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Alveoloplasty—the oral surgeon's point of view
Exodontia Alveoloplasty-the oral surgeon’s point of view Irving
Meyer, D..Sf.D., JlSc., D.Rc.,* Springfield,
Mass.
A
lveolectomy has been defined as “the surgical removal of a portion of the alveolar process.“7 Alveoloplmty is a newer and better term, for, technically, alveolectomy would have us cut off the entire alveolus. ThornaG has stated that some form of alveoloplasty is indicated in nearly every instance of multiple extractions and frequently even in single extractions. Alveoloplasty, whether simple or extensive, is perhaps the most common surgical procedure used to prepare the jaws to receive a prosthesis. While performing extractions, whether of one or many teeth, the oral surgeon should at all times consider the bone and/or soft-tissue procedures needed to leave the mouth in the best possible condition for future prosthrtic replacement. Alveoloplasty often facilitates t,he construction of a better-fitting and more esthetically pleasing denture. Among the factors which the oral surgeon must consider in evaluating this procedure arc the patient’s desire for improvement in his or her dental appearance and the patient’s comfort in wearing the dental prosthesis, whether it is an immediate denture or one fabricated after a delay of 3 or 4 months. There are few things more painful than wearing a denture on a ridge with many sharp spicules or severe undercuts of bone. HISTORY
IIistoricall>~, alveolec*tomy (or alveoloplasty) has lIeen known for more than a century. In 1853 A. T. Willard of Chclsea, Massachusetts, “advocated reduction of the alveolar process in ord~~r to nc~romplish c+omplete approximation of soft tissues over the ridge.“’ In 1876 W. G. Bearce of Xontrcal, Canada, described what he called the of alvcolectomy to help h’ature remodel and reshape the “heroic treatment” dental arch.’ Part of a syuposium on alvroloplasty preswlt.ed at the forty-seventh the American Society of Oral Surgeons, I)envw, Cola., Nov. 3, 1965. ‘Associate Xeseareh Professor of Oral Pathologp, Tufts University Medicine.
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In 1905 W. Shearer’s 3 of Omaha, Nebraska, advocated and described alveolectomy as a procedure similar to the one carried out today. He employed alveolectomy to eliminate alveolar and gingival pathosis as well as to provide a base for the prosthodontist to construct a denture. In 1936 0. T. Dean4 in the Journal of the American Dental Association, described the “intra-septal alveolectomy.” An improvement of Dean’s procedure, with a description of its use for immediate dentures, was presented by Donald R. MaeKay at the forty-fourth annual meeting of the American Society of Oral Surgeons in 1962; this was published in the Journal of the American Dental Association in April, 1964. OBJECTIVES
AND
INDICATIONS
FOR ALVEOLECTOMY
The oral surgeon must start with the maxim that bone is precious and must not be wasted. Conservation of bone is most desirable, wherever and whenever possible. Bone is a living dynamic tissue. Osteoblastic and osteoclastic activity takes place in response to stimulation or stress, as the case may be. Different local situations will bring forth different reactions of the bone. For example, (1) loss of the opposing teeth of the mandible often results in elongation of opposite teeth of the maxilla with their surrounding alveolar bone, and vice versa; (2) atrophy of the alveolus occurs under a poorly fitting denture; (3) abnormal occlusal relationships of dentures often cause atrophy and loss of alveolar bone height as well as changes in the shape and function of the temporomandibular joints; and (4) periodontal destruction of alveolar bone results in marked abnormalities of the jaws. The primary purpose of the alveolar bone is to support the dental apparatus. This is not a static function, however, but rather a dynamic vital one. Following Wolff’s law of bone adaptation, alveolar bone remodels itself in response to each new situation of pressure. It will heal after dental extractions, and it will usually attempt to adapt itself to the general configuration of the rest of the alveolar arch, Alveolar cortical bone will re-form in approximately 3 months, more or less. Whether immediate dentures delay or enhance this reconstructive process has not been fully and scientifically demonstrated, although numerous papers on this subject have been presented. Systemic factors influence the alveolar bone. Generalized diseases, including diabetes, certain anemias (thalassemia) , Paget’s disease, fibrous dysplasia, syphilis, and hormonal dysfunctions, often present problems for the oral surgeon and the prosthodontist. Debilitation and alveolar atrophy, so often seen in the geriatric patient, are frequently difficult to manage. A major consideration is also whether or not, in view of his medical history, a patient can tolerate any extensive surgical procedure. Obviously, a seriously ill patient should be subjected to as little surgical intervention as possible. In view of the necessity of giving the prosthodontist the very best base possible for the retention of a denture, all surgical procedures must be planned in advance. Dental extractions must be done carefully so as to avoid either needless loss of bone by careless fracturing of the cortical plates or tearinp of the
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surrounding soft tissues. Often the judicious use of a surgical technique to remove a deeply rooted or ankylosed tooth will, in the long run, preserve bone; this is especially true with respect to removal of the multirooted maxillary molars where the tuberosity may easily be lost. In exodontia, skill is far more important than brawn. Soft-tissue surgical procedures should hc performed whenever they will help cithcr conserve bone by avoiding extensive alveoloplasty or make better use of the existing alveolar bone which may he diminished in quantity as a result of atrophy or long absence of teeth. There are a number of sound indications for alveoloplasty and soft-tissue surgical procedures in the preparation of the jaws for prostheses. These are as follows : 1. Single and multiple extractions with surrounding irregularities of the alveolar bone 2. Tori mandibulari and palatinus; exostoses; osteomas 3. Bulging or enlarged alveolar processes and tuberosities 4. Knifelike ridges or alveolar crest ; sharp edges 5. Anterior maxillary protrusion 6. Soft-tissue abnormalities A. Redundant, pendulous tissue; granuloma fissuratum B. Loss of depth of the mucobuccal or lingual sulcus C. High frenum of muscle attachments; scar tissue D. Fibromatosis of maxillary tuberosities or mandibular retromolar pad 7. Ankylosed teeth with loss of cortical plate or tuberosityfi, 7 Despite these indications for alveoloplasty, the oral surgeon’s judgment is and must be influenced by the desires and requirements of each prosthodontist with whom he is working. These requirements vary greatly from prosthodontist to prosthodontist. Some want a ridge that is absolutely smooth, with elimination of all undercuts, rolls, exostoses, and even the mylohyoid ridge; others want absolutely nothing done to the ridge after the dental extractions are completed. Where does the answer lie? Which one is correct? I believe that neither extreme is correct but that the correct procedure is somewhere in the middle. However, so long as the prosthodontists cannot decide among themselves just what is best., the oral surgeon must, adapt. the alvcoloplasty for each individual prosthodontist with whom he works. In a recent survey of many oral surgeons in Minnesota, 1)onald K. Mac.Kay” ohserved in surgery of St. I’aul asked what were the five most c'onuno~~ iaiiures for prosthetics. Their ansurers revealed the following : 1. Inadequate surgical preparation of the maxillary posterior tuberosity a.nd inadequate extension of t,hc denture periphery in the area 2. Faulty cast trimming by the laboratory; the prosthodontist should survey and trim his own impression casts in consultation with the oral surgeon 3. Inadequate periphery extension of the maxillary denture, particularly in the post-dam area
