Consideraciones sobre la cirugía periodontal

8/13/2019 Consideraciones sobre la ciruga periodontal

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H P T E R

P r e p r o s t h e t i cS u r g i e a l o n s i d e r a t i o n sD r H enr y Fer guson


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Textbook of Com plete DenturesSurgical goals for treamit-nt of patients should address the folk)v\ing faciois: providingthe patient with the best possible tissue contoui s for prosthesis support, function, andcomfort; maintaining as much bone and soft tissue as possible; and doing this in thesafest, most predictable manner for the patient. With these goals in mind, we can thenwork backward, with a concept of the final result, seque ncing the u ea un en t(s ) tha t willrealize these goals. These goals can he reached through the achievement of specificobjectives, which include creating a broad ridge form, providing an adequate amount offixed tissue over the denture bearing areas, establishing adequate vestibular depth forprosthetic flange extension, establishing proper inter-arch relationships and spacing,supporting arch integrity, providing adequate palatal vault form, and when required, toprovide proper ridge dimensions for implant placement.

I Pat ient va luation an i l xpectat ionsPrior to the performance of any procedure , several key steps must be perfo rm ed. Th eobjective ofa thorough patient evaluation, review of the past medical histoiy, and physi-cal valuation is to identify treatment-modifying factors required for the safe anduneventful treatment of the patient.The physical examination includes thorough evaluation of the oral hard and softtissues and radiographs. This examination will reveal the difticult)' of performing thedesired preprosthetic surgical procedures or even whether they are possible. Forinstance, the refening dentist may desire that the patient receive a reduction of thetuberosities but radiographie evaluation by the surgeon may reveal that tbis pro ce du re isnot possible because of the position of the maxillary sinus.Radiographically, the panoramic radiograph is the workhorse image for prepros-thetic surgeiy. With this radiograph one can visualize many of the important anatotnicand structural relationships necessary to accurately create a treatment plan for prepros-thetic procedures. For the mandible and maxilla in general, pathologic lesions, retainedroots, impacted teetii, and overall ridge morphology can be seen . For Uie man dib le, rela-tionships between the inferior alveolar canal and the ridge crest, and position of themental foramina to the ridge crest can be obsei-ved. For the maxilla, relationshipsbetween the loor ofthe maxillai^ sinus and the alveolar crest, anterior nasal spine, andthe anterior maxillary alveolar crest can be determined. Additionally, the hard tissuecontribution versus soft tissue com pon ent of hv-perplasic tuberosities can be de term ine d.Other radiographie images may be required when specific anatomic relationships needto be observed.

For preprosthcdc procedures and treatment plans, which may include implantplacement, more sophisticated, radiographie studies may be required. Tomograpbicstudies and comp uterized tomo graphy (CT scans) may be used. Th e CT scan can providecross-sectional detail of the maxilla in both the axial and coronal views. This providesexcellent information regarding such im portant p lannin g factors as alveolar heigh t andwidth, facial, lingual, and palatal alveolar contours, relationships between the maxillarycrests and the sinus fioor and nasal fioor, and the m andib ular inferior alveolar canal an dmental foramina to the crestal bone.


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Pre prosthetic Surgical Considerations 67

T r e a t m e n t P i a n n i n g

With the desired preproslhetic surgery identified, and the physical evaluation andradiographie examinations completed, a problem list is made. Treatment planningnow becomes the next critical step. No procedures should be performed without atreatm ent plan designed to seque nce an d address the p atient s problem list. Based onstate of health, complexity of treatment plan, and level of anxiety, referral may be madeto place the patient in an ennronment where all of these important factors can be safelyaddressed.Goals for treatment should address the following factors: providing the patientwith the best possible tissue contours for prosthesis suppon, (unction, and conbrt;maintaining as much bone and soft tissue as possible; and doing this iti the safest mostpredictable m ann er for the patient. With these goals in mind we can sequence the treat-ment(s ) that will achieve these goals.

R e v ie w o f ia p sAccess to an d expo sure of the surgical site is critical. Th e clinician s tool for ade qua teexposure is the full thickness mucoperiosteal fiap. This aggressive surgical approach withits greater visibility, protection of adjacent tissues, time efficiency, and more routine post-operative course is far more valuable and less traumatic to the patient than other lesseffective techniques. Diagnostic casts are excellent aids in outiining areas of surgicalfocus and for flap design.For most ofthe procedures a midline crestal incision is recommended. In edemu-lous areas, the re is usually a dense scar band on the crest of the ridge (Figin e 5- . Thistissue is stronger, m ore resistant to tears, and holds su tures well. WTien te eth a re prese nt


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8 Textbook of Complete Denturesand the su rrou nd ing soft tissues are to be included in the flap, a stdcular inci.sion sharplyto bone is recommended. The reflection should be subperiosteal and deliberate. Whenworking around teeth, the papillae should be gendy reflected, then tlie remainingattached tissues in a uniform plane before attempting to teflcct more apically. Beingdeliberate, precise, and having patience v Wreward tlie clinician with a clean s ubpe-riosteal dissection. The dissection should proceed apically as far as needed to visualizethe area of concern. Dissection antero-posteriorly should be made as necessary toallow for elevation of the flap and appropriate exposure without placing tension on theflap. Althottgh envelope flaps are usually adequate for most procedures, if access isa problem, both anterior and posterior releasing incisions are recommended. The baseof the flap niitst be w ider than the crestal aspect so tiiat blood supply to th e flap will notbe comprom ised.

When the procedure is completed and the flap is repositioned. tlie clinician mustfeel the utiderlying bony contours through the flap to enstire that the intended goal hasbeen reac hed. Th en the flap is reelevated and copiously irrigated alo ng the en tire len gthof the flap to remove all debris. Once the flap is anatomically repositioned, a suture isused to secure the Haps p(,)sition. Sutures are placed to approximate and not strangulatethe tissues.

omm oniy Uset l Pre pros the t ic Proced uresCommon preprosthetic procedures include ridge alveoloplasty \vith extraction (s):ridge alveoloplasty without extractions for recontotiring of the knife edged ridge orother ridge deformity or contour problems; intraseptal alveoloplasty; maxillary tuberos-ity reductions; recontouring of palatal and lateral exostosis and contour problems;mandibular tori remo\'al; maxillaiy toti remoral; myloliyoid ridge reduction; and genialtubercle reduction. Soft tissue procedures might include maxillary tuberosity soft tissuereduction, maxillary labial frenectomy, mandibular lingual frenectomy, and excision ofredtmdant tissue.

R i d g e iu e o io p la s t y w i th E x t ra c t i o nAfter extraction ofa tooth or teeth, the clinician must make a determination about tbeappropriateness of the remaining ridge contour{s) to fit into the p reprosth etic p lan, andif the recon touring w llbe m ade at the time of the ex traction{s) or at a later time. If m orethan finger compression is needed, a full thickness flap should be elevated to a pointapical to the area in need of recotitotiring. Depending on the amount of recontouringneed ed, a bon e flle may be sufficient to prod uce tlie desired co ntours. For grea ter recon-touring, a side cutting rongeur or handpiece and acrylic resin bur can be used (Figure5-2 ). WTien using these b urs, always use copious irrigation to avoid overhe ating the bo neand subsequent bony necrosis. Irrigation also cleans tiie flutes of the b tir and carries awaydebris. After bulk recon tourin g, a bone file is uses to fme tune tiie reconto uring . Bonefiles or rasps give the clitiician a great tactile sense and good contro l. W iien finished, the


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Pre prosthetic Surgical Considerations 69

Figure 5 2 Bone rongeur used to accomplish bone reduction during a ridge alveoplasty along with extractions.pair of scissors or surgical blade to make the cuts. It is usually more prudent to sequen-tially remove small amounts of tissue than to remove too much at one time.Consideration must also be given to maintenance of vestibular deptb and form whentrimming and approximating the flap.

Intrasepta l A lveoloplastyWhen the ridge has acceptable contour and height but presents an unacceptableundercut, which extends to the base of the labial vestibule, the intraseptal alveoloplastymight be considered. This procedure is best accomplished at tlie time of extractionor early in the postoperative healing period, .\fter extraction of the teeth, the crestaltissue is slightiy elevated to fully expose the extraction sockeLs. Using a small rongeuror handpiece and bur, the inti aseptal bone is removed to the dep th of the socket


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70 Textbook of Com plete Dentures

Figure 5 4 Interseptal alveoplasty during extractionprocedures.

(Figure 5-4). After adequate removal of bone, finger pressure is applied in a constantcontrolled manner unlil the labiocorticiil plate is greensiick fracuned and can be positioned palatally, narrowing ie cresi and eliminating lhe undercut. If significant resist-ance is enco unte red, a verdcal cut in the bon e can be m ade using osteoLome or bur frominside Lhe most distal .sockets outward, carefully scoring the bone. Periosteum and softissue should not be violated. Finger pressure should be applied to the area of the vertical bone cut to achieve mobility of the segment and guide its repositioning. A bone filecan be used to smooth rougbened edges, and the site can be irrigated. The crestal softissue can now be approximated and closed witb interrupted or continuous suturesIdeally, a surgical stent or soft-tissue-lined immediate denture can be inserted to maintain the reposidoned bony segment until the initial stages of healing have taken place, aabou t two weeks aiter the p roced ure.

Ede ntu lous R idge lueo lop lastyFor routine eliminadon of sharp (knife-edged) ridges and removal of undesirablecontours, undercuts, or prominences, direct vision and frequent palpation until tliedesired endpoint is reached will be sufficient. When tlie mandibular or maxillary edenttilous ridges require multifocal, moderate, or greater amounts of recontouring, use ofdiagnostic casts tc) identify areas o co ncern , and fabrication of surgical guid es, ar erecommended. In this way, the cUnician has a model with the specific areas outlined toassist in theex clorien tation once tissues are reflected an d. if necessary, a surgical gu idto assist with the detailed removal and recontouring of the bone.

The edentulous ridge alveoloplasty begins with idendfication of the areas ofconcern. A full thickness flap is designed and implemented to fully expose the targetedareas. Using bone files/rasps, rongeurs handpiece, and burs or combinations, thetargeted areas are recontoured. Digital palpation with tlie flap in place is done until the


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Pre-prosthetic Surgical Con siderations 71

Figure 5-5 Marking Uie m idline crestal incision to beused for access to remove buccal exostosis on themandibular ridge.

u c c a l E x o s t o s i sThis approach can be used on either arch and for irregularities on the palatal aspect oftbe maxillaiy alveolus. A crestal incision is made to extend beyond the m argins of theareas reqtiiring rec ontouring Figure 5-5 ). A full thickness flap is elevated to com pletelyexpose th e involved area Figure 5-6). When an envelope fiap will not provide the neces-sary exposure without placing tension on the flap, a releasing incision, as describedearlier, may be incorporated into the flap design. For gaining assess to a palatal exosto-s s make the incision longer and reflect more tissue to gain enough relaxation in theflap.B ecause of the grea ter palatin e and incisive branch anastomosis, vertical releases in

Figure -6 Elevation of ful l thickness flap to expose


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72 Textbook of Complete Dentures

Figure 5 7 Exposed exostosis dem onstra ting the use of arotary instrument for recontouring. Note retractor providing exposure of operating site and protecting adjacent softtissue.the palate area no t recom m end ed. On ce the iiTegularity is exposed , the tissue is elevatedand protected, and the appropriate instrument is used to recontour the bone to thedesired endpoint (Figure 3-7). The area is palpated throtigh the flap to confirmadeq uate reduction o r recontou ring. When com pleted, the area is irrigated an d closed

a x i i i a r y T u b e r o s i t y R e d u c t io n sMaxillary hyperplasic tuberosities present real problems for gaining appropriate interarch distance posteriorly. The tuberosities can be hypcqlastic in the horizontal or vertical planes, and may involve osseous hj-perplasia, soft tissue hyperplasia, or both. Toidentift- the hard tissue and soft tissue component that requires recontouring, apanoramic radiograph will usually suffice. This will provide infonnation about the hardand soft tisstie contributions and the overall contoiu^ of the tuberosity and proximity tothe maxillary sinus. It is important to remember that maxillary sinuses may pneiunatizeinto the tuberosity areas. A crestal incision is ma de from a poiiu ant erio r to where therecontouring will start, over and up behind the tuberosity. Tissue must be elevated onboth the buccal and palatal aspects to fully expose the tuberosity (Figure 5-8). Aftermaking sure that all soft tissue is protected, instrumentation can start (Figure 5-9). Thetuberosit) can be recontoured with bone file, rongeur, or bur (Figures 5-30 and 5-11)If a great deal of bone needs to be removed, again as in other procedures, a surgicalguid e may be necessary. If tlie maxillar)- sinus has pneum atized, care m ust be taketi whenremoving the bone , and the sinus mem brane may becom e expo sed. However, this is nota problem as long as the membrane is intact.

a n d i b u i a r T o r i


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Pre-prosthetic Surg ical Con siderations 73

Figure 5-8 Arrow indicates a bony undercut on the lateralsurface of the maxillary tuberosity.

Figure 5 9 Tissue flap is elevated to expose bony under-cut arrow) that requires recontou ring.


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74 Textbook of Complete Dentures

Figure 5-11 Before /n, a oiier B) recontouring thebuccal bone to eliminate an undercut on the lateral aspectof the maxillary tuberosity.A midline crestal incision is made to extend about 1.0 -1.5 cm distal to the mosposterior tori, to decrease tension and tearing of the flap. A full thickness linguamucosal flap is slowly elevated. Because the tori may be pedimculated. dissection of thvery thin mucosa located in the undercuts may be tenuous. However, like other procedures discussed, patience and a steady hand will prevail. ..Mter elevating all mucosa off othe tori{s) to a point below the tori where normal lingual cortical anatomy is found, tissue retracto r m ust be placed to maintain exposu re and p rotect tbe flap. If aosteotome slips, it should hit the retractor and not perforate the floor of the mouthSimilarly, the tissue must be out ofthe way when using a rotary instrument and bur. Fosmaller tori, bone file and rongeur or rotary instrument and bur may be used for bonreduction Figure 5-12 ).

Figure 5-12 Removal cf a mandibular tori.T he


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Pre prosthetic Surgical Con siderations 75After all tori have been removed and bone smoothed, the flap is repositoned andthe lingual plate palpated to confirm achieving tlie desired contours. Use tbe suturetechnique of choice, but because of the length of the incision, a continuous suturingtechnique with good margin inversion is recom m ended. To minimize hem atom a forma-

tion 4x4 gauze is rolled into tlie appearance of acigar, the to ngu e is elevated to the roofofthe mouth, and the gauzed is placed under tlie anterior aspect ofthe tongue over therepositioned siuured fiap. Have tlie padent lower die tongue . The weight ofth e tonguewill push the gauze down and forward, pushing the gauze against tlie fiap and the flapagainst the bon e. These will tampo nade any smali oozing and eliminate dead space.

a x i ll a r y T o r i maxillarv tori may pose a significant problem in the fabrication and wearing of a maxil-lary com plete d en tu re . T he tori may be especially prob lema tic when it is positioned moreposteriorly, creating pro blem s with posterio r palatal seal of die prosthesis (Figure 5-1 3).A midline incision is placed over die torus \vith oblique releasing incisions at each end.WTien tbe tori are multilobulated and pedunculated, elevation of the thin mucosa maybe difficult. After the tonis is exposed, adequate flap contiol for best \isualizatioti isimportant (Figure 5-14A). An excellent method of keeping the fiaps open is to suturethe margin of the fiap to tlie crest of tlie ridge on the same side. For some larger pedun-culated multilobulated tori, a midcrestal incision with elevation of the entire palatalmucosa is recommended. This dissecdon must stay subperiosteal to avoid injuiy to tliepalatal blood supply. The desirable end point is for the palatal vault to be smooth andconfiuent with no undercuts or elevations (Figure 5-14B).The margins of the llap are digitally positioned and pressed against the bone.Removal of redu nda nt dssue can now be performed, keeping in mind that all bone mustbe covered with tension-free closure. Also keep in tnind that the tbin mucosa overKingthe torus does not bold a suture well, so margin uim m ing should be consei^ative or notat all (Figure 5-15 ). Hem atom a formation in the palate un der the fiap is a great co ncern.Excellent methods of applying pressure are with the placement of a temporary denture


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Figure 5 14 Pedunculated bony tor i exposed by elevatingsubperiosteal flaps A) Smooth palate created by the toriremoval B)with soft reli ne materia l over the surgical site or with a well-fitting, surgical g uid e with soreline placed over the area. The pressure should be maintained for several days. Thpatient can remove the appliances for local wound care and oral rinsing.

M yioh yoid R idge ReductionIn the mandibular post-extraction ridge remodeling sequencing, the alveolar bone anexternal oblique ridge resorb because of lack of stressing and functional remodelinThe m yiohyoid ridge, which supports the attachme nt of th e mylohyoid muscle, remainrelatively intact, and becomes a prominent feature in the posterior mandible.After providing profound anesthesia, a mid cresta incision is made ant erio r to tlsite of ridge reduction and carried posteriorly gradually deviating toward the buccal,


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Pre prosthetic Surgical Con siderations 77avoid potential injury to the lingual nerve. The flap is elevated to expose the mylohyoidridge and a ttached m uscle. Using sha rp dissection the tenden ous attachm ents of tiiemylohyoid muscle are stripped. The muscle will retract into the floor of the mouth andreattach during healing. A bone bu r can be used to reduce the ridge to the desiredheight. A bone file can be used to fine-tune the co ntouring. When com pleted the areashould be copiously irrigated and closed primarily with interrupted or continuoussutures. On ce the fiap has bee n closed ideally a den ture with a soft reline is placed toallow for the lingual fiange to help with displacemen t of the detached mylohyoid muscle.

e n i a l T u b e r c i e R e d u c t io nIn the post-extraction ridge remodeling of the anterior mandible the alveolar ridge andtooih-bearing areas resorb because of lack of stressing and functional loading . Th e supe-rior pair of genial tubercles provides insertion for the paired genioglossus muscles whilethe lower paired tubercles provide insertion for tlie paired geniohyoid mtiscles. Becauseofthe constant movement ofthe tongue and stressing ofthe tubeicles once the alveolushas resorbed and remod eled the genial tubercles can become very prom inent structuresin the anterior mandible and impede proper seating of the denture.

The clinician must be aware that thi.s surgical site lies between two movingstructuresthe tongue and the lip. Therefore thisisan area that may be p ron e to wounddehiscence. making this a very difficult surgery.A full thickness fiap is elevated to expose the genial tuhercle and genioglossusmuscle attachments. The tendenous muscular attachments are sharply detached fromthe bone to randomly reattach more inferiorly. With exposure of the bone and protec-tion of the fiap the bone height can be reduced witii die instnament of choice to thedesired level. The wound is copiously irrigated and closed primarily.

So t T issue Procedures

With loss of teeth bony rsorp tion and rem ode ling soft tissue relationships that existedwith teeth and were not problematic may become concerns. With reduction of ridgeheigh t and con tour soft tissue and muscular attachm ents change. These m uscular andsoft tissue changes are often deleterio us to prostliesis stahility and function and requ ireremoval or alteration. Additionally witii the potential trauma and ch ron ic irritationcaused by ill-fitting prostheses the deve lopm ent of hypei-plastic tissues in the d en ture-bearing and peripheral tissue areas may occur These hvperplastic tissues contribute tolack of den ture fit and stability and can contr ibute to patien t discomfort.Because it is very difficult to replace oral mueosa after it has been remo ved thetreatment plan must detail the sequence in which the sofi tissue abnormalities will beaddres sed. Treaun eni will usually addres s the bony abnorm alities first to achieve no nn albone hea ling with good soft tissue coverage. Additionally if implan t placem ent is part ofthe treatment plan bone augme ntation may be required. Preserving redu nda nt softtissue to provide coverage for bone augmentation should be considered. The soft tissue


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8 Textbook of Complete Denturesthe tissues can occur. Therefore, as a rule, a portion of all excised hyperplastic tissueshould be submitted for histopathologic examination.

M a x i l l a r y S o f t T i s s u e T u b e r o s i t y R e d u c t i o nInterarc h distance is a critical eleme nt for p rop er fabrication of de ntur e bases, anhyperplastic maxillar)- tuberosit) tissues often imping e on ade qu ate in tera rch distan ceTo determine if the reduction will be primarily bone or soft tissue, a panoramic radogi aph that can discriminate the soft tissue shadow from bo ne is req uir ed . If no t avaiable, sounding of the soft tissue with the anesthesia needle after the region ianesthetized will provide the clinician with detail of the tissue thickness. If a great deaof tissue removal is anticipated, a surgical guide is recommended.A midline elliptical incision is made sharply to bon e with th e widest pa rt of thellipse direcfly over the area where tiie most tissue is to be removed. The anterior anposterior portions of the ellipse should tap er into th e no rmal portions of the ridge an teriorly and to the posterior tuberosity posteriorly. The ellipsed portion is elevated anremoved. Th e clinician can now look into th e area m ade by the rem oved sec tion of tissuand evaluate tlie tissue height above the bone. Directing attention to tlie buccal anpalatal edges of Uie incision, tlie clinician will thin the tissue by removing a uniformthicknessstaying an even distance from ie surface and remembering to adjust thangle while thinning around the curve. Buccally, there are no structures of concern ttlie clinician as he/she makes contact with the bony lateral aspect of the ridge. Palatallythe clinician needs to be caieful not to extend the thinning too deep into the palataiispect of the ridge because of the greater palatine neurovascular bimdle. Once thexcess tissue has been rem oved and there is a uniform thickness of mucosa, digital pressure will approxim ate th e buccal and palatal flap m argins to evaluate the a m ou nt of vertcal reduction that has been accomplished. Having the patient close down gently on thclinician s fingersw llallow for evaluation of tlie chan ge in interarc h distance . If the vertcal reduction is acceptable, the wound margins are approximated and trimmed to get tension-free butt Joint closure. Th e wound is closed with an inteiTtipted, or co ntin uo ussuture technique.

If the tissue has been thinned and no additional vertical change is possible withithe soft ti.ssue, and yet more is nee ded , then the flaps will need to be reflected buccaliand palatally. Bony redu ction wiil need to be d on e to achieve the desired vertical ch ang e(Refer back to bony tuberosity reduction).

M a M ilia r y L a b ia i r e n e c t o m yLabial frenal attachments are thin bands of fibrous tissue/mtiscle covered with mucosthat extend from the lip or cheek and attach into the periosteum on tlie sides of, or thcrest of, the alveolar ridge. Except for frenal attachments, which attach at the incisivpapillae and contribute to tlie midline diastema, most frenal attachmentslike othesoft tissue structuresare of litde consequence when teeth are present. On the edentulous ridge, which has experienced rsorption and remodeling, the muscular and softissue attachments may direcdy aect the seating, stabilization, and construction of th


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Pre prosthetic Surg ical Con siderations 79Injecting directly into the frenum may distort the anatomy. After achieving good anes-thesia, two small, curved hemostats are placed witii the curved sides against the tissuesover the superior aspect of the frenum and the inferior aspect of the frenum. Th e tips ofthe hem ostats will touch in the d eep aspect near the vestibtile. surgical assistant shouldsuction and retract the tip superiorly. Holding tlie top hemoslat, tiie clinician will use asurgical blade and follow the curvature of the upper hemostat, cutting through theupper aspect of th e frenum Figiue . T - I 6 ) .This is repeated for the lower hemostat. Thefrenum will now be excised, leaving a diam ond-sha ped w ound Figure 5-17). E xploringthe wo und, any frenal r em nan ts should be excised directiy to periosteum . A sutu re isplaced through tlie wound margin engaging the periosteum in the depth ofthe vestibuleright below Uie anterior nasal spine. A knot is tied and the margins will be drawntogether and pulled down to the periosteum in the depth of the vestibule. Additionalsutures are placed in a similar manner so that the dianiond-shaped wound now closes ina linear ma nn er Figure 5-1 8). If tlie frenum ex tend ed to Uie crest ofthe ridg e and was

Figure 5 16 Maxillary labial frenectomy using two curvedhemostats as guides for tissue excision.


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Figure 5 18 Maxillary labial frenectomy primary closurewith sutures.excised thorough attached tissue, all parts of the wound v\ill close primarily except thpart in the attached tissue. No attempt should be made to close that area and it shoube left to granulate and heal by secondary intention.

E x c is io n o f R e d u n d a n l /H y p e r m o b i i e T i s s u e O v e r ly in g t h e T n b e r o s i t ie sRed und ant h>-permobile dssue is often the result of ill-fitting de ntu res , ridge reso iptioor both. After identifying the area to be excised, parallel incisions on the buccal anlingual or palatal aspects of the tissue are made sharply to bone. Tbe incisions will tapinto each other posterior to the area to be incised. The excised piece of tissue will bdissected from the bon e an d removed. Digital pressure is applie d to check for primaclosure of the wound margins. If additional tissue needs to be removed, tangential incsions on the buccal and palatal, or lingual, sides of the wound are made to remove anthin out additional tissue. Tbis is done carefully until the wound margins approximaprimarily. The wound is irrigated and closed primarily. Care should be taken to avosignificant undermining of the buccal/facial aspects of the flaps, and loss of vesdbuldepth when closing the wound.

E x c is io n o t i n l i a m m a t o r y F i b ro u s H y p e r p i a s ia E p u i is F i s s u r a t u m )Infiammatory fibrous hyperplasia is a generalized hyperplastic enlargement of thmucosa and fibrous dssue in the alveolar ridge and vestibular area. The etiology is moclosely associated witli chronic trauma to the involved areas from ill-fitting prosthesiInfiammatory fibrous h\perplasia progresses in stages, and the surgical procedure indcated varies with the stage. For those lesions in the early stages, there is not a significadegree of fibrosis of the involved tissues, and nonsurgical therapies may be effecdvIn the later stages where the re is significant fibrosis an d hyperplastic cha nge s, excision


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Pre prosthetic Surg ical Con siderations 81

Figure 5 19 Inflamm atory fiberous hyperplasia in themaxillary labial vestibule.techniques provides good results for tissue excision. For more extensive tissue masses,the margins of the tissue ma.ss are elevated using tissue forceps, an d an incision is mad eat the base of the mass, but not tiirough the periosteum. A suprapcriosteal dissection ismade under the entire mass ofthe hyperplastic tissue, and the mass is removed.The normal mucosal margins are sutured in place, and the superior margins aresutured to the depth of the vestibule. In order to minimize soft tissue creeping and lossof vestibular height with secondarv intension healing, a surgical stent with an extendedante rior Cange lined v\ith soft tissue cond itioner, or the existing de ntu re with the flangeexten ded to engage the height of the vestibule. A soft tissue con ditio ner should beplaced, and the prosthesis should only be removed for wound care and rinsing, andcleansing of tbe intaglio surface of the prosthesis. Secondary epithelialization v\ill takefour to six weeks.

Infiammatory Papiiiary yperpiasia ot the PaiateInflammatory- papillarv hvpeiplasia of the palate is a condition affectitig the palatalmucosa, tliought to be caused by ill-fitting prosthesis, poor hygiene, or fungal infectionsand the as.sociated inflammation. Its clinical presentation appears as multiple nodularprojections in die palatal mucosa. The lesions may be ervthematous or may have normalpalatal mucosal coloration (Figure 5-20).Early treatment consists of prosthesis adjustments, tissue conditioner, and properoral hygiene. In more advanced presentations, several treatment options have beensuggested. Because this is primarily an inflammatory disorder, th ere is no ne ed to excisethe full thickness of the palatal tissue. In any of the described treatment options, thesuperficial infiamed layers of the palatal mticosa are removed leaving the palatal perios-teum intact to heal by secondary intension. These techniques include removal of tiieinflamed mucosa with electrosu rgery loops, laser ablation of th e superficial layers, sharp


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Pre prosthetic Surgical Considerations 8areasof soft tissue bl an ch in g are obser \ ed. Thes e blanch ing areas repre sent area s whereaddi t iona l r emo\a l of b o n e and r e c on tou r ing are s ti ll requ ired . This pro ced ure isrepea ted unt ilno b lanch ing exists an d the surgical gu ide is stab le w he n se ated . Soft tissuet r imming , ifnecessary, can now be d o n e .

e f e r e n e sMiloro, M., Ghali, G-E., Larsen, RE-, Waile, P.D.; Peter s P rinciples o f Oral and MaxofiUial Surgery,Hamilton, Ontario: BC Decker Inc., pp. 157-188.Ochs, M.W., Tucker. M.R.: Preprosthetic Surgery- In: Coniemporary OralandMaxillofacial Surgery,4th Ed, St. Louis, MO: .Mosby Publishing pp . 248-304.Peterson, L. J., Indresano,A.T, Marciani. R-L., Roser, S.M.: Principles of Oral andMaxillofacialSurgery, Volume2,Philade lphia, P.-\: Lippcuc ott Oim pany, p p. 110.^1132.Spagnoli, D.B.. Gollehon, S.G., Misiek. D.J.: Preprcsthetic and Reconstructive Surgery

In: Principles of Oral and Maxillofacial Surgery 2ed., Hamilton, Ontario: B.C. D ecker, Inc.,pp. 157-187Tucker, M.R,: .^mbulatoiy Prepro.stheUc Reconstructive Surgery In: OralandM axillofacialVolume 3,St Louis, MO.: Mosby PubUshing. pp. 1103-1132.

1. WTiat other diagnostic imaging might be used for preprosthetic surgery treat-ment planning besides typical panographic radiographs?

2. Surgical access is often gained through the use of full thickness mucope-riosteal flaps. \Miai are the advantages to this surgical approach over otherflap techniques?

3. \\Tiat three instruments are commonly used for recontouring bone duringpreprosthetic surgery?

4. True or False: Maxillar) tori may present more of a problem for a completedenture patient if it extends past the vibrating line where the posteriorpalatal seal is usually placed.

5. What techniques can be tised to remove inflammatory papular) hypeqlasiaafter controlling the causative factors?


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Consideraciones sobre la cirugía periodontal