Pre-Prosthetic Periodontal Surgeries

INTRODUCTION AND DEFINITION

• Stable, healthy periodontium as a foundation for restorations
• Adequate attached gingiva and vestibular depth
• Correct crown dimensions and biological width
• Favourable ridge morphology for esthetic pontics and dental implants
• Removal of soft and hard tissue impediments to prosthesis insertion and retention

SEQUENCE OF TREATMENT IN PREPARING THE PERIODONTIUM FOR RESTORATIVE DENTISTRY (Box 71-1, Carranza)

1. Control of active disease (emergency treatment, extraction of hopeless teeth, oral hygiene instructions, scaling and root planing, reevaluation, periodontal surgery, adjunctive orthodontic therapy)
2. Pre-prosthetic Surgery (Management of mucogingival problems, preservation of ridge morphology after tooth extraction, crown-lengthening procedures, alveolar ridge reconstruction)

CLASSIFICATION OF PRE-PROSTHETIC PERIODONTAL SURGERIES

1. Procedures to increase the width of attached gingiva (gingival augmentation)
2. Root coverage procedures
3. Frenectomy / Frenotomy
4. Vestibuloplasty

1. Gingivectomy approach
2. Flap with osseous recontouring

1. Ridge preservation / socket grafting after extraction
2. Soft tissue ridge augmentation
3. Hard tissue (alveolar ridge) augmentation using Guided Bone Regeneration (GBR)

1. Alveoloplasty
2. Tori reduction (mandibular and maxillary)
3. Genial tubercle reduction
4. Mylohyoid ridge reduction
5. Removal of epulis / hyperplastic tissue

DETAILED DESCRIPTION

I. PROCEDURES TO INCREASE THE WIDTH OF ATTACHED GINGIVA (GINGIVAL AUGMENTATION)

• Teeth with subgingival restorations and narrow keratinized zones show higher gingival inflammation scores than those with wider zones
• Teeth serving as abutments for fixed partial dentures (FPDs) or removable partial dentures (RPDs) require an adequate width of attached gingiva to withstand functional loads and prosthetic margin placement
• A wider keratinized zone facilitates plaque removal and reduces inflammation around restored teeth
• Vestibular depth is required for denture flange extension (especially in complete denture prosthodontics)

A. FREE GINGIVAL AUTOGRAFT (FGA)

• Inadequate attached gingiva in the pre-prosthetic site
• Shallow vestibule
• High frenal attachment that threatens the gingival margin
• Prior to placement of subgingival restorations or around RPD abutments

1. After adequate anesthesia, an incision is made at the mucogingival junction (MGJ), or at the cut gingival margin if a narrow band of attached gingiva remains.
2. Vertical releasing incisions delineate the lateral borders of the recipient site, extending approximately to twice the desired width of attached gingiva (accounting for approximately 50% contraction during healing).
3. A split-thickness flap is dissected, leaving a periosteal bed free of muscle attachments. Alternatively, the graft may be placed directly on bone (periosteal bed stripped to bone) which reduces mobility and shrinkage of the graft, though it has a 2-week healing lag.
4. The apical portion of the flap is sutured to maintain the periosteal bed.
5. An aluminum foil template of the recipient site is made.

1. The palate in the region of the premolars is the classic donor site.
2. A graft of ideal thickness (1.0-1.5 mm) is harvested. A graft that is too thin risks necrosis; one too thick compromises revascularization and may injure palatal arteries.
3. The submucosa in the posterior palate (thick and fatty) should be trimmed to prevent interference with vascularization.
4. Mucous glands may appear in palatal grafts as graft tissue re-establishes its original epithelial structure.

• Initial phase (0-3 days): Graft survives by avascular "plasmatic circulation" from the recipient bed. Graft epithelium degenerates and desquamates. Critical that the graft is closely adapted to the bed.
• Revascularization phase (2-11 days): Anastomoses form between recipient bed vessels and graft vessels; capillary proliferation occurs; fibrous union established; re-epithelialization begins from adjacent tissues.
• Tissue maturation phase (11-42 days): Vascular density normalizes; epithelium matures with keratin layer formation.

