilla

** Now regarding the extra oral structures the main changes that can occur is like
this:
1 general age changes: (reduced vision hearing and taste, reduced muscular
coordination, reduced comprehension and bone density reduction)
2 lymph nodes groups defects
3 affection of the muscle around the mouth (loss of muscle tone, drop of modulus,
drop of nose and retraction of the upper lip and loss of lip vermillion)
4 TMJ and muscle (loss of muscle leading to TMD)
5 mouth area (creases of face and accentuation of naso-labial and labio-mental
folds)
6 facial profile (loss of lower facial height leading to advancing of mandible in
relation to maxilla)
** The ideal case and the ideal denture is done and made by these factors if they
were present:
1. bony support
2. soft tissue coverage
3. no undercuts
4. no sharp ridges
5. perfect sulci
6. no peripheral scar bands
7. no muscle fibers (that mobilize the denture )
8. no hypertrophies
9. no neoplastic lesion
10. proper maxilomandibulare arch relation
**intraoral structures are very critical and we may need to do some surgeries if we
need to have the most acceptable denture
Resorbtion of the residual ridge: this thing has many rates with variable causes like
1 periodontal disease
2 traumas
3 patient factors (age, gender and skeletal morphology)
4 endocrine and metabolic disorders
5 dietary considerations
6 mechanical factors
Part 2
Introduction
This lecture is about the surgical procedure and their effect and their goals for the
patient.
The major goals of the treatment must be like this:
1 provide the best possible tissue contours for denture support function and
comfort
2 economy in bone and tissue (no need to make the patient lose a lot of them)
** do it in the safest way and in the most predictable manner for the patient

In this filed you can work on a method called the final result backward: where you
can reach this result by completing some objectives and they are:
1 create a broad ridge form
2 provide a good amount of fixed tissue over the denture bearing area
3 Establish enough amount of the vestibular depth for prosthetic flange
extension
4 Provide a good palatal vault form
5 Provide a proper ridge dimension for implant placement
** Once u did all of these you can reach the final result you want it and expect it
with your patient


Patient evaluation and expectations
Archiving the most safest and uneventful treatment of a patient depends on these
factors so we can identify any treatment modifying factors before the surgery:
1 patient overall evaluation
2 patient paste medical histories
3 physical examination: which include the evaluation of the hard and soft tissue
and
** importance is to reveal the degree of difficulty of the surgery for example the
dentist may say I want to remove the tuberosities but the surgeon may see it
impossible due to maxillary sinus
4 radiographs: in here we will mention the most important one which is the
panoramic radiograph and some types that is needed according to case
Panoramic radiograph: the workhouse of the pre-prosthetic surgery
** It can give visualize of many important anatomical and structural relationship
that we need to put a suitable treatment plan like:
(For mandible = relation b/w the inferior alveolar canal and the ridge crest +
observation of position of mental foramina to the ridge crest)
(For maxilla = relation b/w the floor of the maxillary sinuses and alveolar crest +
observation of both anterior nasal spine and the anterior maxillary alveolar crest)
(Hard tissue relation with the soft tissue)
**** In case of more sophisticated cases like implants other things are needed like
the radiographic studies and the tomographic studies and computerized studies (CT
scan)
** CT scan helps in:
1 providing a cross sectional detail for maxilla and mandible in axial and coronal
views
2 it helps in collecting info about the: alveolar height, width, facial, lingual, palatal
alveolar contours
3 relationships between the maxillary crests and the sinus floor and nasal floor
4 mandibular inferior alveolar canal and mental foramina to the crestal bone

Treatment planning
After finishing the evaluation in all its types and before even thinking of starting
any surgery you must as a dentist to place a treatment plan that with it the patient
can get the best result including the surgery needs if presented
Review of flaps
Flaps: is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a
donor site and moved to a recipient site with an intact blood supply. This is similar to but different
from a graft, which does not have an intact blood supply and therefore relies on growth of new blood
vessels. This is done to fill a defect such as a wound resulting from injury or surgery when the
remaining tissue is unable to support a graft, or to rebuild more complex anatomic structures such as
breast or jaw.
[

The best things help in procedure:
1 the tool used for an adequate exposure is the full thickness of mucoperiosteal flap
that has many advantages like: ((visibility, protection of adjacent tissue, time
efficiency and more valubality and less traumatic to the patient))
2 diagnostic cast: help in outlining the areas of surgical focus and for flap design
****general information about surgery steps and how it is done ****
1 midline crestal incision is recommended
2 edentulous arch have dense scar band on the crest of the ridge which is a strong
area and more resistant to tear and holds the sutures as well (VIP in flaps)
3flap must include the teeth and the surrounding tissue if present
4 sulcular incisions sharply to bone is recommended
5 reflection of the flap must be subperiosteal and deliberate
6papillary should be gently reflected when working around the teeth then the
remaining attached tissue in uniform plane before attempting to reflect more
apically
7clean subperiosteal dissection is produced by being: deliberated, precise
8dissection is reflected apically as much as we want to see area of concern
9anterio-posteriorly dissection is needed to elevate the flap and for appropriate
exposure
** helps in avoiding the tension over the flap
10envelop flap is recommended if the access was hard to be done
11anterior and posterior releasing incision is important
12 base of flap should be wider than the crestal aspect so blood supply dont get
compromised
13the underlying bony contour must be felt through the flaps after surgery is done
14 remove any debris from the flap by reelevating it then reposition it anatomically
then suture it
Commonly used preprosthetic procedure
These are the main but we will go in details for each one of these surgeries:
1. Ridge alveoloplasty with extraction
2. Ridge alveoloplasty without extraction
3. Intraseptal alveoloplasty
4. Buccal exostoses
5. Maxillary tubersity reduction
6. Mandibular tori
7. Maxillary tori
8. Mylohyoid ridge reduction
9. Genial tubercle reduction
These types are concerning the hard tissue surgeries now the soft tissue
surgeries are:
1. Maxillary soft tissue tuborisity reduction
2. Maxillary labial frenectomy
3. Excision of the redundant hyperombility tissue overlying the tuberosities
4. Excision of the inflammatory fibrous hyperplasia (epulis fissuratum )
5. Inflammatory of the papillary hyperplasia of the palate
Now look at this table it simply calccify all surgeries why we do them and the
result after them for each one
surgery The cause of the surgery Result after surgery
Ridge alveoloplasty with
extraction
the appropriate ridge
contour is not established
after we did the extraction
+ recontouring it again
depend on the degree that
varies from finger size to
massive recontour
The desirable contour will
be achieved and denture
can successfully been
fabricated
Intraseptal alveoloplasty If the ridge has an
acceptable contour and
height but with presence
of unacceptable undercut
Narrowing the crest and
removal of the undercut
+repositioning of bone if
there was any significance
resistance
Edentulous ridge
alveoloplasty
Elimination of sharp knife
edged ridge +removal of
undesirable contour,
undercuts and prominence
+any type of recontouring
Achieve the exact
orientation we need and
removal of unwanted
bone then recontour
Buccal exostosis Removal of the exostosis
on each arch +removal of
irregularity of the palatal
aspect of the maxillary
alveolus




Irregularity will be
removed + reduction of
recontouring
Maxillary tuborisity
reduction
Gaining the appropriate
inter-arch distance
posteriorly + recontouring
of hard + soft tissue
depending on type of
tuborisity
Removal of tuborisity by
removing of bone and
ensure safety of both soft
tissue + the maxillary
sinuses
Mandibular tori In dentate patient it will
interfere with tongue
mobility and speech +it is
injured while eating
In edentulous it must be
removed coz it will
interfere with wearing the
denture
Removal of tori to a point
where normal lingual
cortical anatomy is found
+ contour has been
achieved
Maxillary tori Interfere with fabricating
+ wearing of maxillary
denture specially if it was
posteriorly + to remove
the problems of post
palatal seal
Having desirable end
point for palatal vault to
be smooth and confluent
with no undercut or
elevations
Mylohyoid ridge
reduction
Ridge remodeling
sequencing because it
become prominent in the
posterior mandible due to
resorbtion of the external
oblique ridge +alveolar
bone which will lead
eventually to problems in
the denture fabrication
Ridge will be reduced to
the desired height
+contour will be fine
tuned
Genial tubercle reduction Ridge remodeling in the
ant. Part of the mandible
due to resorbtion of
alveolar ridge +teeth
bearing areas
Removal of the
prominence that is formed
which will become
unsuitable for seating the
denture

Bone height reduction and
denture can fit there and
seated after healing
Maxillary soft tissue
tuborisity reduction
To achieve the
appropriate inter arch
distance coz it impinge by
this tuborisity
Excess tissue is removed
+ vertical reduction is
achieved and the desirable
inter arch distance is
accomplished
Maxillary labial
frenectomy
Allow for more seating
stabilization and
construction of the
denture + remove the
reduced function and
discomfort for the patient
Frenum will be excised +
all targets will be
achieved
Excision of the redundant
hyperombility tissue
overlying the tuberosities
Removal of the mobile
tissue to fabricate the
denture mobility acquired
due to ill fitting denture +
ridge resorbtion
The tissue is removed
from bone and vestibular
depth is saved
Excision of the
inflammatory fibrous
hyperplasia (epulis
fissuratum )

Removal of the tissue that
has been affected due to
trauma or ill-fitting
denture which lead to
hyper plastic enlargement
of mucosa at alveolar
ridge + vestibular area
(depend on severity )
The traumatized tissue is
removed and we
minimized the soft tissue
creeping after the surgery
Inflammatory of the
papillary hyperplasia of
the palate

Removal of multiple
nodular projection that
found on the palatal
mucosa that can be either
erythrymatous or normal
in color due to many
causes : ill-fitting denture
+ poor oral hygiene +
fungal infection +
inflammation
The tissue is remove and
the palate is covered and
back to normal also
periosteum is safe



By here the chapter 3 + 4+ 5 was covered but after asking the dr we need to know
these diseases coz she was soooooooooooooooooo accurate when she asked about
them and they are as in the table:
Disease Location of
occurrence
Causes Effect on
denture
The effect of
the denture
Angular
cheilits
Corners of
the mouth
Infection of
bacteria + dry
mouth +
immunosuppresion
+wearing of poor
fitted denture
Poor fitted
denture will
cause it
Hyperkeratotic
lesion
Cheek of oral
mucosa
Different causes Causing
mobility of the
mucosa on the
ridge leading
to problems in
fabricating the
denture

Denture
stomatites
On ridges +
palates
Denture causes Denture will
be infected +
can't be
wearied due to
pain and
instability due
to trauma
Wearing the
denture for
very long
time without
cleaning it
or taking it
off
Inflammatory
papillary
palate
hyperplasia
Palate Denture causes Infect new
denture with
fungi and
making areas
beneath it
erythrymatous
Poor denture
hygiene +
denture
overuse +
ill-fitting
denture
Epulis
fissuratum
Gingiva Denture causes Pain+
discomfort
Flanges of
poorly fitted
dentures
cause it

By this we finished the third lec
Done by Ahmad fawzi abdo
Study with pleasure