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PREPARATION OF

June 28, 2024

PREPARATION OF THE MOUTH TO THE PROSTHESIS

Preprosthetic surgery involves operations aiming to eliminate certain lesions or abnormalities of the hard and soft tissues of the jaws, so that the subsequent placement of prosthetic appliances is successful.

Hard Tissue Lesions or Abnormalities The abnormalities associated with hard tissues are classified into two categories: a. Those thatmay be smoothed with alveoloplasty immediately after extraction of the teeth (sharp spicules, bone edges),or those detected andrecontoured in an edentulous alveolar ridge. b. Congenital abnormalities, such as torus palatinus, torus mandibularis, multiple exostoses.

Alveoloplasty Alveoloplasty is the surgical procedure performed to smooth or recontour the alveolar bone, aiming to facilitate the healing procedure as well as the successful placement of a future prosthetic restoration. After tooth extractions, appropriate recontouring of the alveolar process and care of the wound are necessary prerequisites for placement of a prosthetic appliance. Sometimes, the residual crest presents irregularities, undercuts, or bone spicules (Fig. 10.1), which, if not removed before placement of the partial or complete denture, lead to injury and stability or retention problems. If the alveolar ridge is suspected of presenting abnormal morphology after the extraction of one or more teeth, in order to avoid such a possibility, alveoloplasty must be performed at the same surgical session (Fig. 10.2).

Alveoloplasty After Extraction of Single Tooth. When a tooth is hypererupted due to the absence of an antagonist, bone irregularity is usually observed after its extraction (Fig. 10.3). This may cause problems forthe normal healing process and abnormality of the alveolar bone, resulting in obstruction of the placement of a prosthetic restorative appliance. In such cases, immediately after extraction of the tooth, recontouring of the bone in the areamust be performed. The relative procedure is generally as follows. After extraction of the tooth, a flap is created and a rongeur is used to cut the jagged parts of the tooth socket, untila clinically appropriate interarch space is created (Fig. 10.4 a). Afterwards, the bone surface is smoothed using a bur and bone file (Figs. 10.4 b, 10.5), and excess gingivae are trimmed with soft tissue scissors. The area is irrigated with plenty of saline solution and the wound is sutured with interrupted sutures (Fig. 10.6).

Fig. 10.1. Protrusion of alveolar bone of the premaxilla after multiple extractions of anterior teeth

Fig. 10.2. Supraeruption ofmaxillary teeth dragging down the alveolar ridge. Indication for alveoloplasty after extraction

Fig. 10.3 a, b. Supraeruption of a maxillary molar. After extraction of the tooth, surgical recontouring of alveolar bone is required. The procedure aims to create

a normal interarch space. a Diagrammatic illustration. b Clinical photograph

Fig. 10.4 a,b. Smoothing of the alveolar ridge with a bone rongeur (a), and with a bone bur (b)

Fig. 10.5 a, b. Smoothing of bone surfacewith a bone file. a Diagrammatic illustration. b Clinical photograph

Fig. 10.6 a, b. Operation site after suturing. A satisfactory interarch space is created to allow the placement of prosthetic restoration. a Diagrammatic illustration. b Clinical photograph

Alveoloplasty After Extraction of Two or Three Teeth. When two or three teeth of the maxilla or mandible are to be extracted (Fig. 10.7), the procedure is almost the same as that mentioned above for extraction of a single tooth. More specifically, after extraction of the teeth, if there are grossly irregular alveolar margins or if the alveolar ridge is high, parts of the mucosa are first removed with wedge-shaped incisions, mesial and distal to the postextraction sockets (Fig. 10.8). Afterwards, the bone is recontoured using a rongeur and an acrylic-type bur, while the wound is then sutured (Figs. 10.9–10.11). When the presence of bone irregularity in postextraction sockets is ascertained by palpation, bone recontouring may be performed with a bone file, alone or in combination with a rongeur (Figs. 10.12–10.16). Fig. 10.6 a, b. Operation site after suturing. A satisfactory interarch space is created to allow the placement of prosthetic restoration. a Diagrammatic illustration. b Clinical photograph Fig. 10.7 a,b. a Periapical radiograph of the region of the canine and first premolar of themandible. b Clinical photograph. Supraeruption of teeth and a high alveolar ridge are noted Alveoloplasty Using Bone Rongeur and Bone Bur

Fig. 10.7 a,b. a Periapical radiograph of the region of the canine and first premolar of themandible. b Clinical photograph. Supraeruption of teeth and a high alveolar ridge are noted

Fig. 10.8 a, b. Removal of wedge-shaped portions of mucosa from the alveolar ridge, fromthe area mesial and distal to the Sockets

Fig. 10.9 a, b. Reflection of the mucoperiosteum and removal of bone margins of the woundwith a rongeur

Fig. 10.10 a, b. Smoothing of the bone surface with a bone bur. a Diagrammatic illustration. b Clinical photograph

Fig. 10.11 a, b. a Operation site after placement of sutures. b Postoperative clinical photograph 1month after the surgical procedure Alveoloplasty Using Bone File and Rongeur

Fig. 10.12. Postextraction sockets of the canine and pre- Fig. 10.13. Removal of intraseptal bone with rongeur molars of the mandible. Gross intraseptal bone irregularities noted

Fig. 10.14. Smoothing of the alveolar ridge with a bone file Fig. 10.15. Suturing of wound margins. Passing of the needle from the lingual towards the buccal side (correct procedure) is observed

Fig. 10.16. Operation site after suturing Alveoloplasty After Multiple Extractions. This procedure includes: a. Scheduled extractions. b. Reflection of the gingivae. c. Smoothing of alveolar bone. d. Care of wound. e. Suturing of themucoperiosteum. More specifically, the procedure is as follows. After clinical and radiographic examination of the teeth to be extracted (Fig. 10.17), a local anesthetic is administered and all the teeth are removed one at a time very carefully, so that the alveolar walls are left as intact as possible (Fig. 10.18). An incision is then made on the alveolar ridge to cut the interdental papillae and the gingivae are reflected from the alveolar process (Figs. 10.19, 10.20). Immediately afterwards, the sharp bony edges are removed (irregular intraseptal bone and bony projections) using a rongeur (Fig. 10.21) and after retracting the mucoperiosteum, the bone is smoothedwith a bone file, until the bone surface feels smooth to the touch (Fig. 10.22). The flap margins are also trimmed with soft tissue scissors in such a way that there is perfect contact after bone removal(Fig. 10.23). Afterwards, copious amounts of saline solution are used to irrigate the wound and suturing with a continuous suture follows (Fig. 10.24, 10.25). Alveoloplasty must be restricted to the recontouring of large irregularities and bone spicules. Otherwise, totally smoothing out the alveolar ridgewill lead to negative results as far as stability and retention of the complete denture are concerned. Recontouring of Edentulous Alveolar Ridge. Sometimes, after tooth extractions and the wound has been healed for a long time, the residual ridge may present irregularities at a certain point or even along the entire alveolar ridge. This is usually the result of not taking the necessary measures of bone recontouring after extracting teeth so as to ensure optimal and speedy healing. In such cases, the bonemust be smoothed, to avoid injury and avoid obstructing the proper support of complete dentures. Therefore, if there is a large bony projection at some point along the alveolar ridge, first an incision is made along the length of the crest of the alveolar ridge, where the projection has been localized, and reflection of the mucoperiosteum follows (Figs. 10.26–10.28). The area is then smoothed using a bone file, and the bone is palpated to ensure smoothness (Figs. 10.29, 10.30). Copious irrigation with saline solution follows, as well as suturing of the wound (Fig. 10.31). During reflection and use of the bone file, the index finger of the nondominant handmust be positioned on the lingual side of the flap, protecting it and ensuring its integrity in case of inadvertent sudden slippage of an instrument, which would otherwise result in tearing of the flap. When bone irregularities are present along the entire alveolar ridge, the surgical technique includes an extensive incision along the alveolar ridge, reflection of themucoperiosteum, smoothing of the bone,wound cleansing, and suturing (Figs. 10.32–10.40). This procedure, despite its extent, is not particularly difficult, because large or smaller vessels and nerve branches of the

area have a known course and emergence, so that it is easy to avoid injury or trauma.

Fig. 10.17 a, b. a Radiograph of maxillary teeth, after whose removal smoothing of alveolar bone is required. b Clinical photograph of teeth to be extracted

Fig. 10.18 a, b. Diagrammatic illustration (a) and clinical photograph (b) of gross intraseptal irregularities aftermultiple tooth extractions

Fig. 10.19. Incision along the alveolar ridge to cut the interdental papillae of the gingivae

Fig. 10.20. Reflection and elevation of the mucoperiosteal flap to expose the bone area to be recontoured

Fig. 10.21 a, b. Removal of sharp bone edges with a rongeur. a Diagrammatic illustration. b Clinical photograph

Fig. 10.22 a, b. Smoothing of bone with a bone file. a Diagrammatic illustration. b Clinical photograph

Fig. 10.23 a, b. Removal of excess soft tissues with soft tissue scissors. a Diagrammatic illustration. b Clinical photograph Fig

Fig. 10.24. Operation site after suturing

Fig. 10.25. Postoperative clinical photograph 2 months after surgical procedure Recontouring of Edentulous Area of Alveolar Ridge

Fig. 10.26. Gross lingual bone irregularity after the extraction of mandibular posterior teeth

Fig. 10.27. Incision along the alveolar ridgewhere the bone abnormality is located

Fig. 10.28. Exposure of exostosis after reflection of the mucoperiosteal flap

Fig. 10.29. Smoothing of bone surfacewith bone file

Fig. 10.30. Surgical field after the recontouring of bone

Fig. 10.31. Operation site after placement of sutures Recontouring of Entire Alveolar Ridge

Fig. 10.32. Bone irregularities of an edentulous alveolar ridge of the mandible after multiple tooth extractions

Fig. 10.33. Incision along the alveolar ridgewhere the bone irregularity is located

Fig. 10.34. Reflection of themucoperiosteum to expose the bone irregularity

Fig. 10.35. Smoothing of the alveolar ridge with a bone file

Fig. 10.36. Removal of excess soft tissues with soft tissue Scissors

Fig. 10.37. Surgical field after the smoothing of bone and removal of excess soft tissue

Fig. 10.38. Continuous suture along the alveolar ridge

Fig. 10.39. Operation site after placement of sutures

Fig. 10.40. Clinical photograph of the area 20 days after the surgical procedure.

Satisfactory smoothing of the area where prosthetic restoration is to be placed Exostoses Exostoses are generally bony protuberances, which develop in various areas of the jaw. They are not considered real neoplasms, but dysplastic exophytic lesions. The etiology of these lesions remains unknown, even though evidence suggests that genetic and environmental factors determine their development. Exostoses are classified into three types: (1) torus palatinus, (2) torus mandibularis, and (3)multiple exostoses. Torus Palatinus This exostosis is localized at the center of the hard palate and the exact causes remain unknown. Clinically, they are common asymptomatic bone protuberances, covered by normal mucosa (Fig. 10.41). They vary in size, and the shape ranges from a single discrete exostosis, to multiloculated, to bosselated, to irregular in shape. They usually do not require any special therapy, except for edentulous patients ieed of prosthetic rehabilitation, and in cases where the patient is greatly bothered by the exostoses. Surgical Technique. In order to remove the lesion surgically, an incision is made along themidline of the palate, which is composed of two anterior and posterior oblique incisions (Fig. 10.42). The incision is designed so as to avoid injuring branches of the palatine artery, but also so that there is adequate visualization of, and access to, the surgical field without tension and injurious manipulations during the procedure. After reflection, the flaps are retracted with the aid of sutures or broad periosteal elevators. After complete exposure of the lesion, it is sectioned with a fissure bur and the segments are individually removed using a monobevel chisel (Figs. 10.43, 10.44). More specifically, the chisel is positioned at the base of the exostosis with the bevel in contact with the palatal bone and, thereafter, each segment of the lesion is removed after a slight blowwith themallet (Fig. 10.45).After smoothing the bone surface, excess soft tissue is trimmed and, after copious irrigation with saline solution, the flaps are repositioned and sutured with interrupted sutures (Figs. 10.46–10.48). If the torus palatinus is small in size, the incision for creation of the flap is again made along the midline, but only with anterior oblique releasing incisions. The procedure is then performed in exactly the same way as that alreadymentioned.

Fig. 10.41 a,b. Torus palatinus. a Diagrammatic illustration. b Clinical photograph

Fig. 10.42 a,b. Surgical procedure for removal of torus palatinus. Incision along the midline of the palate with anterolateral and posterolateral incisions. a Diagrammatic illustration. b Clinical photograph

Fig. 10.43 a,b. Mucoperiosteal flaps on either side of the exostosis. Retraction of flaps during the surgical procedure is achievedwith the help of traction sutures. a Diagrammatic illustration. b Clinical photograph

Fig. 10.44 a,b. Sectioning of the lesion into smaller parts using a fissure bur. a Diagrammatic illustration. b Clinical photograph

Fig. 10.45 a,b. Removal of the exostosis in fragments with a monobevel chisel. a Diagrammatic illustration. b Clinical Photograph

Fig. 10.46 a,b. Smoothing of the bone surface with a bone bur. a Diagrammatic illustration. b Clinical photograph

Fig. 10.47 a,b. Operation site after the placement of sutures. a Diagrammatic illustration. b Clinical photograph

Fig. 10.48. Postoperative clinical photograph immediately after removal of sutures

TorusMandibularis Torus mandibularis is an exostosis of unknown etiology. It is localized in the lingual aspect of the body of the mandible, either on one side or more commonly on both sides, and as a rule in the canine and premolar region (Fig. 10.49). Clinically, it is an asymptomatic bony protuberance covered by normal mucosa.Radiographically, it presents as a circumscribed radiopacity in the area of localization. Torusmandibularis is completely innocent iature and does not require any therapy whatsoever, except in cases where complete dentures are to be constructed. Surgical Technique. An incision is made at the crest of the alveolar ridge for the surgical removal of exostoses, and, after extensive reflection of the flap lingually, the lesion is removed using a chisel, bone file, or bur (Figs. 10.50–10.54). The wound is then irrigated with plenty of saline solution and is suturedwith interrupted sutures (Fig. 10.55).

Fig. 10.49 a,b. Tori mandibularis in edentulous (a) and dentulous (b) patients

Fig. 10.50. Incision along the alveolar ridge (without vertical releasing incisions)

Fig. 10.51. Mucoperiosteal flap reflected to expose the Exostoses

Fig. 10.52. Removal of exostoseswith a bone bur

Fig. 10.53. Smoothing of the bone surface with a bone file

Fig. 10.54. Surgical field after the recontouring of bone

Fig. 10.55. Operation site after suturing

Multiple Exostoses These are rare asymptomatic bony excrescences, usually localized at the buccal surface of the maxilla and mandible (Figs. 10.56, 10.57). The causes are unknown, although some people suggest that they may be due to bruxism as well as chronic irritation of the periodontal tissues. No therapy is usually required, except for those cases where, due to the large size of the exostoses, severe esthetic and functional problems are created. Surgical Technique. After administration of a local anesthetic, an incision for the creation of a trapezoidal flap is made. The mucoperiosteum is then reflected carefully, which is quite difficult due to the large size and nodular presentation of the exostoses (Fig. 10.58). During reflection, the index finger of the nondominant hand is positioned above the created flap, in order to facilitate its reflectionwhile protecting its integrity in case of accidental slippage of the periosteal elevator, which would otherwise result in perforation. The exostoses are removed with a rongeur or special bur, under a steady stream of saline solution, in order to avoid overheating of the bone (Fig. 10.59). The bony wound is then smoothed with a bone file and is inspected to ensure the smoothness of the alveolar ridge (Fig. 10.60). After this procedure, the surgical field is irrigated with saline solution and the excess soft tissues are trimmed, especially the interdental papillae of the gingivae. This aims at more precise reapproximation and immobilization of the flap during suturing with interrupted sutures (Fig. 10.61). LocalizedMandibular Buccal Exostosis This case presents rarely, and, depending on its size, creates esthetic and functional problems in edentulous as well as dentulous patients. Its presence especially in edentulous patients obstructs the placement of complete dentures, in which case its removal is deemed necessary. Surgical Technique. The surgical technique applied depends on its size and the area of lesion localization. If the premolar area is involved in the exostosis (Figs. 10.62, 10.63), the procedure used is as follows. After local anesthesia, a trapezoidal flap is created, with particular care taken to avoid injuring themental neurovascular bundle.Therefore, the vertical incisions must be made at a distance from the mental foramen (Fig. 10.64). After being exposed, the lesion is cleaved at its base, in a direction parallel to that of the alveolar ridge (Figs. 10.65–10.67). The bone is then smoothed with a bone bur and the wound is cared for and sutured (Figs. 10.68–10.71). Fig. 10.62.

Fig. 10.56. Multiple exostoses at the anterior region of the Maxilla

Fig. 10.57. Extremely large multiple exostoses in the maxilla with a multilobular and irregular shape

Fig. 10.58. Case of Fig. 10.57 after exposure of exostoses

Fig. 10.59. Removal of lesionswith a bone bur

Fig. 10.60. Smoothing of the bone surface with a bone file

Fig. 10.61. Operation site after placement of sutures

Fig. 10.62. Radiograph showing exostosis of the mandible, with a buccal localization

Fig. 10.63. Clinical photograph of the case of Fig. 10.62. Swelling of the mandible is noted buccally at the area beneath the premolars

Fig. 10.64 a, b. Exposure of exostosis after reflection of the flap. Arrow points to the mental nerve. a Diagrammatic illustration. b Clinical photograph

Fig. 10.65 a, b. Small trough created at the base of the exostosis with a fissure bur. a Diagrammatic illustration. b Clinical photograph

Fig. 10.66. Removal of bone along the line of cleavage completed. Removal is performed using a chisel

Fig. 10.67. Removal of the excised portion of the exostosis with a hemostat

Fig. 10.68. Smoothing of the bone surface with a bone bur

Fig. 10.69. Surgical field after removal of the exostosis and smoothing of the area

Fig. 10.70. Operation site after suturing

Fig. 10.71. Exostosis after removal

Soft Tissue Lesions or Abnormalities Lesions or abnormalities associated with soft tissues and which require alteration are also classified into two categories: a. Congenital abnormalities, such as a hypertrophic frenum, etc. b. Abnormalities created after the use of dentures (e.g., fibrous hyperplasia of the mucosa), and other causes. Frenectomy In many cases, the placement of a complete denture of the maxilla, or orthodontic procedures in younger persons requires the removal of the labial frenum, especially if it is hypertrophic (Fig. 10.72). Also, in the mandible, the lingual frenum may create problems, causing partial or complete ankyloglossia (Fig. 10.73). This case is due to attachment of the frenum to the floor of the mouth or to the alveolar mucosa. It may even be the result of an extremely short frenum that is connected to the tip of the tongue. Ankyloglossia greatly limits movements of the tongue, resulting in speech difficulties.

Fig. 10.72. Hypertrophic maxillary labial frenum

Fig. 10.73. Ankyloglossia as a result of a short frenum

Maxillary Labial Frenectomy Excision of the labial frenum is easy, within the reach of the general practitioner, andmay be performedwith various techniques. The method usually employed is that of excision using two hemostats. In this case, the procedure used is as follows. After local anesthesia, the lip is pulled upwards, and the frenum is grasped using two curved hemostats, which are positioned at the superior and inferior margins (Figs. 10.74, 10.75). The lip is then further retracted and a thin scalpel blade incises the tissue found behind the hemostat, first behind the lower hemostat and then behind the upper hemostat (Figs. 10.76–10.78). If the frenum is hypertrophic and there is a large space between the central incisors, the tissues found between and behind the central incisors are also removed (Fig.10.79). Interrupted sutures are placed along the lateral margins of the wound in a linear direction, after the mucosa of the wound margins is undermined using scissors (Figs. 10.80–10.82).

Fig. 10.74 a,b. Characteristic case of a maxillary labial frenum with a low gingival attachment. The orthodontist recommended its removal

Fig. 10.75 a,b. The superior and inferiormargins of the frenum are grasped using curvedmosquito hemostats. a Diagrammatic illustration. b Clinical photograph

Fig. 10.76 a,b. Initial step in excision of the frenumwith a scalpel in contact with the posterior surface of the lower hemostat. a Diagrammatic illustration. b Clinical photograph

Fig. 10.77 a,b. Final step in excision of the frenum. Incision behind the upper hemostat is performed in a way similar to that shown in Fig. 10.76. a Diagrammatic illustration. b Clinical photograph

Fig. 10.78 a,b. Surgical field after frenectomy. a Diagrammatic illustration. b Clinical photograph

Fig. 10.79 a,b. Removal of hypertrophic tissue found between and behind the central incisors. aDiagrammatic illustration. b Clinical photograph

Fig. 10.80 a, b. Undermining of mucosa of wound margins from underlying tissues. a Diagrammatic illustration. b Clinical photograph

Fig. 10.81 a, b. The first suture is placed at the middle of the wound to facilitate subsequent suturing. a Diagrammatic illustration. b Clinical photograph

Fig. 10.82 a, b. aOperation site after placement of sutures. b Postoperative clinical photograph 3 months later

Lingual Frenectomy Removal of the lingual frenum is also a simple procedure, which may be performed with or without the help of a hemostat. Technique Using Hemostat. After local anesthesia, the tongue is retracted upwards and posteriorly with a traction suture that is passed through the tip of the tongue. The frenum is then grasped approximately at themiddle of the vertical length with a straight hemostat, which is parallel to the floor of the mouth (Fig. 10.83). Using a scalpel the clasped portion of tissue is excised, first above the hemostat and then below (Figs. 10.84, 10.85). The wound margins are then undermined with scissors and interrupted sutures are placed (Figs. 10.86–10.88). Technique Without the Aid of Hemostat. The lingual frenum may be removed with a scalpel without the aid of a hemostat. More specifically, after upward retraction of the tongue, the frenum is incised with converging incisions, first on the area of lingual attachment and then on the other side.After the frenum is loosened and the tongue is released, the tongue is retracted even further superiorly and posteriorly, to facilitate the removal of the rest of the frenum, which is still inplace. After removal of the frenum, thewound margins are undermined and suturing follows, as outlined in the previous case (Figs. 10.89–10.93). Because the frenum is attached close to the deep lingual vein and the submandibular duct, careful attentionmust be given so that injury is avoided during the surgical procedure Steps in Frenectomy with Hemostat

Fig. 10.83 a, b. a Lingual frenum (ankyloglossia) requiring surgical intervention. b Elevation of the tongue with the aid of a suture and retraction of the frenumwith a straight hemostat, to facilitate removal

Fig. 10.84 a, b. First step in frenectomy. The scalpel is always in close contact with the upper surface of the hemostat. a Diagrammatic illustration. b Clinical photograph

Fig. 10.85 a, b. Second step in frenectomy, involving the portion beneath the hemostat. The procedure is similar to that shown in Fig. 10.84. a Diagrammatic illustration. b Clinical photograph

Fig. 10.86 a, b. Surgical field after removal of the frenum. a Diagrammatic illustration. b Clinical photograph

Fig. 10.87 a, b. Undermining the mucosa at wound margins from underlying tissues. a Diagrammatic illustration. b Clinical Photograph

Fig. 10.88 a, b. Operation site after suturing. a Diagrammatic illustration. b Clinical photograph Steps in Frenectomy without Hemostat

Fig. 10.89. Excision of the lingual frenum (case of ankyloglossia) using the technique without a hemostat

Fig. 10.90. Elevation of the tongue with a suture placed at the tip of the tongue

Fig. 10.91. Excision of the frenum with converging incisions towards the

base of the tongue

Fig. 10.92. Undermining the wound margins with scissors

Fig. 10.93. Operation site after the placement of sutures

Denture-Induced Fibrous Hyperplasia Fibrous hyperplasia of themucosa (formerly known as epulis fissuratum or inflammatory hyperplasia) is usually due to chronic trauma of the mucosa of the mucolabial or mucobuccal fold, due to ill-fitting complete or partial dentures (Fig. 10.94).More specifically, the denture flanges injure this area, because they are very thin and longer thaormal. The lesion may present during initial placement of the dentures, or after a period of time, when, due to resorption of the alveolar process, the anatomy of the region changes and the necessary adjustment of the prosthetic appliance is neglected. Treatment is surgical and consists of excision of the hyperplasia. Surgical Technique. After local anesthesia, the lesion is grasped with surgical forceps and is gradually excised along the length of the lesion superficial to the underlying periosteum (Figs. 10.95, 10.96). After this procedure is complete, the portion of mucosa that has not been reflected, found at the margin of the lesion and which corresponds to the superior horizontal aspect of the incision, is sutured with the intact periosteum along its entire length, thus creating a void (Fig. 10.97). Reattachment of the wound margins is therefore avoided, which would otherwise result in elimination of the depth of the mucolabial vestibule. After the surgical procedure, and after being lined with a tissue conditioner, the denture is inserted into the mouth and is continuously worn until the day the sutures are removed (Fig. 10.98). Almost the same procedure is performed for smaller lesions that are the result of ill-fitting dentures (Figs. 10.99–10.106). Steps of Removal of Extensive Denture-Induced Fibrous Hyperplasia

Fig. 10.94 a, b. Extensive fibrous hyperplasia of the mucosa as a result of ill-fitting dentures. a Diagrammatic illustration. b Clinical photograph

Fig. 10.95 a, b. Removal of the lesion in segmentswith a scalpel. a Diagrammatic illustration. b Clinical photograph

Fig. 10.96 a, b. Final step in the removal of hyperplasia. a Diagrammatic illustration. b Clinical photograph

Fig. 10.97 a, b. Suturing of the woundmargins with periosteumthat has not been reflected, which remains exposed, avoiding a decrease in the depth of themucobuccal fold. a Diagrammatic illustration. b Clinical photograph

Fig. 10.98 a, b. Replacement of old denture, immediately after the end of the operation, retaining the depth of mucosa of the newly created sulcus. The internal surface of the denture is lined with tissue conditioner. a Diagrammatic illustration. b Clinical photograph

Removal of Localized Denture-Induced Hyperplasia

Fig. 10.99. Localized fibrous hyperplasia of mucosa as a result of ill-fitting denture

Fig. 10.100. Lesion of Fig. 10.99, after removal of denture

Fig. 10.101. Injection of local anesthetic peripherally around the lesion

Fig. 10.102. Gradual excision of hyperplasia with scalpel and scissors

Fig. 10.103. Surgical field after excision of lesion

Fig. 10.104. Suturing of superior lip of incision with periosteumthat has not been reflected, to avoid a decrease of the depth of the mucolabial fold

Fig. 10.105. Postoperative clinical photograph immediately after removal of

sutures

Fig. 10.106. Surgical specimen (hyperplasia) after excision

Fibrous Hyperplastic Retromolar Tuberosity Fibrous hyperplasia of the soft tissues of the alveolar process is reactive iature, usually observed in the retromolar edentulous area of the maxilla and is the result of constant irritation during mastication. Clinically, bilateral asymptomatic symmetric lesions with a smooth surface are noted, which are elastic and firm during palpation. Size varies and sometimes the lesion may grow to be so big that it occupies all of the interarch space during occlusion, creating serious problems for construction of a partial or complete denture (Fig. 10.107). Treatment is surgical and aims to decrease the size of the fibrous connective tissue lesion, thus recontouring the alveolar process. Surgical Technique. After administration of a local anesthetic, the portion of hyperplastic tissue to be excised is demarcated (Fig. 10.108). Two elliptic incisions are then made along the length of the fibrous hyperplasia, onebuccallyandtheotherpalatally(Figs. 10.109, 10.110). The extent of divergence of the incisions depends on the size of the lesion. That is, the larger the diameter of the hyperplastic lesion, the more the incisions must diverge. The incisions begin at the site of formation of hyperplastic tissue, and are wedgeshaped, with the scalpel proceeding until it touches bone (Figs. 10.111, 10.112). The elongated wedgeshaped portion of the hyperplasia is then removed and the periosteum is reflected buccally and palatally, in order to readapt the wound margins (Fig.10.113). Thereafter, the buccal and palatal parts are sutured at the midline of the alveolar ridge using a continuous suture (Figs. 10.114–10.116).

Fig. 10.107 a, b. Fibrous hyperplastic retromolar tuberosity of left maxilla. a Diagrammatic illustration. b Clinical photograph

Fig. 10.108 a, b. a Diagrammatic illustration and b clinical photograph showing demarcated segment of hyperplastic tissue to be removed

Fig. 10.109 a, b. Removal of lesion. a Diagrammatic illustration and b clinical photograph showing buccal incision

Fig. 10.110 a,b. Continuation of the incision of Fig. 10.109 towards the palatal side

Fig. 10.111 a, b. Gradual excision of the lesion with a wedge-shaped incision reaching as far as the bone. a Diagrammatic illustration. b Clinical photograph

Fig. 10.112 a, b. Surgical field after removal of hyperplastic tissue. a Diagrammatic illustration. b Clinical photograph

Fig. 10.113 a, b. Reflection of tissues with periosteum, so thatwound margins can be reapproximated and sutured

Fig. 10.114 a, b. Operation site after placement of sutures. a Diagrammatic illustration. b Clinical photograph

Fig. 10.115. Hyperplastic tissue segment after removal

Fig. 10.116. Postoperative clinical photograph 6months after the surgical procedure Papillary Hyperplasia of the Palate Papillary hyperplasia is a rare pathologic condition localized most often in the palate. It usually occurs in edentulous patients who have been wearing dentures for a long time and is possibly due to inflammatory hyperplasia of the mucosa because of chronic local irritation (Fig. 10.117 a). The lesion may present, to a limited extent, even in patients with dentition (Fig. 10.117 b). In such a case, etiological factors include mechanical and thermal irritation from foods, smoking, etc. Clinically, these are multifocal hyperplastic nodules of the mucosa of the palate, between which food may accumulate, potentiating the inflammatory reaction. Treatment is surgical and consists of removal of the lesionwith a scalpel or electrosurgical loop. Surgical Technique. Excision of the papillary hyperplasia is performed with the instrument in constant contact with the superficial mucosa (curettage with large surgical blade as far as the periosteum). An electrosurgical loop may also be used (Fig. 10.118), which is very effective in such cases. The traumatized area is coveredwithasurgical dressingandhealing isachieved by secondary intention (Fig. 10.119).

Fig. 10.117 a, b. Papillary hyperplasia of the palate. a Diagrammatic illustration of the lesion in an edentulous patient. b Clinical photograph in a patient with full dentition

Fig. 10.118 a, b. Diagrammatic illustrations showing removal of the lesion with an electrosurgical loop

Fig. 10.119 a,b. Diagrammatic illustrations showing the surgical field after removal of the lesion

Gingival Fibromatosis This is a benign condition, which is characterized by slow progressive swelling of the gingivae proper (attached gingivae) and alveolarmucosa (loose gingivae). The lesion may be generalized or localized and is due to hereditary or acquired causes. Clinically, gross hyperplasia of the gingivae is observed, which may partially or completely cover the crowns of the teeth, depending on the case. The surface of the gingivae is lobular, reddish, and firm to palpation, while the inflammation and bone resorption vary (Figs. 10.120, 10.121). Treatment is surgical and consists of segmental excision of the gingivae. Surgical Technique. After administration of a local anesthetic, the teeth presenting excessive mobility are removed. An incision is then made on the alveolar ridge and the hyperplastic gingivae are reflected buccally and lingually (Fig. 10.122). Excision of the lesion is performed in segments with beveling and is done very carefully, so that the mental and lingual nerves are not injured (Figs. 10.123, 10.124). The alveolar ridge is then smoothed and, after the woundmargins are reapproximated, interrupted sutures are placed (Figs. 10.125–10.127).