B. SUBEPITHELIAL CONNECTIVE TISSUE GRAFT (SCTG)

II. ROOT COVERAGE PROCEDURES

• Subgingival margin placement is planned over a receded root
• Esthetic demands are high (anterior zone)
• Root sensitivity is present
• Recession threatens the periodontal support of prosthetic abutments

• Class I: Recession not extending to the MGJ; no loss of interdental bone/soft tissue
• Class II: Recession extending to or beyond the MGJ; no loss of interdental bone/soft tissue
• Class III: Recession extending to/beyond MGJ; loss of interdental bone/soft tissue or malposition of tooth (partial root coverage achievable)
• Class IV: Severe recession extending to/beyond MGJ with severe interdental bone/soft tissue loss (root coverage not achievable)

A. LATERALLY REPOSITIONED (SLIDING) FLAP (Grupe and Warren, 1956)

B. CORONALLY ADVANCED FLAP (CAF)

1. Oblique submarginal incisions in the interdental areas, connected with intracrevicular incisions at recession defects
2. A split-thickness flap is dissected in the interdental regions; full-thickness flap is raised apical to recession to preserve maximum tissue thickness
3. At the apical margin of the flap, the periosteum is incised and blunt dissection into the vestibular mucosa releases muscle tension, permitting passive coronal movement
4. Facial portions of interdental papillae are de-epithelialized
5. The flap is advanced coronally and sutured 1-2 mm coronal to the CEJ

C. DOUBLE PAPILLA FLAP

D. SUBEPITHELIAL CONNECTIVE TISSUE GRAFT WITH CORONALLY ADVANCED FLAP

E. GUIDED TISSUE REGENERATION (GTR) FOR ROOT COVERAGE

III. FRENECTOMY / FRENOTOMY

1. Distend the gingival sulcus and foster plaque accumulation, accelerating periodontal recession
2. Cause or perpetuate diastema formation
3. In edentulous patients, compromise denture stability and retention by:
   • Creating notches that weaken the denture base (particularly the maxillary complete denture base - the labial frenal notch geometry can cause midline fractures, Peterson's, Ch. 6)
   • Reducing the effective denture-bearing area
   • Preventing optimal extension of the denture flange into the buccal/labial sulcus

A. SIMPLE ELLIPTICAL EXCISION

B. Z-PLASTY

C. FRENECTOMY AT TIME OF DENTURE INSERTION

IV. VESTIBULOPLASTY

• Preserve gingiva
• Remove aberrant frenula or muscle attachments
• Increase depth of vestibule
• Provide mechanical resistance to prosthesis displacement forces
• Provide stable denture-bearing area

• Inadequate vestibular depth for complete/partial denture flanges
• High mentalis muscle insertion (mandible) impairing lower denture stability
• Pre-implant soft tissue preparation to allow implant-supported overdenture stability

A. CLOSED SUBMUCOUS VESTIBULOPLASTY

B. OPEN SUBMUCOUS VESTIBULOPLASTY (OBWEGESER TECHNIQUE)

C. SECONDARY EPITHELIALIZATION TECHNIQUES

• Kazanjian's Technique (lip switch procedure): An incision is made in the lip mucosa; a large flap of labial/vestibular mucosa is retracted; the mentalis muscle is detached from periosteum to the required depth; the vestibule is deepened by supraperiosteal dissection. A mucosal flap is reflected downward and sutured to the periosteum on the labial alveolar ridge. A surgical splint is placed in the deepened vestibule (Peterson's, Ch. 6).
• Edlan-type (lip switch) procedure: Transposition of lip/cheek mucosa onto the labial alveolar ridge after periosteal excision. Provides vestibular depth but places mobile, non-keratinized lip mucosa onto the denture-bearing ridge - susceptible to ulceration under loading.
• Clark's and Godwin's procedures: Other modifications of the above.

D. SPLIT-THICKNESS SKIN GRAFT (STSG) VESTIBULOPLASTY

V. CROWN-LENGTHENING PROCEDURES

1. Provide retention form to allow for proper tooth preparation, impressions, and placement of restorative margins
2. Adjust gingival levels for esthetics (equalizing gingival heights in the esthetic zone)
3. Access subgingival caries or tooth fracture for restoration
4. Correct biological width violations

• Connective tissue attachment = 1.07 mm
• Junctional epithelium = 0.97 mm
• Total biological width ≈ 2 mm
• Mean healthy gingival sulcus depth = 0.69 mm

• Subgingival caries or fracture
• Inadequate clinical crown length for retention
• Unequal or unesthetic gingival heights
• Biological width violation

• Surgery would create an unesthetic outcome
• Deep caries or fracture would require excessive bone removal on contiguous teeth
• The tooth is a poor restorative risk

A. GINGIVECTOMY APPROACH

B. FLAP WITH OSSEOUS RECONTOURING

1. A full-thickness mucoperiosteal flap is elevated (buccal and lingual/palatal)
2. Granulation tissue is removed; root surfaces are debrided and planed
3. Osseous recontouring is performed with rotary burs and hand instruments to establish a level of bone at least 3 mm apical to the planned restorative margin
4. In cases of caries or fracture, at least 4 mm is required from the apical extent of caries/fracture to the bone crest (to provide 1 mm of sound tooth structure above the gingival margin + 2 mm biological width + 1 mm sulcus)
5. The flap is repositioned apically (apically repositioned flap) and sutured
6. A healing period of several weeks is allowed before final impressions