444
Jfcyer
4. Incomplete surgical preparation and extension t,he posterior lingual region of the mandible 5. Faulty bite registration
O.S., O.M. & O.P. October, 1966
of the denture
in
SURGICAL PROCEDURES Alveoloplasty
Simple alaeoZopZusty. The ideal situation is that in which the oral surgeon is able to limit himself to extracting the teeth, elevating the mucoperiosteum 1 or 2 mm., excising the sharp edges of alveolar occlusal bone, filing, and suturing the soft tissues back into position. Some cases lend themselves to this basic simple alveoloplasty procedure; when they do, all concerned (the oral surgeon, the prosthodontist, and, above all, the patient), are delighted. Radicab alveoloplasty. The radical alveoloplasty consists of extensive excision of alveolar bone and may be performed on either the alveolar ridge with teeth or the endentulous ridge. The radical alveoloplasty of the alveolus with teeth consists of extracting the teeth and carrying out the excision of bone. Some surgeons prefer to do the extractions first and then reflect the mucoperiosteum; others reflect the mucoperiosteum first, cut awa.y the heavy bone over the cuspids and molars to facilitate the extractions, and then extract the teeth. The latter believe that this procedure of first cutting away the heavy bone prevents fra,cture of the alveolar cortical bone and subsequently leads to conservation of bone. Generally, the mucoperiosteum should be elevated as conservatively as possible, certainly no further than the estimated level of the middle third of the root. This helps maintain the depth of the mucobuccal or labial sulcus. Where prominent protrusion of the anterior maxillary bone is present, the labial cortical alveolar plate is often excised with ronguers to a position decided upon in the preoperative planning. This permits the prosthodontist to give the patient a much better esthetic result (Fig. 1). Whether or not placing an immediate full maxillary denture over this area results in excessive loss of bone, as some authors claim, is a debatable question, which will be considered further in a discussion of immediate dentures. Excessive undercuts of the tuberosities are excised in the ra.dical alveoloplasty (Fig. 2). When there are bilateral tuberosity undercuts, frequently only one side need be excised and the prosthodontist can construct the denture so that it is inserted over the one undercut. He should instruct the patient in how to do this. When the buccal tuberosity bulges are excised, the cortical plate should be shaped vertically rather than slanted inwardly; this will give the denture greater stability. Although some prosthodontists prefer to leave both bulging tuberosities and end their flange periphery at the most outward level of the bony protuberance, most do not and want the undercuts removed. Exostoses and minor irregularities of the alveolar buccal bone are often troublesome and painful to the patient when dentures are placed on them. It is a simple surgical procedure to excise them with ronguers or with mallet and chisel. Torus palatinus and torus mandibularis are bone exostoses and should also
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Pig. 1. Proclosed bite.
Aheolopl.asty
and postoperative
Fi{ I. m. Pi Y’ - an tuber01 sities ‘. !I‘h ese tissues and ah ‘W 71opl
views
of patient
with
marked
maxillary
protrusion
445
and
ma xillary hit !d soft
be removed t,o aid in the fabrication of dentures. These massive csostoses arc of no value to the prosthodontist and should be removed by any of the wellknown surgical techniques (Figs. 3 and 4). Sharp, knifelike alveolar ridges often have to be rounded over because of pain caused when the denture presses down during mastication. Elimination of the mylohyoid ridge is rarely necessary. Occasionally, however, it will cause sufficient pain that it becomes necessary to remove it. The area is exposed through reflection of the lingual mucoperiostcum, after which
Fig. 3. Pre- and postoperative views of large torus palatinus treated 1)~ excision. was obtained by relaxing lateral incisions to permit sliding of palatal flaps containing blood vessels together in midline.
Fig. 4. Preoperative their removal.
and operative
views
showing
large
bilateral
tori
mandibulari
Closure palatal
and
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the mylohyoid muscle is stripped off and the ridge is excised with ronguers, chisels, or burs. The mucoperiosteum can be sutured along the crest, or deep lingual sutures can be placed through the mylohyoid muscle to the skin in order to maintain the newly created lingual sulcus depth. This and similar techniques have been described by Caldwell, Trauner, and others.“-I2 In rare instances in which the mandible has atrophied greatly, the genial tubercles of the mandible may present a pain problem. In such cases the tubercles are excised by the techniques described by Shea and Wolford’” and others. The alveolar ridge of the cdentulous mandible which has a marked roll of crestal bone producing a definite undercut is anot,her problem about which there are differences of opinion among prosthodontists. Some want the roll of crestal bone removed and an inverted U produced; others want the roll left intact and decry any attempt by the oral surgeon to eliminate the undercut. Again, this is a matter for the individual prosthodontist and oral surgeon to settle between themselves; it is not a major technical problem, and the surgeon can give the prosthodontist exactly what he wants. Radical alveoloplasty with the extraction of all teeth in the area should be performed when the mouth is being prepared for radiation therapy in the case of oral malignancy. This radical alveoloplasty consists of excising the interdental and interradicular septa and smoothing all sharp edges of cortical bone in order to leave an absolutely smooth alveolar ridge. If t.he septa are not removed, they may eventually pierce through the overlying mucoperiosteum and act as a starting focus for the development of osteoradionecrosis (Fig. 5). With the advent of cobalt-60 and the other megavoltage modalities of radiation therapy, these requirements of radical alvcwloplasty seem to be less stringent. However, we have not as yet accumulated a sufficient number of cases to make a categorical statement to this effect. The fabrication of dentures should be delayed for at least 6 months, and preferably even longer, in these patients who rcquirc radiat.ion t,reatment.l* Intraseptal cdzwjloplasty or ah*eolotomy. The technique of intraseptal alveolotomy provides for the reduction of prominent undercuts or the reduction of a prominent. premaxilla without loss of the labial or buccal cortical plate. When the technique is employed in the anterior maxilla, the cortical plate extending from the cuspid-premolar area of one side to the same position on the other becomes a tension-free onlay bone graft. This is done by first reflecting the mnc~operiostruln and extraat.ing the terth and then excising the interdental septa to their very depth wi-ith rongeur forcel)s. A V-shaped wedge is cut in the premolar or cuspid buccal cortical bone on each side. A small chisel is introduced to the depth of each socket, and the labial cortical bone is cracked from within the socket; this permits the large cortical fragment to be pushed toward the palate by squeezing it between the thumb and first finger. Forcible reduction of this anterior external cortical plate without separating it from the remainder of the boric with a chisel through the socket will often result in its springing back to its original position, causing a pressure necrosis of the bone with sloughing of the soft tissues.5
448
O.S., O.M. & O.P. October, 1966
Meye
EXTRACTED TEETH OF MAXILLA TO CWPID
REFLECTIOtd Of .“CaL UICOPERIOETEUM
B NAWDISLE
TO MIDLINE
D
C SUTURED
AFTERRouGE”RO~O
/
T.L.‘“F
f(LLr*T-
views Fig. 5. Diagrammatic nation of interdental septa.
demonstrating
preradiation
radical
alveolectomy
with
elimi-
The amount of maxillary alveolar bone lost beneath immediate full dentures in the radical labial alveoloplasty and in the intraseptal alveoloplasty was studied in ten patients by Gazabatt and associates.15 Intraseptal alveolotomy was performed on one side of the arch and labial alveolectomy was performed on the other; impressions were made at intervals up to 13 months, and the changes between the sides were recorded. The studies indicated that the intraseptal alveolotomy procedure showed a slight advantage over the labial alveoloplasty procedure. Since the series included only ten patients, however, the findings are not conclusive. Secondary alveoloplasty. Many oral surgeons prefer to perform a secondary alveoloplasty several weeks after the teeth have been removed. This technique helps to conserve alveolar bone, especially in the lower jaw. The procedure consists of reflecting the alveolar mucosa and excising any residual sharp edges or undercuts. It has the distinct disadvantage of subjecting the patient to a second surgical procedure, to which many patients strenuously object. Soft-tissue
surgery
An evaluation of alveoloplasty must include mention of some of the softtissue techniques which are used either in conjunction with bone surgery or alone. Ridge extension. Kazanjian’s ridge extension technique is well known and quite effective (Fig. 6). It has been modified in its various technical aspects by different surgeons. In general, the mucosa is taken from either the labial-
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A
B
Pig. 6. A, Preoperative views of gxtensive granuloma fissuratum and hyperplasia alveolar soft tissues. B, Postoperative view following excision of redundant soft tissues ridge extension employing technique of Kazanjian.
of and
buccal areas or from the alveolus, depending on which technique is followed, and is repositioned to give a new sulcus depth. It is maintained in position by means of a rubber tube or stent sutured into the sulcus. Modifications of this technique include circumferential wiring of a lower denture with the flanges cxt,ended by dental compound or periodontal pack to the mandible. A maxillary splint can be wired to the zygomatic arches, but often it can be maintained in position with just the use of dent,ure adhesive. These splints, which can be lined with a,ny of the accepted surgical packs of tissue conditioners, are kept in place for 10 to 14 days. In mandibular ridge extension the mental foramen is frequently the limit.ing margin of the ridge extension, but in certain cases the opening may be lowered by careful use of a bone bur (Fig. 7). Alt,hough placing a skin graft on a newly crcat,ed sulcus is advocated by some ( Obwegcser”S and others), 1 do not, believe that this is generally necessary, inasmuch as epithclization will follow the margins as outlined and maintained by the surgical splint. in approximately 2 weeks. Ridge extensions for the lingual area of the mandible have been described by Trauner, ‘0 ~‘aldwrll ‘J and othersl’~ I6 and consist essentially of transferring t,he attachments of the’mylohyoid muscle to a lower position along the lingual inferior border of the mandible. This technique has limited use, and it does expose tile floor of the mouth and its spaces to postoperative sequelae. Redur&ant or pendulous tbsue; g~mndoma~ fissurntu.m. The redundant, multiple folds of heavy granulation tissue so often seen in the sulcus of both the maxilla and the mandible pose a problem for the oral surgeon and the
450
Me?/t?,
O.S., O.M. & O.P. October, 1966
A
c
D
E
G
Fig. 7. A to D, Preoperative, operative, and postoperative views of redundant maxillary alveolar soft tissues. C illustrates use of old denture with its flanges extended with dental compound and surgical pack. E to Z, Preoperative, operative, and postoperative views of redundant mandibular alveolar soft tissues. G illustrates circumferential wiring of old denture to mandible; here also flanges are extended with compound and surgical pack.
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prosthodont.ist. When t,hese are excised, there is often a loss of sulcus height; the use of the old denture with its flanges built up as a splint will help preserve t,he sulcus and often extend it to a greater depth (Fig. 7). Electrosurgery has also proved helpful in removing these masses of redundant tissue. This technique has the advantage of providing hemostasis, but it also has the dissiivantage of causing an unpleasant odor plus, occasionally, a pa.inful postoperative ronrsc associated with necrotic burnt tissue or exposed bone (Fig. 8).
d
Fig. 8. A and I?, Pre- and postoperative views of excision of extensive granuloma fissuratum by electrosurgical technique. G’ shows surgical specimen. Old denture, with its flanges built up with compound and surgical pack, was used as splint to preserve new depth of sulcus. D shows a 3 weeks’ postoperative view; tab of recurrent granulation tissue of right sulcus was re-excised with cautcry just prior to starting impressions for new denture.
Fig. 9. Clinical photograph of massive palafal and tuberosity hyperplasia This \vas treated surgically by extensive alveolectomy and submucous resection
and exostosis. of soft tissues.
452
O.S., O.M. & O.P. October, 1966
Meyer
Fibromafosir of the tubewsity CLII~ r&onzoler pads. Submucous resection of the heavy, pendulous fibromatous mass of the maxillary tubcrosity or retromolar pad of the mandible has been described by Thorns” and others. This procedure consists of excising the underlying heavy fibrous tissue but leaving the surface epithelium intact (Fig. 9), and it is often combined with excision of a concomitant bone bulge, so that both the undercut and the pendulous mass are removed at the same time. PROSTHETIC
CONSIDERATIONS
The oral surgeon must know and appreciate the problems of the prosthodentist.. We must have knowledge of both the newer techniques and the materials used in prosthetic dentistry. Often our training programs are deficient in teaching students alveoloplasty and soft-tissue techniques. Perhaps a year or two in general dentistry, or a rotating internship, would be helpful in teaching the trainee the procedures needed for prosthodontics. Immediate
dentures
There are several approaches to the insertion of immediate dentures. The classic technique is to extract the posterior teeth, allow the ridges to heal, and then insert the immediate denture at the time the remaining six anterior teet.h are extracted. There are variations of this procedure. Some dentists prefer to have all the teeth of both jaws removed and immediate dentures inserted in both jaws at the same sitting. Although it seems that this should be extremely painful, it is surprising how well the patients tolerate it (Fig. 10). Some prosthodontists have found the new soft acrylics which become pliable in ordina,ry hot tap water of immeasurable help in their immediate dentures; others would not consider using this material under any circumstances. Some prefer to make the immediate denture without a labial flange and butt the teeth directly into the sockets. Others leave the labial flange off but employ a thin hornlike extension from the flange margins in the cuspid areas of each side; these horns rest high in the labial sulcus and aid in retention of these open-faced dentures. Heartwell and Salisbury17 have listed the advantages of the immediate denture as follows : 1. The immediate denture acts as a splint to control bleeding. 2. The immediate denture promotes healing by protecting the exposed sockets. 3. The patient with an immediate denture does better in speech, deglutition, and mastication than the patient who is without a denture for even a short period of time. 4. The patient more readily accepts extraction of diseased teeth. 5. The patient can continue in business. 6. Psychologically, the patients are happier. These authors also recommend careful evaluation of the following advantages : 1. The vertical dimension is retained.
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C
Z;ii/. 10. A and II, PIP- and postoperative views of extraction of all mnsilhy teeth and insrrtion of denture. (‘, taken 5 days post,operatively, shows maxillary ridge following suture I? moval.
2. Teeth in the immediate denture can be placed in the same posit,ion as the natural denture. 3. Rone is contonred by the immediate denture. This latter point has been qnestioned by some inwstigatuw, who believe that osteoclastic activity is greater in unhealed l)one and that pressure changes of the immediate denture map cause too great a resorption of bone.2u‘C3 The prosthodontist ean help tilt? 0l2t.C SLll+W~l I)lY+pMl’t’ llie Jjiiticiii ‘S ja?TX for the immrdiate denture by sending along surgical guides. These include :I cdlra,r acrylic surgical tray, stone models of t,he patient (both before a11cl after or vcl*bal the reqursted surgical pracedurc) , and, above all, (lither written directions (preferably written). Implants,
magnets,
and
grafts
Implants, magnets, and bone grafts are some of t,he news approaches to the problem of making prostheses for patients who have had repeated denture
454
O.S.,O.M.&O.P. October, 1966
Mege?
failures for one reason or another. The most common cause of failure in these patients is the atrophic, thin, edentulous mandible. Implant dentures, although fairly successful in some patients, have not as yet proved universally satisfactory. Obwegeser’ reported that of thirty-five implants inserted in thirty-three patients, two-thirds had definite complications after 1 to 3 years. Others have reported similar poor results, but still others have claimed great success for this method. In our practice the implant denture has not proved successful. We believe that this lack of success is due to the seepage and infection around the posts, because the tissue obviously cannot attach to the metal. Behrman2” has discussed the successful use of magnets in denture retention in a large series of patients; others have not been able to duplicate his good results. We have not had any experience with this technique. Bone grafts, using either the patient’s own crest of ilium, bank bone, or freeze-dried bone, have not worked out too well so far. These grafts, though meticulously handled and placed generally have not fared well beneath the dentures but have resorbed. Several successful cases hare been reported, but there is necessity for further investigation in this field. Obwegeser?” has recently demonstrated excellent results employing autogenous bone grafts of both crest of ilium and ribs. SUMMARY
AND
CONCLUSION
In this article the problems of alveoloplasty have been presented from the oral surgeon’s point of view. In essence, the oral surgeon has at his disposal many surgical techniques based on sound principles. However, he must depend on the prosthodontist’s directions to determine exactly what has to be done. Until such time as the prosthodontists have somewhat standardized their techniques, and as long as there is variation among patients, the oral surgeon’s relationship to the prosthodontist must continue to be on an individual basis. REFERENCES
1. Hayward, J. R., and Thompson, S.: Principles 1958. 2. Shearer, W. L.: History of Alveolectomy and of Pathological Condition of the Jaws, Chron. 1950. 3. Shearer, W. L.: Alveolectomy, Chron. Omaha D. for the Denture Patient, 4. Dean, D. T.: Surgery 5. MaeKay, D. R.: Intraseptal Alveolectomy for 68: 549, 1964. ed. 3, St. Louis, 6. iigy;4; K. H.: Oral Surgery, 7. 8. 9. 10.
of Alveoleetomy,
J. Oral
Surg. 16: 101,
Partial Alveolectomy and Management Omaha D. Sot. 13: 127, 129-135, 146, Sot. 16: 247-252, 1953. J. Am. Dent. A. 23: 2124, 1936. Immediate Dentures, J. Am. Dent. 1955, The C. V. Mosby
Company,
A. pp.
Goodsell, J. 0.: Surgical Aids to Intraoral Prosthesis, J. Oral Surg. 13: 8, 1955. MacKay, D. R.: Personal Communication. Caldwell, J. S.: Lingual Ridge Extension, J. Oral Surg. 13: 287, 1955. Trauner, 11.: slveoloplasty With Ridge Extensions on the Lingnal Side of the Lower Jaw to Solve the Problem of a Lower Dental Prosthesis, ORAL SUFG., ORAL MED. & ORAL PATH.~: 340,1952. 11. Goodsell, J. O., and Morin, G. E.: Abnormalities of the Mouth. In Kruger, G. 0.: Textbook of Oral Surgery, St. Louis, 1959, The C. V. Mosby Company, Chap. 6, pp. 121-145. 12. Kruger, G. 0. : Ridge Extension: Review of Indications and Technics, J. Oral Sure;. 16: 191, 1958.
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13. Shea, C. R., and Wolford, D. R.: Removal of Genial Tubercle for Prosthesis, ORAL SURG., ORAL MED. & ORAL PATH. 8: 1044, 1955. 14. Xiyer, I.: Osteoradionecrosis of the Jaws, Chicago, 1958, The Yearbook Publishers, 15. Gazabatt, C., Parra, N., and Meissner, E.: A Comparison of Bone Resorption Following Intraseptal Alveolotomy and Labial Alreolectomy, J. Pros. Dent. 15: 435, 1965. 16. Molt, F. F.: Surgical Preparation of the Mouth, J. Oral Surg. 7: 20, 1949. li. Heartwell, D. M., Jr., and Sali;bury, F. I\‘.: Tmmediate Complete Dentures; an Evaluationl ,T. Pros. Dent. 15: 615. 1965. 18. Schlosser. It. D.: (Conservative Procedures in Complete 1)enture Prosthesis, Northwest. l?niv. Hull. 40: 3, 1940. 19. I,isoa-ski, 0. R.: A Comparative Stud\- of the Resorption of Alveolar Ridge Tissue Ender Immediate Dentures, Northwest. ‘Univ. Rull. 45: il, 1945. 20. Simpson, H. E.: Experimental Investigation Into the Healing of Extraction Wounds in Ma.caous rhesus Monkeys, J. Oral Surg., Anesth. & Hosp. I>. Serv. 18: 391, 1960. 21. Simpson, II. E., Healing of Surgic.al Extraction \Vounds in Xecaczls rhesus Monkeys, J. Oral Hurg., Anesth. & Hosp. I). Serv. 19: 3-9, 277.231, 1961. 22. ~vO,:““,$~;‘. R.: Clinical Study of R epair of Bone After Alveolectomy, J. Oral Surg. r 23. Simp)son, H. E.: Effects of Suturing Extraction ‘\\‘ounds in Jfacac~s rl~s::s Monkeys, J. Oral Surg., Anesth. & Hosp. I). Serv. 18: 461, 1960. 24. Obwegeser, H. I,.: Experiences \Vith Subperiosteal Implants, ORAL Suao., ORAL MED. & ORAL PATH. 12: 777. 1959. 25. Obwegeser, H. L. : Conference on “Comprehensive Oral Surgery,” held at Walter Reed Army Medical Center, Washington, D. C., June 20-22, 1966. 26. Behrman, S. : Personal communication. 40 Maple St.
Meyer, D..Sf.D., JlSc., D.Rc.,* Springfield,
Mass.
A
lveolectomy has been defined as “the surgical removal of a portion of the alveolar process.“7 Alveoloplmty is a newer and better term, for, technically, alveolectomy would have us cut off the entire alveolus. ThornaG has stated that some form of alveoloplasty is indicated in nearly every instance of multiple extractions and frequently even in single extractions. Alveoloplasty, whether simple or extensive, is perhaps the most common surgical procedure used to prepare the jaws to receive a prosthesis. While performing extractions, whether of one or many teeth, the oral surgeon should at all times consider the bone and/or soft-tissue procedures needed to leave the mouth in the best possible condition for future prosthrtic replacement. Alveoloplasty often facilitates t,he construction of a better-fitting and more esthetically pleasing denture. Among the factors which the oral surgeon must consider in evaluating this procedure arc the patient’s desire for improvement in his or her dental appearance and the patient’s comfort in wearing the dental prosthesis, whether it is an immediate denture or one fabricated after a delay of 3 or 4 months. There are few things more painful than wearing a denture on a ridge with many sharp spicules or severe undercuts of bone. HISTORY
IIistoricall>~, alveolec*tomy (or alveoloplasty) has lIeen known for more than a century. In 1853 A. T. Willard of Chclsea, Massachusetts, “advocated reduction of the alveolar process in ord~~r to nc~romplish c+omplete approximation of soft tissues over the ridge.“’ In 1876 W. G. Bearce of Xontrcal, Canada, described what he called the of alvcolectomy to help h’ature remodel and reshape the “heroic treatment” dental arch.’ Part of a syuposium on alvroloplasty preswlt.ed at the forty-seventh the American Society of Oral Surgeons, I)envw, Cola., Nov. 3, 1965. ‘Associate Xeseareh Professor of Oral Pathologp, Tufts University Medicine.
annual School
meeting of
of
Dental
441
OS., O.M. & O.P. October, 1966
In 1905 W. Shearer’s 3 of Omaha, Nebraska, advocated and described alveolectomy as a procedure similar to the one carried out today. He employed alveolectomy to eliminate alveolar and gingival pathosis as well as to provide a base for the prosthodontist to construct a denture. In 1936 0. T. Dean4 in the Journal of the American Dental Association, described the “intra-septal alveolectomy.” An improvement of Dean’s procedure, with a description of its use for immediate dentures, was presented by Donald R. MaeKay at the forty-fourth annual meeting of the American Society of Oral Surgeons in 1962; this was published in the Journal of the American Dental Association in April, 1964. OBJECTIVES
AND
INDICATIONS
FOR ALVEOLECTOMY
The oral surgeon must start with the maxim that bone is precious and must not be wasted. Conservation of bone is most desirable, wherever and whenever possible. Bone is a living dynamic tissue. Osteoblastic and osteoclastic activity takes place in response to stimulation or stress, as the case may be. Different local situations will bring forth different reactions of the bone. For example, (1) loss of the opposing teeth of the mandible often results in elongation of opposite teeth of the maxilla with their surrounding alveolar bone, and vice versa; (2) atrophy of the alveolus occurs under a poorly fitting denture; (3) abnormal occlusal relationships of dentures often cause atrophy and loss of alveolar bone height as well as changes in the shape and function of the temporomandibular joints; and (4) periodontal destruction of alveolar bone results in marked abnormalities of the jaws. The primary purpose of the alveolar bone is to support the dental apparatus. This is not a static function, however, but rather a dynamic vital one. Following Wolff’s law of bone adaptation, alveolar bone remodels itself in response to each new situation of pressure. It will heal after dental extractions, and it will usually attempt to adapt itself to the general configuration of the rest of the alveolar arch, Alveolar cortical bone will re-form in approximately 3 months, more or less. Whether immediate dentures delay or enhance this reconstructive process has not been fully and scientifically demonstrated, although numerous papers on this subject have been presented. Systemic factors influence the alveolar bone. Generalized diseases, including diabetes, certain anemias (thalassemia) , Paget’s disease, fibrous dysplasia, syphilis, and hormonal dysfunctions, often present problems for the oral surgeon and the prosthodontist. Debilitation and alveolar atrophy, so often seen in the geriatric patient, are frequently difficult to manage. A major consideration is also whether or not, in view of his medical history, a patient can tolerate any extensive surgical procedure. Obviously, a seriously ill patient should be subjected to as little surgical intervention as possible. In view of the necessity of giving the prosthodontist the very best base possible for the retention of a denture, all surgical procedures must be planned in advance. Dental extractions must be done carefully so as to avoid either needless loss of bone by careless fracturing of the cortical plates or tearinp of the
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surrounding soft tissues. Often the judicious use of a surgical technique to remove a deeply rooted or ankylosed tooth will, in the long run, preserve bone; this is especially true with respect to removal of the multirooted maxillary molars where the tuberosity may easily be lost. In exodontia, skill is far more important than brawn. Soft-tissue surgical procedures should hc performed whenever they will help cithcr conserve bone by avoiding extensive alveoloplasty or make better use of the existing alveolar bone which may he diminished in quantity as a result of atrophy or long absence of teeth. There are a number of sound indications for alveoloplasty and soft-tissue surgical procedures in the preparation of the jaws for prostheses. These are as follows : 1. Single and multiple extractions with surrounding irregularities of the alveolar bone 2. Tori mandibulari and palatinus; exostoses; osteomas 3. Bulging or enlarged alveolar processes and tuberosities 4. Knifelike ridges or alveolar crest ; sharp edges 5. Anterior maxillary protrusion 6. Soft-tissue abnormalities A. Redundant, pendulous tissue; granuloma fissuratum B. Loss of depth of the mucobuccal or lingual sulcus C. High frenum of muscle attachments; scar tissue D. Fibromatosis of maxillary tuberosities or mandibular retromolar pad 7. Ankylosed teeth with loss of cortical plate or tuberosityfi, 7 Despite these indications for alveoloplasty, the oral surgeon’s judgment is and must be influenced by the desires and requirements of each prosthodontist with whom he is working. These requirements vary greatly from prosthodontist to prosthodontist. Some want a ridge that is absolutely smooth, with elimination of all undercuts, rolls, exostoses, and even the mylohyoid ridge; others want absolutely nothing done to the ridge after the dental extractions are completed. Where does the answer lie? Which one is correct? I believe that neither extreme is correct but that the correct procedure is somewhere in the middle. However, so long as the prosthodontists cannot decide among themselves just what is best., the oral surgeon must, adapt. the alvcoloplasty for each individual prosthodontist with whom he works. In a recent survey of many oral surgeons in Minnesota, 1)onald K. Mac.Kay” ohserved in surgery of St. I’aul asked what were the five most c'onuno~~ iaiiures for prosthetics. Their ansurers revealed the following : 1. Inadequate surgical preparation of the maxillary posterior tuberosity a.nd inadequate extension of t,hc denture periphery in the area 2. Faulty cast trimming by the laboratory; the prosthodontist should survey and trim his own impression casts in consultation with the oral surgeon 3. Inadequate periphery extension of the maxillary denture, particularly in the post-dam area
444
Jfcyer
4. Incomplete surgical preparation and extension t,he posterior lingual region of the mandible 5. Faulty bite registration
O.S., O.M. & O.P. October, 1966
of the denture
in
SURGICAL PROCEDURES Alveoloplasty
Simple alaeoZopZusty. The ideal situation is that in which the oral surgeon is able to limit himself to extracting the teeth, elevating the mucoperiosteum 1 or 2 mm., excising the sharp edges of alveolar occlusal bone, filing, and suturing the soft tissues back into position. Some cases lend themselves to this basic simple alveoloplasty procedure; when they do, all concerned (the oral surgeon, the prosthodontist, and, above all, the patient), are delighted. Radicab alveoloplasty. The radical alveoloplasty consists of extensive excision of alveolar bone and may be performed on either the alveolar ridge with teeth or the endentulous ridge. The radical alveoloplasty of the alveolus with teeth consists of extracting the teeth and carrying out the excision of bone. Some surgeons prefer to do the extractions first and then reflect the mucoperiosteum; others reflect the mucoperiosteum first, cut awa.y the heavy bone over the cuspids and molars to facilitate the extractions, and then extract the teeth. The latter believe that this procedure of first cutting away the heavy bone prevents fra,cture of the alveolar cortical bone and subsequently leads to conservation of bone. Generally, the mucoperiosteum should be elevated as conservatively as possible, certainly no further than the estimated level of the middle third of the root. This helps maintain the depth of the mucobuccal or labial sulcus. Where prominent protrusion of the anterior maxillary bone is present, the labial cortical alveolar plate is often excised with ronguers to a position decided upon in the preoperative planning. This permits the prosthodontist to give the patient a much better esthetic result (Fig. 1). Whether or not placing an immediate full maxillary denture over this area results in excessive loss of bone, as some authors claim, is a debatable question, which will be considered further in a discussion of immediate dentures. Excessive undercuts of the tuberosities are excised in the ra.dical alveoloplasty (Fig. 2). When there are bilateral tuberosity undercuts, frequently only one side need be excised and the prosthodontist can construct the denture so that it is inserted over the one undercut. He should instruct the patient in how to do this. When the buccal tuberosity bulges are excised, the cortical plate should be shaped vertically rather than slanted inwardly; this will give the denture greater stability. Although some prosthodontists prefer to leave both bulging tuberosities and end their flange periphery at the most outward level of the bony protuberance, most do not and want the undercuts removed. Exostoses and minor irregularities of the alveolar buccal bone are often troublesome and painful to the patient when dentures are placed on them. It is a simple surgical procedure to excise them with ronguers or with mallet and chisel. Torus palatinus and torus mandibularis are bone exostoses and should also
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Pig. 1. Proclosed bite.
Aheolopl.asty
and postoperative
Fi{ I. m. Pi Y’ - an tuber01 sities ‘. !I‘h ese tissues and ah ‘W 71opl
views
of patient
with
marked
maxillary
protrusion
445
and
ma xillary hit !d soft
be removed t,o aid in the fabrication of dentures. These massive csostoses arc of no value to the prosthodontist and should be removed by any of the wellknown surgical techniques (Figs. 3 and 4). Sharp, knifelike alveolar ridges often have to be rounded over because of pain caused when the denture presses down during mastication. Elimination of the mylohyoid ridge is rarely necessary. Occasionally, however, it will cause sufficient pain that it becomes necessary to remove it. The area is exposed through reflection of the lingual mucoperiostcum, after which
Fig. 3. Pre- and postoperative views of large torus palatinus treated 1)~ excision. was obtained by relaxing lateral incisions to permit sliding of palatal flaps containing blood vessels together in midline.
Fig. 4. Preoperative their removal.
and operative
views
showing
large
bilateral
tori
mandibulari
Closure palatal
and
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the mylohyoid muscle is stripped off and the ridge is excised with ronguers, chisels, or burs. The mucoperiosteum can be sutured along the crest, or deep lingual sutures can be placed through the mylohyoid muscle to the skin in order to maintain the newly created lingual sulcus depth. This and similar techniques have been described by Caldwell, Trauner, and others.“-I2 In rare instances in which the mandible has atrophied greatly, the genial tubercles of the mandible may present a pain problem. In such cases the tubercles are excised by the techniques described by Shea and Wolford’” and others. The alveolar ridge of the cdentulous mandible which has a marked roll of crestal bone producing a definite undercut is anot,her problem about which there are differences of opinion among prosthodontists. Some want the roll of crestal bone removed and an inverted U produced; others want the roll left intact and decry any attempt by the oral surgeon to eliminate the undercut. Again, this is a matter for the individual prosthodontist and oral surgeon to settle between themselves; it is not a major technical problem, and the surgeon can give the prosthodontist exactly what he wants. Radical alveoloplasty with the extraction of all teeth in the area should be performed when the mouth is being prepared for radiation therapy in the case of oral malignancy. This radical alveoloplasty consists of excising the interdental and interradicular septa and smoothing all sharp edges of cortical bone in order to leave an absolutely smooth alveolar ridge. If t.he septa are not removed, they may eventually pierce through the overlying mucoperiosteum and act as a starting focus for the development of osteoradionecrosis (Fig. 5). With the advent of cobalt-60 and the other megavoltage modalities of radiation therapy, these requirements of radical alvcwloplasty seem to be less stringent. However, we have not as yet accumulated a sufficient number of cases to make a categorical statement to this effect. The fabrication of dentures should be delayed for at least 6 months, and preferably even longer, in these patients who rcquirc radiat.ion t,reatment.l* Intraseptal cdzwjloplasty or ah*eolotomy. The technique of intraseptal alveolotomy provides for the reduction of prominent undercuts or the reduction of a prominent. premaxilla without loss of the labial or buccal cortical plate. When the technique is employed in the anterior maxilla, the cortical plate extending from the cuspid-premolar area of one side to the same position on the other becomes a tension-free onlay bone graft. This is done by first reflecting the mnc~operiostruln and extraat.ing the terth and then excising the interdental septa to their very depth wi-ith rongeur forcel)s. A V-shaped wedge is cut in the premolar or cuspid buccal cortical bone on each side. A small chisel is introduced to the depth of each socket, and the labial cortical bone is cracked from within the socket; this permits the large cortical fragment to be pushed toward the palate by squeezing it between the thumb and first finger. Forcible reduction of this anterior external cortical plate without separating it from the remainder of the boric with a chisel through the socket will often result in its springing back to its original position, causing a pressure necrosis of the bone with sloughing of the soft tissues.5
448
O.S., O.M. & O.P. October, 1966
Meye
EXTRACTED TEETH OF MAXILLA TO CWPID
REFLECTIOtd Of .“CaL UICOPERIOETEUM
B NAWDISLE
TO MIDLINE
D
C SUTURED
AFTERRouGE”RO~O
/
T.L.‘“F
f(LLr*T-
views Fig. 5. Diagrammatic nation of interdental septa.
demonstrating
preradiation
radical
alveolectomy
with
elimi-
The amount of maxillary alveolar bone lost beneath immediate full dentures in the radical labial alveoloplasty and in the intraseptal alveoloplasty was studied in ten patients by Gazabatt and associates.15 Intraseptal alveolotomy was performed on one side of the arch and labial alveolectomy was performed on the other; impressions were made at intervals up to 13 months, and the changes between the sides were recorded. The studies indicated that the intraseptal alveolotomy procedure showed a slight advantage over the labial alveoloplasty procedure. Since the series included only ten patients, however, the findings are not conclusive. Secondary alveoloplasty. Many oral surgeons prefer to perform a secondary alveoloplasty several weeks after the teeth have been removed. This technique helps to conserve alveolar bone, especially in the lower jaw. The procedure consists of reflecting the alveolar mucosa and excising any residual sharp edges or undercuts. It has the distinct disadvantage of subjecting the patient to a second surgical procedure, to which many patients strenuously object. Soft-tissue
surgery
An evaluation of alveoloplasty must include mention of some of the softtissue techniques which are used either in conjunction with bone surgery or alone. Ridge extension. Kazanjian’s ridge extension technique is well known and quite effective (Fig. 6). It has been modified in its various technical aspects by different surgeons. In general, the mucosa is taken from either the labial-
Volume Number
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Alveoloplasty
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A
B
Pig. 6. A, Preoperative views of gxtensive granuloma fissuratum and hyperplasia alveolar soft tissues. B, Postoperative view following excision of redundant soft tissues ridge extension employing technique of Kazanjian.
of and
buccal areas or from the alveolus, depending on which technique is followed, and is repositioned to give a new sulcus depth. It is maintained in position by means of a rubber tube or stent sutured into the sulcus. Modifications of this technique include circumferential wiring of a lower denture with the flanges cxt,ended by dental compound or periodontal pack to the mandible. A maxillary splint can be wired to the zygomatic arches, but often it can be maintained in position with just the use of dent,ure adhesive. These splints, which can be lined with a,ny of the accepted surgical packs of tissue conditioners, are kept in place for 10 to 14 days. In mandibular ridge extension the mental foramen is frequently the limit.ing margin of the ridge extension, but in certain cases the opening may be lowered by careful use of a bone bur (Fig. 7). Alt,hough placing a skin graft on a newly crcat,ed sulcus is advocated by some ( Obwegcser”S and others), 1 do not, believe that this is generally necessary, inasmuch as epithclization will follow the margins as outlined and maintained by the surgical splint. in approximately 2 weeks. Ridge extensions for the lingual area of the mandible have been described by Trauner, ‘0 ~‘aldwrll ‘J and othersl’~ I6 and consist essentially of transferring t,he attachments of the’mylohyoid muscle to a lower position along the lingual inferior border of the mandible. This technique has limited use, and it does expose tile floor of the mouth and its spaces to postoperative sequelae. Redur&ant or pendulous tbsue; g~mndoma~ fissurntu.m. The redundant, multiple folds of heavy granulation tissue so often seen in the sulcus of both the maxilla and the mandible pose a problem for the oral surgeon and the
450
Me?/t?,
O.S., O.M. & O.P. October, 1966
A
c
D
E
G
Fig. 7. A to D, Preoperative, operative, and postoperative views of redundant maxillary alveolar soft tissues. C illustrates use of old denture with its flanges extended with dental compound and surgical pack. E to Z, Preoperative, operative, and postoperative views of redundant mandibular alveolar soft tissues. G illustrates circumferential wiring of old denture to mandible; here also flanges are extended with compound and surgical pack.
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prosthodont.ist. When t,hese are excised, there is often a loss of sulcus height; the use of the old denture with its flanges built up as a splint will help preserve t,he sulcus and often extend it to a greater depth (Fig. 7). Electrosurgery has also proved helpful in removing these masses of redundant tissue. This technique has the advantage of providing hemostasis, but it also has the dissiivantage of causing an unpleasant odor plus, occasionally, a pa.inful postoperative ronrsc associated with necrotic burnt tissue or exposed bone (Fig. 8).
d
Fig. 8. A and I?, Pre- and postoperative views of excision of extensive granuloma fissuratum by electrosurgical technique. G’ shows surgical specimen. Old denture, with its flanges built up with compound and surgical pack, was used as splint to preserve new depth of sulcus. D shows a 3 weeks’ postoperative view; tab of recurrent granulation tissue of right sulcus was re-excised with cautcry just prior to starting impressions for new denture.
Fig. 9. Clinical photograph of massive palafal and tuberosity hyperplasia This \vas treated surgically by extensive alveolectomy and submucous resection
and exostosis. of soft tissues.
452
O.S., O.M. & O.P. October, 1966
Meyer
Fibromafosir of the tubewsity CLII~ r&onzoler pads. Submucous resection of the heavy, pendulous fibromatous mass of the maxillary tubcrosity or retromolar pad of the mandible has been described by Thorns” and others. This procedure consists of excising the underlying heavy fibrous tissue but leaving the surface epithelium intact (Fig. 9), and it is often combined with excision of a concomitant bone bulge, so that both the undercut and the pendulous mass are removed at the same time. PROSTHETIC
CONSIDERATIONS
The oral surgeon must know and appreciate the problems of the prosthodentist.. We must have knowledge of both the newer techniques and the materials used in prosthetic dentistry. Often our training programs are deficient in teaching students alveoloplasty and soft-tissue techniques. Perhaps a year or two in general dentistry, or a rotating internship, would be helpful in teaching the trainee the procedures needed for prosthodontics. Immediate
dentures
There are several approaches to the insertion of immediate dentures. The classic technique is to extract the posterior teeth, allow the ridges to heal, and then insert the immediate denture at the time the remaining six anterior teet.h are extracted. There are variations of this procedure. Some dentists prefer to have all the teeth of both jaws removed and immediate dentures inserted in both jaws at the same sitting. Although it seems that this should be extremely painful, it is surprising how well the patients tolerate it (Fig. 10). Some prosthodontists have found the new soft acrylics which become pliable in ordina,ry hot tap water of immeasurable help in their immediate dentures; others would not consider using this material under any circumstances. Some prefer to make the immediate denture without a labial flange and butt the teeth directly into the sockets. Others leave the labial flange off but employ a thin hornlike extension from the flange margins in the cuspid areas of each side; these horns rest high in the labial sulcus and aid in retention of these open-faced dentures. Heartwell and Salisbury17 have listed the advantages of the immediate denture as follows : 1. The immediate denture acts as a splint to control bleeding. 2. The immediate denture promotes healing by protecting the exposed sockets. 3. The patient with an immediate denture does better in speech, deglutition, and mastication than the patient who is without a denture for even a short period of time. 4. The patient more readily accepts extraction of diseased teeth. 5. The patient can continue in business. 6. Psychologically, the patients are happier. These authors also recommend careful evaluation of the following advantages : 1. The vertical dimension is retained.
Volume 22 Number 4
Alveoloplasty
453
C
Z;ii/. 10. A and II, PIP- and postoperative views of extraction of all mnsilhy teeth and insrrtion of denture. (‘, taken 5 days post,operatively, shows maxillary ridge following suture I? moval.
2. Teeth in the immediate denture can be placed in the same posit,ion as the natural denture. 3. Rone is contonred by the immediate denture. This latter point has been qnestioned by some inwstigatuw, who believe that osteoclastic activity is greater in unhealed l)one and that pressure changes of the immediate denture map cause too great a resorption of bone.2u‘C3 The prosthodontist ean help tilt? 0l2t.C SLll+W~l I)lY+pMl’t’ llie Jjiiticiii ‘S ja?TX for the immrdiate denture by sending along surgical guides. These include :I cdlra,r acrylic surgical tray, stone models of t,he patient (both before a11cl after or vcl*bal the reqursted surgical pracedurc) , and, above all, (lither written directions (preferably written). Implants,
magnets,
and
grafts
Implants, magnets, and bone grafts are some of t,he news approaches to the problem of making prostheses for patients who have had repeated denture
454
O.S.,O.M.&O.P. October, 1966
Mege?
failures for one reason or another. The most common cause of failure in these patients is the atrophic, thin, edentulous mandible. Implant dentures, although fairly successful in some patients, have not as yet proved universally satisfactory. Obwegeser’ reported that of thirty-five implants inserted in thirty-three patients, two-thirds had definite complications after 1 to 3 years. Others have reported similar poor results, but still others have claimed great success for this method. In our practice the implant denture has not proved successful. We believe that this lack of success is due to the seepage and infection around the posts, because the tissue obviously cannot attach to the metal. Behrman2” has discussed the successful use of magnets in denture retention in a large series of patients; others have not been able to duplicate his good results. We have not had any experience with this technique. Bone grafts, using either the patient’s own crest of ilium, bank bone, or freeze-dried bone, have not worked out too well so far. These grafts, though meticulously handled and placed generally have not fared well beneath the dentures but have resorbed. Several successful cases hare been reported, but there is necessity for further investigation in this field. Obwegeser?” has recently demonstrated excellent results employing autogenous bone grafts of both crest of ilium and ribs. SUMMARY
AND
CONCLUSION
In this article the problems of alveoloplasty have been presented from the oral surgeon’s point of view. In essence, the oral surgeon has at his disposal many surgical techniques based on sound principles. However, he must depend on the prosthodontist’s directions to determine exactly what has to be done. Until such time as the prosthodontists have somewhat standardized their techniques, and as long as there is variation among patients, the oral surgeon’s relationship to the prosthodontist must continue to be on an individual basis. REFERENCES
1. Hayward, J. R., and Thompson, S.: Principles 1958. 2. Shearer, W. L.: History of Alveolectomy and of Pathological Condition of the Jaws, Chron. 1950. 3. Shearer, W. L.: Alveolectomy, Chron. Omaha D. for the Denture Patient, 4. Dean, D. T.: Surgery 5. MaeKay, D. R.: Intraseptal Alveolectomy for 68: 549, 1964. ed. 3, St. Louis, 6. iigy;4; K. H.: Oral Surgery, 7. 8. 9. 10.
of Alveoleetomy,
J. Oral
Surg. 16: 101,
Partial Alveolectomy and Management Omaha D. Sot. 13: 127, 129-135, 146, Sot. 16: 247-252, 1953. J. Am. Dent. A. 23: 2124, 1936. Immediate Dentures, J. Am. Dent. 1955, The C. V. Mosby
Company,
A. pp.
Goodsell, J. 0.: Surgical Aids to Intraoral Prosthesis, J. Oral Surg. 13: 8, 1955. MacKay, D. R.: Personal Communication. Caldwell, J. S.: Lingual Ridge Extension, J. Oral Surg. 13: 287, 1955. Trauner, 11.: slveoloplasty With Ridge Extensions on the Lingnal Side of the Lower Jaw to Solve the Problem of a Lower Dental Prosthesis, ORAL SUFG., ORAL MED. & ORAL PATH.~: 340,1952. 11. Goodsell, J. O., and Morin, G. E.: Abnormalities of the Mouth. In Kruger, G. 0.: Textbook of Oral Surgery, St. Louis, 1959, The C. V. Mosby Company, Chap. 6, pp. 121-145. 12. Kruger, G. 0. : Ridge Extension: Review of Indications and Technics, J. Oral Sure;. 16: 191, 1958.
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13. Shea, C. R., and Wolford, D. R.: Removal of Genial Tubercle for Prosthesis, ORAL SURG., ORAL MED. & ORAL PATH. 8: 1044, 1955. 14. Xiyer, I.: Osteoradionecrosis of the Jaws, Chicago, 1958, The Yearbook Publishers, 15. Gazabatt, C., Parra, N., and Meissner, E.: A Comparison of Bone Resorption Following Intraseptal Alveolotomy and Labial Alreolectomy, J. Pros. Dent. 15: 435, 1965. 16. Molt, F. F.: Surgical Preparation of the Mouth, J. Oral Surg. 7: 20, 1949. li. Heartwell, D. M., Jr., and Sali;bury, F. I\‘.: Tmmediate Complete Dentures; an Evaluationl ,T. Pros. Dent. 15: 615. 1965. 18. Schlosser. It. D.: (Conservative Procedures in Complete 1)enture Prosthesis, Northwest. l?niv. Hull. 40: 3, 1940. 19. I,isoa-ski, 0. R.: A Comparative Stud\- of the Resorption of Alveolar Ridge Tissue Ender Immediate Dentures, Northwest. ‘Univ. Rull. 45: il, 1945. 20. Simpson, H. E.: Experimental Investigation Into the Healing of Extraction Wounds in Ma.caous rhesus Monkeys, J. Oral Surg., Anesth. & Hosp. I>. Serv. 18: 391, 1960. 21. Simpson, II. E., Healing of Surgic.al Extraction \Vounds in Xecaczls rhesus Monkeys, J. Oral Hurg., Anesth. & Hosp. I). Serv. 19: 3-9, 277.231, 1961. 22. ~vO,:““,$~;‘. R.: Clinical Study of R epair of Bone After Alveolectomy, J. Oral Surg. r 23. Simp)son, H. E.: Effects of Suturing Extraction ‘\\‘ounds in Jfacac~s rl~s::s Monkeys, J. Oral Surg., Anesth. & Hosp. I). Serv. 18: 461, 1960. 24. Obwegeser, H. I,.: Experiences \Vith Subperiosteal Implants, ORAL Suao., ORAL MED. & ORAL PATH. 12: 777. 1959. 25. Obwegeser, H. L. : Conference on “Comprehensive Oral Surgery,” held at Walter Reed Army Medical Center, Washington, D. C., June 20-22, 1966. 26. Behrman, S. : Personal communication. 40 Maple St.