DR.

TAJMULLA AHMED
Department of Prosthodontics
a.tajammul@gmail.com UNIVERSITY OF MAJMAAH, COLLEGE OF DENTISTRY, AZ-ZULFI, KSA.

SURGICAL AND NON-SURGICAL PREPARATION OF THE MOUTH FOR COMPLETE DENTURE SERVICE

INTRODUCTION A thorough examination of the mouth prior to the construction of complete dentures is necessary to identify potential problem areas. Since the support, retention, and stability of a denture base depend on the quantity and quality of the denture bearing area and border seal, every effort is to be made to preserve the alveolar bone. A determination of whether surgery is necessary is an essential part of that examination and plays an important role in successful patient management.

 There is a risk in wearing dentures for prolonged periods. This risk, manifests itself in a number of adverse changes in the denture foundations. Consequently, several conditions in the edentulous mouth should be corrected or treated before the construction of complete dentures.

The methods of treatment to improve the patients denture foundation and ridge relations are usually either non-surgical or surgical in nature, or a combination of both methods. Surgical correction should be made only after alternate non-surgical approaches have been considered and evaluated. A patient who presents with deformed, abused pathologic tissues from an existing denture should first undergo non-surgical approach.

Some of the characteristics of denture bearing area for maximum support and stability and minimum interference with function are:
Adequate bone support for dentures. Bone covered by adequate soft tissue. No undercuts or overhanging protuberances. No sharp ridges. Adequate buccal and lingual sulcus. No scar bands to prevent normal seating of denture. No muscle fibers or frenula to interfere with the periphery of the prostheses. Satisfactory ridge relationship between the maxilla and the mandible. No soft tissue folds or hypertrophies on the ridge or sulci. A ridge free of neoplastic disease.

NON-SURGICAL METHODS Non-surgical methods of edentulous mouth preparation include: 1. Rest for denture supported tissues. 2. Occlusal and vertical dimension correction of old prostheses. 3. Good nutrition 4. Conditioning of the patients musculature

1.

Rest for denture supporting tissues:

Rest can be achieved by; the removal of the dentures from the mouth for an extended period or the use of temporary soft liners inside the old dentures. Regular finger or toothbrush massage of denture bearing mucosa, especially of those areas that appear edematous and enlarged.

Tissue abuse caused by improper occlusion can be made to disappear by, Withholding the faulty denture from the patient. Adjusting/correcting the occlusion and/or refitting the denture by means of a tissue conditioner. Substituting properly made dentures.

2. Occlusal correction of old prostheses: An attempt should first be made to restore an optimum vertical dimension of occlusion to the dentures presently worn by the patient by using an interim resilient lining material. Consequently, ridge relations are improved and also facilitates the occlusal adjustments intraorally and extraorally, i.e., on an articulator.

3. Good nutrition: A good nutritional program must be emphasized for each edentulous patient. This program is especially important for the geriatric patient whose metabolic and masticatory efficiency have decreased.

4. Conditioning the patient's musculature:

The use of jaw exercises can permit relaxation of the muscles of mastication. and strengthen their coordination as well as help prepare the patient psychologically for the prosthetic service.

SURGICAL METHODS Non-surgical methods of edentulous mouth preparation include:

Correcting conditions that preclude optimal prosthetic function. Correcting frenular attachments and pendulous maxillary tuberosities. Correcting bony prominences, undercuts, spiny ridges, and nonparallel bony ridges. Correcting discrepancies in jaw size. Correcting enlargement of denture bearing areas (vestibuloplasty) Replacing tooth roots by osseointegrated dental implants.

Correcting conditions that preclude optimal prosthetic function ( Hyperplastic ridge, Epulis fissuratum, Papillomatosis.) The mobile tissues (e.g., a hyperplastic ridge), The tissue that interfere with seating of dentures (eg; epulis) The tissues that readily harbor microbes ( papillomatosis) are not conducive to firm healthy foundations for complete dentures.

Whenever possible, these tissues should be rested, massaged, and / or treated with an antifungal agent prior to their surgical excision. If the patient's health precludes surgical intervention, the impression technique and design of the denture base have to be modified.

Frenular attachments and pendulous maxillary tuberosities. If the frenum is close to the crest of the bony ridge, it may be difficult to obtain the ideal extension and border of the flange of the denture. The frenectomy can be carried out before prosthetic treatment is begun, or it can be done at the time of denture insertion when the new denture can act as a surgical template.

Pendulous fibrous maxillary tuberosities are frequently encountered and may interfere with denture construction by excessive encroachment on or obliteration of the interarch space. Surgical excision is the treatment of choice, but occasionally maxillary bone must be removed. Care must be used to avoid opening into the maxillary sinus.

Bony prominences, undercuts, spiny ridges, and nonparallel bony ridges.

Tori are usually removed to avoid undercuts and to make possible a border seal beyond them against the floor of the mouth.

The indications for the removal of maxillary tori are as follows:

An extremely large torus that prevents the formation of an adequately extended and stable maxillary denture. An under cut torus that traps food debris, causing a chronic inflammatory condition. A torus that extends past the junction of the hard and soft palates and prevents an adequate posterior palatal seal. One that causes the patient concern (because of a cancerphobia)

Bony exostoses may occur on both jaws but are more frequent on the buccal sides of the posterior maxillary segments. They may create discomfort if covered by a denture and usually are excised. Sometimes, the genial tubercles are prominent interfering with genioglossus muscle, then they are excised.

Residual alveolar ridge undercuts are rarely excised as a routine part of improving a patient's denture foundations. Usually, a path of insertion and withdrawal of the prosthesis can be determined together with careful adjustment of a denture flange, which enable the dentist o use the undercuts for extra stability.

Discrepancies in jaw size.

Impressive advances in surgical techniques of mandibular and maxillary osteotomy have enabled the oral surgeon to create optimal jaw relations for prosthetic patients who have discrepancies in jaw size. Usually an adjunctive face-lifting procedure in this type of patient produces impressive results.

Pressure on the mental foramen.

If bone resorption in the mandible has been extreme, the mental foramen may open near or directly at the crest of the residual bony process. This causes the margins of the mental foramen to extend and have very sharp edges 2 to 3 mm higher than the surrounding mandibular bone. Pressure from the denture against the mental nerve exiting the foramen and over this sharp bony edge will cause pain. The most suitable way of managing this is to alter the denture so pressure does not exist. However, in rare instances it may be necessary to trim the bone to relieve the mental nerve of pressure.

ENLARGEMENT OF DENTURE BEARING AREAS (VESTIBULOPLASTY)

The anterior part of the body of the mandible is the sight most frequently involved: the labial sulcus is virtually obliterated and the mentalis muscle attachment appear to migrate to the crest of the residual ridge.

When the absent sulcus is accompanied by little or no attached alveolar mucosa in this area, it is virtually impossible for a lower denture to be retained. Sulcus deepening is carried out in an attempt to improve denture retention. This enables the prosthodontist to increase the vertical extensions of the denture flanges.

Ridge augmentation. For many years surgeons have attempted to restore mandibular bulk by placing onlay bone grafts from an iliac or rib source above or below the mandible. However, it is a formidable undertaking for elderly patients.

REPLACING TOOTH ROOTS BY OSSEOINTEGRATED DENTAL IMPLANTS. Complete dentures are not the only method available for treating edentulous patients. In implant technique, a number of cylindrically shaped screws, made of specific materials are buried inside the selected host bone sites and

They are left to heal in situ for 4 to 6 months while osseointegration occurs. The screws or tooth root analogues are uncovered at a second surgical procedure, when an elective removable fixed bridge is attached to the implants. The technique also improves the scope for use of supporting over dentures and is widely regarded as having completely eclipsed the previously mentioned pre prosthetic surgical methods.

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