VI. PRESERVATION OF RIDGE MORPHOLOGY AFTER TOOTH EXTRACTION

1. The socket is debrided without damaging the bony walls
2. A bone substitute (e.g., deproteinized bovine bone - Bio-Oss®, freeze-dried bone allograft, or calcium sulfate) is placed into the socket to fill the space and minimize ridge collapse
3. The socket may be covered with a collagen membrane
4. A provisional fixed partial denture with an ovate pontic extending 2 mm into the socket supports surrounding tissues during healing
5. After approximately 8 weeks, the socket heals with preserved gingival and papillary architecture

VII. ALVEOLAR RIDGE RECONSTRUCTION (AUGMENTATION)

• Class I: Dentate
• Class II: Post-extraction
• Class III: Convex ridge with adequate height and width
• Class IV: Knife-edge ridge with adequate height but inadequate width
• Class V: Flat ridge with loss of alveolar process
• Class VI: Loss of basal bone

• Class I: Buccolingual width deficiency
• Class II: Apicocoronal height deficiency
• Class III: Combined deficiency

A. SOFT TISSUE RIDGE AUGMENTATION

B. GUIDED BONE REGENERATION (GBR)

• Based on the concept of tissue exclusion that originated with Guided Tissue Regeneration (GTR) in periodontics (Melcher 1976; Nyman et al. 1982)
• The key principle is that exclusion of rapidly growing soft tissue cells allows slower-growing osteoprogenitor cells adequate time to establish within the defect
• Space maintenance under the barrier is critical - a blood clot must be protected and stabilized to allow bone regeneration
• Requirements: wound closure, angiogenesis, space creation and maintenance, and blood clot stability

• expanded Polytetrafluoroethylene (ePTFE, Gore-Tex®) - gold standard for space maintenance
• Titanium-reinforced ePTFE for larger defects requiring rigid space maintenance
• Advantage: can remain in place for 6-12 months; excellent space maintenance
• Disadvantage: requires second surgery for removal; if exposed, must be removed promptly

• Natural (xenogeneic collagen Type I or III) or synthetic polymers (polylactic acid, polyglycolic acid, polyorthoester)
• Degrade by hydrolysis or enzymatic degradation
• Advantage: no second surgery; reduced patient morbidity
• Disadvantage: less stiffness (may collapse into defect); variable resorption rate; mild inflammatory reaction during resorption

• Class I defects (horizontal deficiency): One-step GBR - simultaneous implant placement and bone augmentation
• Class II and III defects (horizontal + vertical): Two-step GBR procedure - bone augmentation first, implant placement after bone maturation (4-6 months)

VIII. ALVEOLOPLASTY

• Sharp bony prominences, undercuts, spiny ridges following extraction
• Irregularly shaped alveolar ridge impeding denture insertion
• Excessive alveolar height requiring reduction for interarch space or esthetic requirements (particularly for implant-supported fixed prostheses)

1. A crevicular incision (concurrent with extraction) or a crestal incision (on an edentulous ridge) with an envelope flap with or without labial releasing incisions
2. Subperiosteal dissection to expose the alveolar ridge - periosteal stripping should be minimized as it increases bone resorption by 1-2 mm
3. Bony contouring with bone files, rongeurs, rotary burs, or a power rasp
4. Edematous and diseased interdental papillae are removed with sharp scissors to prevent interference with flap closure
5. Digital palpation over the closed flap confirms uniformity and smoothness of the ridge
6. The flap is sutured; a healing/provisional denture may be placed as a surgical dressing and to maintain vestibular height

IX. TORI REDUCTION

A. MANDIBULAR TORI (TORUS MANDIBULARIS) REDUCTION

• Prevents proper path of insertion of removable prosthesis
• Traumatic ulcer formation
• Speech/masticatory dysfunction
• Obstructive sleep apnea (extensive tori)
• Interferes with fabrication of oral appliances

1. Subperiosteal dissection exposes the torus
2. An elliptical incision over the torus facilitates excess tissue removal
3. A trough is created between the torus and alveolus with a bur
4. An osteotome with a mallet separates the torus from the alveolus
5. Smaller tori may be recontoured with a bone file or rotary instrument
6. Residual rough margins are smoothed with a bone file
7. Lingual flap is replaced and sutured; a surgical splint is applied to prevent hematoma formation and protect the friable overlying mucosa

