Alveoloplasty

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Alveoloplasty is a surgical pre-prosthetic procedure performed to facilitate removal of teeth, and smoothen or reshape the jawbone for prosthetic and cosmetic purposes. [1] In this procedure, the bony edges of the alveolar ridge and its surrounding structures is made smooth, redesigned or recontoured so that a well-fitting, comfortable, and esthetic prosthesis may be fabricated or implants may be surgically inserted. This pre-prosthetic surgery which may include bone grafting prepares the mouth to receive a prosthesis or implants by improving the condition and quality of the supporting structures so they can provide support, better retention and stability to the prosthesis. [1] [2]

Contents

After tooth extraction, the residual crest irregularities, undercuts or bone spicules should be removed, because they may result in an obstruction in placing a prosthetic restorative appliance. Recontouring can be made at the time of extraction or at a later time.

History

In 1853: Willard described the procedure of contouring the alveolar bone and alveolar mucosa in order to achieve primary wound closure in preparation for future denture placement. His statement mentioned the purpose of this procedure is to allow bone and tissue of patient to heal faster.

In 1876: Beers described radical alveolectomy with cutting forceps. However, this technique has been classified as too aggressive due to great amount of bone loss after surgical procedure. Hence, nowadays, this particular procedure is not favourable.

In 1919: Armin Wald of New York City was among the first oral and maxillofacial surgeons in the United States to successfully perform the operation and publish his widely accepted procedure. [3]

In 1923: Dean claimed that his technique aim to preserve the labial cortex and contoured intraradicular bone. His technique does not include mucoperiosteal dissection and therefore, patient will experience less pain, swelling and bone resorption.

In 1976: Michael and Barsoum researched on patients who had immediate denture placement. They related the amount of bone resorption in relation with different surgical techniques. The above-mentioned surgical techniques include extraction without alveoplasty, extraction with labial alveolectomy, and extraction with intraseptal alveoplasty as described by Dean in 1923. The result of their study showed labial alveoloplasty had the most bone resorption occurring at the procedure area. [4]

Indications

The main purpose of alveoloplasty procedure is to recontour and restructure alveolar bone to provide a functional skeletal relationship.

Indications of alveoloplasty should nevertheless include recontouring or reshaping alveolar bone during tooth extraction surgery. For instance, if alveolar bone has sharp edges after tooth removal, it is necessary to smoothen the bone surfaces to facilitate tooth socket healing process and to avoid any procedural complications such as pain or long standing open wound. [4]

The next indication for alveoloplasty involves a standalone procedure which is usually done prior to treatment planning of any prosthetic appliances such as placement of fixed or removable prosthetic appliances. In relation with the first point of indication of the procedure, the bone contouring after dental extractions also helps in preparation for prosthetic rehabilitation. This serves as an important procedure as any sharp bony projections under removable appliances such as dentures will cause discomfort and pain when patient perform masticatory functions. [4] [5]

The main essence of prosthetic rehabilitation in regard to alveoloplasty is maintaining the width and height of alveolar ridge so that it will provide stability and retention for prosthesis such as denture and even dental implants as the forces acting from the prostheses will be distributed evenly on the alveolar mucosa and alveolar ridge. In another point of view, alveoloplasty serves as debulking procedures for some pathologic conditions of the jaw bone as well. [4] [5]

Contraindications and Limitations

Alveoloplasty is contraindicated in situations whereby vital structures such as nerve bundle, blood vessel and/or vital tooth will be harmed during removal of bone structure. [4] Nerve injury is unfavourable as there will be a risk of complications such as paraesthesia, neuropathic pain, allodynia and others. In addition to this, if there is existing diminished volume or atypical architecture of bone; alveoloplasty is not a recommended procedure as well. [6]

Some important points to be included as contraindications of alveoloplasty consist of individuals who have undergone head and neck radiation therapy or individuals with medical condition which will result in certain medical complications such as uncontrolled or excessive bleeding, poor healing response or immunocompromised. [5] As a reference, patient who has underlying bleeding disorder or individuals who are currently on anticoagulant medications has risk of uncontrolled bleeding; whilst individuals with uncontrolled diabetes or infection has poor healing response after procedure.

Armamentarium

  1. Bone rongeurs
    • Has sharp blades which are squeezed together by the handles to cut the bone.
    • Major designs which are side-cutting forceps and side and end-cutting forceps
    • Can be used to remove large amounts of bone efficiently
  2. Bone file
    • Double ended instrument
    • Cannot be used for removal of large amount of bone and only used for final smoothing.
    • Teeth of the bone files are designed in a fashion that bone can be smoothened by pull stroke only
    • Pushing stroke of bone files can cause crushing of bone and this should be avoided.
  3. Rotary burs and handpieces

[7]

Preoperative Planning

The clinical examination focuses on bony projections and undercuts, large palatal and mandibular tori, and other gross ridge abnormalities. A dentist should always evaluate the interarch relationship in 3 dimensions while doing treatment planning for denture patients. Radiographs examinations are indicated for any retained root tips, impacted teeth, bony pathology and impacted teeth to minimise post denture insertion discomfort. The degree of maxillary sinus pneumatization, and the position of the inferior alveolar canal and mental foramina are important as well to avoid impingement of denture on these vital structures which may trigger more problems to the patient.

Simple Alveoloplasty

[7]

At the time of extraction or after healing and bone remodeling has happened, alveolar bone irregularities may be found. The goal for alveoloplasty [8] is to achieve optimal tissue support for the planned prosthesis, while preserving as much bone and soft tissue as possible.

Simple alveoloplasty can be done in conjunction with or after extraction of teeth. Gross irregularities of bone contour are usually found in the area after extraction. It is typically indicated to remove sharp edges, bony prominences, or undercuts prior to prosthetic rehabilitation.

The degree of bony abnormality will dictate the most effective method for alveoloplasty. Smaller irregularities at an extraction site may only require digital compression of the socket walls. Greater bony defects should be removed by raising an envelope flap to expose the bony areas requiring recontouring. Along the ridge crest, mucoperiosteal incision is done to gain sufficient access and visualisation of the alveolar ridge.

Intraseptal Alveoloplasty

This technique is also known as Dean’s technique. [9] [7] Rather than removal of excessive or irregular areas of labial cortex, it involves the removal of intraseptal bone and repositioning of labial cortical bone.

This technique is commonly used in an area where the ridge is of relatively regular contour and adequate height but presents an undercut to the depth of the labial vestibule because of the anatomic variations of the alveolar ridge.

There are a few advantages in this technique. The muscle attachments to the area of alveolar ridge can be left undisturbed. Postoperative bone resorption and remodeling can be reduced as the periosteal attachment to the underlying bone is maintained. The height of the ridge can be preserved while reducing the labial prominence of the alveolar ridge.

Maxillary Tuberosity Reduction

Maxillary tuberosity is a rounded eminence which can be prominent after the eruption of third molars. [10] Maxillary tuberosity is important for the stability of the upper complete denture. Maxillary tuberosity reduction can be soft tissue in nature due to the thick alveolar mucosa in the region or hard tissue related.

There can be vertical [11] or lateral excess of the maxillary tuberosity. [12] Proper orientation of occlusal plane and teeth can be interrupted by vertical excess. The lateral excess limit the thickness of the buccal flange of denture between itself and the coronoid process and also cause problems in path of insertion. Examination of mounted diagnostic cast is mandatory to assess the amount of removal.

When the tuberosity is enlarged, undercuts on the buccal aspect of the maxillary tuberosity are frequently found, complicating the successful fabrication of upper complete denture. An enlarged tuberosity can make posterior palatal seal hard to achieve, affecting the stability of the upper denture. Recontouring of maxillary tuberosity may be necessary to remove the bony undercuts or to create adequate interarch space for good construction of prosthesis at the posterior regions.

Mylohyoid Ridge Reduction

Mylohyoid ridge is a ridge on the inner side of the bone of the lower jaw extending from the junction of the two halves of the bone in front of the last molar on each side. When there is loss of posterior teeth, the alveolar ridge gets resorbed, causing extremely sharp ridge and making the mylohyoid ridge prominent. Denture may cause pressure on that area, producing significant pain in this area. Tonicity of the mylohyoid ridge itself can cause problems with denture retention. Mylohyoid ridge reduction is indicated whenever the alveolar ridge is at the same level or higher level than the alveolar process. [13]

Genial Tubercle Reduction

As the mandible begins to undergo resorption, the area of the attachment of the genioglossus muscle in the anterior portion of the mandible may become prominent. Before a decision to remove this prominence is made, consideration should be given to possible augmentation of the anterior portion of the mandible rather than reduction of the genial tubercle. If augmentation is the preferred treatment, the tubercle should be left to add support to the graft in this area. Local anesthetic infiltration and bilateral lingual nerve blocks should provide adequate anesthesia. [14]

Clinical Procedure

The simplest form of alveoloplasty can be in the form of a digital compression on the lateral walls of bone after simple tooth extraction, provided that there are no gross bone irregularities. When more irregularities exist, other techniques can be adopted, such as the conservative technique, interseptal (Dean's) alveoloplasty, Obwegeser's modification of interseptal, alveoloplasty after post extraction and the alveoloplasty performed on edentulous ridges. [15] [16] In cases where there are severe undercuts, radical alveoloplasty is required. This involves the removal of the whole buccal or labial plate after extraction. [17] In addition, secondary alveoloplasty sometimes occurs after the initial procedure to eliminate any gross bone irregularities. [18]

A full thickness flap is usually elevated to a point apical to the desired area to be contoured, and according to the amount of bone needed to be removed, a bone file, or a bone rongeur, or a burr under copious irrigation can be used to provide the desired contour. Taking in consideration that lack of irrigation can lead to bone necrosis. When finished, the flap is repositioned and sutured. The alveolar mucosa covering bone should have uniform thickness, density and compressibility to evenly distribute the masticatory forces to the underlying bone. [19]

Postoperative Considerations

In any surgery, the most common complications include pain, swelling, infection and bleeding. Besides that, if operative site is approximating vital structures such as nerve bundle, clinicians should access nerve injury at the time of surgery and/or keep reviewing those patients for assessment and management of the condition. However, sequestra may result due to excessive thin bone which fail to be revascularized, and will eventually lead to delay wound healing, infection and pain. If prosthetic rehabilitation is in the treatment plan, proper tissue healing should be achieved before construction of removable prosthesis. In cases whereby immediate denture is indicated, clinicians could consider the option of relining the immediate denture to allow appropriate soft tissue healing. [4] [16]

Related Research Articles

<span class="mw-page-title-main">Dentures</span> Prosthetic devices constructed to replace missing teeth

Dentures are prosthetic devices constructed to replace missing teeth, supported by the surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable. However, there are many denture designs, some of which rely on bonding or clasping onto teeth or dental implants. There are two main categories of dentures, the distinction being whether they fit onto the mandibular arch or on the maxillary arch.

<span class="mw-page-title-main">Dental implant</span> Surgical component that interfaces with the bone of the jaw

A dental implant is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, or facial prosthesis or to act as an orthodontic anchor. The basis for modern dental implants is a biological process called osseointegration, in which materials such as titanium or zirconia form an intimate bond to the bone. The implant fixture is first placed so that it is likely to osseointegrate, then a dental prosthetic is added. A variable amount of healing time is required for osseointegration before either the dental prosthetic is attached to the implant or an abutment is placed which will hold a dental prosthetic/crown.

A removable partial denture (RPD) is a denture for a partially edentulous patient who desires to have replacement teeth for functional or aesthetic reasons and who cannot have a bridge for any reason, such as a lack of required teeth to serve as support for a bridge or financial limitations.

<span class="mw-page-title-main">Maxillary sinus</span> Largest of the paranasal sinuses, and drains into the middle meatus of the nose

The pyramid-shaped maxillary sinus is the largest of the paranasal sinuses, located in the maxilla. It drains into the middle meatus of the nose through the semilunar hiatus. It is located to the side of the nasal cavity, and below the orbit.

<span class="mw-page-title-main">Dental extraction</span> Operation to remove a tooth

A dental extraction is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes impacted wisdom teeth cause recurrent infections of the gum (pericoronitis), and may be removed when other conservative treatments have failed. In orthodontics, if the teeth are crowded, healthy teeth may be extracted to create space so the rest of the teeth can be straightened.

<span class="mw-page-title-main">Alveolar process</span> Bulge on jaws holding teeth

The alveolar process or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones. The structures are covered by gums as part of the oral cavity.

Inflammatory papillary hyperplasia (IPH) is a benign lesion of the oral mucosa which is characterized by the growth of one or more nodular lesions, measuring about 2mm or less. The lesion almost exclusively involves the hard palate, and in rare instances, it also has been seen on the mandible. The lesion is mostly asymptomatic and color of the mucosa may vary from pink to red.

<span class="mw-page-title-main">Toothlessness</span> Lacking teeth

Toothlessness or edentulism is the condition of having no teeth. In organisms that naturally have teeth, it is the result of tooth loss. Organisms that never possessed teeth can also be described as edentulous. Examples are the members of the former zoological classification order of Edentata, which included anteaters and sloths, as they possess no anterior teeth and no or poorly developed posterior teeth.

<span class="mw-page-title-main">Palatal lift prosthesis</span>

A palatal lift prosthesis is a prosthesis that addresses a condition referred to as palatopharyngeal incompetence. Palatopharyngeal incompetence broadly refers to a muscular inability to sufficiently close the port between the nasopharynx and oropharynx during speech and/or swallowing. An inability to adequately close the palatopharyngeal port during speech results in hypernasalance that, depending upon its severity, can render speakers difficult to understand or unintelligible. The potential for compromised intelligibility secondary to hypernasalance is underscored when consideration is given to the fact that only three English language phonemes – /m/, /n/, and /ng/ – are pronounced with an open palatopharyngeal port. Furthermore, an impaired ability to effect a closure of the palatopharyngeal port while swallowing can result in the nasopharyngeal regurgitation of liquid or solid boluses.

<span class="mw-page-title-main">Torus palatinus</span> Medical condition

A torus palatinus, or palatal torus, is a bony protrusion on the palate. Palatal tori are usually present on the midline of the hard palate. Most palatal tori are less than 2 cm in diameter, but their size can change throughout life.

<span class="mw-page-title-main">Buccal exostosis</span> Medical condition

A buccal exostosis is an exostosis on the buccal surface of the alveolar ridge of the maxilla or mandible. More commonly seen in the maxilla than the mandible, buccal exostoses are considered to be site specific. Existing as asymptomatic bony nodules, buccal exostoses don’t usually present until adult life, and some consider buccal exostoses to be a variation of normal anatomy rather than disease. Bone is thought to become hyperplastic, consisting of mature cortical and trabecular bone with a smooth outer surface. They are less common when compared with mandibular tori.

<span class="mw-page-title-main">Crown lengthening</span> Dental procedure

Crown lengthening is a surgical procedure performed by a dentist, or more frequently a periodontist, where more tooth is exposed by removing some of the gingival margin (gum) and supporting bone. Crown lengthening can also be achieved orthodontically by extruding the tooth.

Guided bone regeneration (GBR) and guided tissue regeneration (GTR) are dental surgical procedures that use barrier membranes to direct the growth of new bone and gingival tissue at sites with insufficient volumes or dimensions of bone or gingiva for proper function, esthetics or prosthetic restoration. Guided bone regeneration typically refers to ridge augmentation or bone regenerative procedures; guided tissue regeneration typically refers to regeneration of periodontal attachment.

Inferior alveolar nerve block is a nerve block technique which induces anesthesia (numbness) in the areas of the mouth and face innervated by one of the inferior alveolar nerves which are paired on the left and right side. These areas are the skin and mucous membranes of the lower lip, the skin of the chin, the lower teeth and the labial gingiva of the anterior teeth, all unilaterally to the midline of the side on which the block is administered. However, depending on technique, the long buccal nerve may not be anesthetized by an IANB and therefore an area of buccal gingiva adjacent to the lower posterior teeth will retain normal sensation unless that nerve is anesthetized separately, via a (long) buccal nerve block. The inferior alveolar nerve is a branch of the mandibular nerve, the third division of the trigeminal nerve. This procedure attempts to anaesthetise the inferior alveolar nerve prior to it entering the mandibular foramen on the medial surface of the mandibular ramus.

Socket preservation or alveolar ridge preservation is a procedure to reduce bone loss after tooth extraction. After tooth extraction, the jaw bone has a natural tendency to become narrow, and lose its original shape because the bone quickly resorbs, resulting in 30–60% loss in bone volume in the first six months. Bone loss, can compromise the ability to place a dental implant, or its aesthetics and functional ability.

<span class="mw-page-title-main">All-on-4</span>

The term All-on-4, also known as All‐on‐Four and All‐in‐Four, refers to 'all' teeth being supported 'on four' dental implants, a prosthodontics procedure for total rehabilitation of the edentulous (toothless) patient, or for patients with badly broken down teeth, decayed teeth, or compromised teeth due to gum disease. It consists of the rehabilitation of either edentulous or dentate maxilla and / or mandible with fixed prosthesis by placing four implants in the anterior maxilla, where bone density is higher. The four implants support a fixed prosthesis with 10 to 14 teeth, and it is placed immediately, typically within 24 hours of surgery.

Zygoma implants are different from conventional dental implants in that they anchor in to the zygomatic bone rather than the maxilla. They may be used when maxillary bone quality or quantity is inadequate for the placement of regular dental implants. Inadequate maxillary bone volume may be due to bone resorption as well as to pneumatization of the maxillary sinus or to a combination of both. The minimal bone height for a standard implant placement in the posterior region of the upper jaw should be about 10 mm to ensure acceptable implant survival. When there is inadequate bone available, bone grafting procedures and sinus lift procedures may be carried out to increase the volume of bone. Bone grafting procedures in the jaws have the disadvantage of prolonged treatment time, restriction of denture wear, morbidity of the donor surgical site and graft rejection.

<span class="mw-page-title-main">Oroantral fistula</span> Medical condition

Oroantral fistula (OAF) is an epithelialised oroantral communication (OAC). OAC refers to an abnormal connection between the oral cavity and antrum. The creation of an OAC is most commonly due to the extraction of a maxillary (upper) tooth closely related to the antral floor. A small OAC may heal spontaneously but a larger OAC would require surgical closure to prevent the development of persistent OAF and chronic sinusitis.

A complete denture is a removable appliance used when all teeth within a jaw have been lost and need to be prosthetically replaced. In contrast to a partial denture, a complete denture is constructed when there are no more teeth left in an arch, hence it is an exclusively tissue-supported prosthesis. A complete denture can be opposed by natural dentition, a partial or complete denture, fixed appliances or, sometimes, soft tissues.

<span class="mw-page-title-main">Overdenture</span> Removable dental prosthesis

Overdenture is any removable dental prosthesis that covers and rests on one or more remaining natural teeth, the roots of natural teeth, and/or dental implants. It is one of the most practical measures used in preventive dentistry. Overdentures can be either tooth supported or implant supported. It is found to help in the preservation of alveolar bone and delay the process of complete edentulism.

References

  1. 1 2 Pre-prosthetic surgery: Mandible Veeramalai Naidu Devaki; Kandasamy Balu; Sadashiva Balakrishnapillai Ramesh; Ramraj Jayabalan Arvind; Venkatesan Journal of Pharmacy and Bioallied Sciences, 01 January 2012, Vol.4(6), pp.414-416[Peer
  2. ↑ Gandevivala, AM; Kaul, DD; Gupta, AK (2011). "Premaxillary alveolar recontouring - A case report of secondary alveoloplasty". Universal Research Journal of Dentistry. 1 (1): 46–48.
  3. ↑ "The Dental Summary". 1919.
  4. 1 2 3 4 5 6 Kademani, Deepak; Tiwana, Paul S. (2015-03-15). Atlas of oral & maxillofacial surgery. Elsevier Health Sciences. ISBN   978-0-323-29132-3. OCLC   912233495.
  5. 1 2 3 "ORAL SURGERY: ALVEOLOPLASTY AND VESTIBULOPLASTY" (PDF). UnitedHealthcare.
  6. ↑ "Peripheral Neuropathy Fact Sheet". National Institute of Neurologic Disorders and Stroke.
  7. 1 2 3 Hupp, James R.; Tucker, Myron R.; Ellis, Edward (2013-03-19). Contemporary Oral and Maxillofacial Surgery - E-Book. Elsevier Health Sciences. ISBN   978-0-323-22687-5.
  8. ↑ "Reconstructive preprosthetic oral and maxillofacial surgery". Journal of Oral and Maxillofacial Surgery. 44 (11): 930. November 1986. doi:10.1016/0278-2391(86)90262-4. ISSN   0278-2391.
  9. ↑ Michael, C. G.; Barsoum, W. M. (February 1976). "Comparing ridge resorption with various surgical techniques in immediate dentures". The Journal of Prosthetic Dentistry. 35 (2): 142–155. doi:10.1016/0022-3913(76)90273-0. ISSN   0022-3913. PMID   1061808.
  10. ↑ Motamedi Mohammad Hosein Kalantar (May 2011). "Technique to Manage the Enlarged Maxillary Tuberosity in Elderly Edentulous Patients Requiring Dentures". Journal of Oral and Maxillofacial Surgery. 69 (5): 1283–1285. doi:10.1016/j.joms.2010.06.192. PMID   21185641 – via Elsevier ClinicalKey.
  11. ↑ Ephros, Hillel; Klein, Robert; Sallustio, Anthony (August 2015). "Preprosthetic Surgery". Oral and Maxillofacial Surgery Clinics of North America. 27 (3): 459–472. doi:10.1016/j.coms.2015.04.002. ISSN   1042-3699. PMID   26231818.
  12. ↑ Chakravarthy Ramasamy and Abby Abraham (December 2011). "Prosthodontic Management of Undercut Tuberosities: A Clinical Report" (PDF). Journal of Clinical and Diagnostic Research. 5 (8): 1692–1694.
  13. ↑ Roberts, B. J. (1977-05-01). "Mylohyoid ridge reductions as an aid to success in complete lower dentures". The Journal of Prosthetic Dentistry. 37 (5): 486–493. doi:10.1016/0022-3913(77)90160-3. ISSN   0022-3913. PMID   321761.
  14. ↑ Devaki, Veeramalai Nadu; Balu, Kandasamy; Ramesh, Sadashiva Balakrishnapillai; Arvind, Ramraj Jayabalan; Venkatesan (August 2012). "Pre-prosthetic surgery: Mandible". Journal of Pharmacy & Bioallied Sciences. 4 (Suppl 2): S414–S416. doi: 10.4103/0975-7406.100312 . ISSN   0976-4879. PMC   3467894 . PMID   23066301.
  15. ↑ Textbook of Oral and Maxillofacial Surgery By Rajiv M Borle
  16. 1 2 Contemporary Oral and Maxillofacial Surgery - E-Book By James R. Hupp, Myron R. Tucker, Edward Ellis
  17. ↑ Sanghai, S; Chatterjee, P (2009). A concise textbook of oral and maxillofacial surgery. pp. 148–49.
  18. ↑ Peterson, LJ (2004). Peterson's Principles of oral and maxillofacial surgery. pp. 168–69.
  19. ↑ Wisdom Tooth Extraction
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