B. MAXILLARY (PALATAL) TORI (TORUS PALATINUS) REDUCTION

• Speech disturbance
• Masticatory dysfunction
• Chronic traumatic ulceration
• Food retention and hygiene issues
• Inability to construct stable removable prosthesis

• Straight-line incision with Y-shaped releasing incisions
• Full palatal flap
• Modified palatal flap
• Sectioning with osteotomes or burs and removal in pieces for multi-lobulated tori
• Smaller tori: recontoured with bone file/rotary instrument

X. GENIAL TUBERCLE REDUCTION

• Blunt subperiosteal dissection exposes the tubercles
• Chisel, rongeurs, rotary drill, or power rasp removes the bony projections
• Residual rough margins are smoothed with a bone file
• Caution: risk of hematoma formation or airway obstruction from aggressive muscle detachment

XI. MYLOHYOID RIDGE REDUCTION

XII. REMOVAL OF EPULIS AND HYPERPLASTIC TISSUE

• New or replacement dentures are to be constructed
• Epulis makes existing dentures ill-fitting and/or uncomfortable

1. Supraperiosteal dissection with blade or electrocautery removes excess tissue (electrocautery aids hemostasis)
2. Options for wound management:
   • Secondary intention healing (most relapse)
   • Split-thickness skin graft (STSG)
   • Soft-lined maxillary splint placed to preserve vestibular depth gained during surgery (Zarb, Ch. 8 recommends this)
3. Excision of fibrous maxillary tuberosities (pendulous fibrous maxillary tuberosities) may be required when they interfere with denture construction by encroaching on interarch space - care must be taken to avoid opening the maxillary sinus (Zarb, Ch. 8)

ROLE OF PRE-PROSTHETIC PERIODONTAL SURGERY IN IMPLANT DENTISTRY

• Keratinized Tissue Width (KTW) at 24 months: 3.4 ± 0.6 mm (PPPS group) vs. 1.1 ± 0.3 mm (control; P < 0.001)
• Marginal Bone Loss (MBL) at 24 months: 0.35 ± 0.15 mm (PPPS) vs. 0.78 ± 0.25 mm (control; P < 0.001)
• Bleeding On Probing (BOP): 12.5% (PPPS) vs. 30% (control; P = 0.03)
• Peri-implant mucositis: 5.3% (PPPS) vs. 18.9% (control; P = 0.04)
• Patient satisfaction (Oral Health Impact Profile-14 score): significantly higher in PPPS group
• Implant survival: 97.4% vs. 94.6% (P = 0.61 - comparable)

TIMING AND SEQUENCING OF PRE-PROSTHETIC SURGERY

• Control of active periodontal infection (nonsurgical and surgical therapy)
• Resolution of acute conditions
• Completion of adjunctive orthodontic tooth movement (in most cases)
• At least 4 weeks post-Phase I therapy for tissue reevaluation

• Soft tissue grafting: at least 2 months healing (Carranza, Ch. 71)
• GBR: 4-6 months for mandible; 6 months for maxilla (Carranza, Ch. 77)
• GBR membrane removal (non-resorbable): 6-12 months
• Crown lengthening: typically 4-8 weeks before final impressions (allows tissue to stabilize)

CONCLUSION

LIST OF ABBREVIATIONS

REFERENCES

1. Melnick PR. Preparation of the Periodontium for Restorative Dentistry (Chapter 71). In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds. Carranza's Clinical Periodontology, 10th ed. Elsevier, 2006.
2. Spear FM, Cooney JP. Restorative Interrelationships (Chapter 72). In: Carranza's Clinical Periodontology, 10th ed. Elsevier, 2006.
3. Takei HH, Carranza FA. Gingival Surgical Techniques (Chapter 62). In: Carranza's Clinical Periodontology, 10th ed. Elsevier, 2006.
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8. Cillo JE Jr. Pre-Prosthetic Surgery (Chapter 6). In: Miloro M et al., eds. Peterson's Principles of Oral and Maxillofacial Surgery, 4th ed. Springer, 2022.
9. Zarb GA, Bryant SR. Preprosthetic Surgery: Improving the Patient's Denture-Bearing Areas and Ridge Relations (Chapter 8). In: Zarb GA, Bolender CL, eds. Prosthodontic Treatment for Edentulous Patients, 12th ed. Mosby.
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11. Parihar AS et al. Influence of Pre-Prosthetic Periodontal Surgery on Peri-Implant Tissue Stability and Prosthetic Success: A Prospective Dual-Center Randomized Controlled Trial. Journal of Pharmacy and Bioallied Sciences, Vol. 17, Suppl. 3, September 2025: S2707-S2710.The answer above has been comprehensively prepared directly from all your uploaded references. Here is a quick guide to what was covered and which reference each section draws from: