Introduction:
Apart from the removal of natural teeth, the other most commonly performed pre-prosthetic surgical procedure is alveoloplasty. Alveoloplasty is a pre-prosthetic procedure that aids in alveolar ridge correction. This procedure aims at improving denture wearing by either preserving the existing ridge or surgically remodeling it to help set a stable and comfortable denture prosthesis. According to Boucher, alveoloplasty is the excision of a portion of the alveolar process. It is the procedure that is usually performed to facilitate:
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The removal of the teeth.
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Correction of the irregularities present in the alveolar ridge after removal of the tooth.
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Residual ridge preparation for the reception of the artificial denture.
When Is Alveoloplasty Done?
Once extraction has been done, the alveolar bone surrounding the tooth initially undergoes resorption (destruction of bone tissues that results in bone loss). The clot in the socket slowly transforms into the bone. A majority of the irregularly shaped sharp bony projections may be present on the ridge. It is likely for these bony projections to resorb with time. In order to construct a denture, the ridge should be free of sharp projections as this can cause discomfort under the denture, ulcerations, and an uneven distribution of masticatory forces.
However, some bony projections may actually be beneficial as they can act as undercuts for the retention of dentures, which do not need excision. Alveoloplasty is a procedure that can be done after the extraction of a single tooth or multiple teeth, or even on an edentulous (toothless) ridge. However, it should be remembered that some amount of bone resorption takes place even after alveoloplasty as it is also a surgical procedure. So it is better to be conservative during bone removal.
What Are the Types of Alveoloplasty?
There are four different types of alveoloplasty that help sharpen the edges and correct the gross irregularities. They are:
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Alveolar compression after extraction.
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Simple alveoloplasty.
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Dean's interseptal alveoloplasty.
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Obwegeser's alveoloplasty.
1. Alveolar Compression After Extraction:
This is the easiest and quickest form of alveoloplasty. It just involves the compression of the alveolar ridge surrounding the extracted tooth socket using fingers after an extraction. The compression reduces the width of the socket and eliminates undercuts. Sutures may be placed at times to maintain soft tissue position.
2. Simple Alveoloplasty:
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After Single-Tooth Extraction - A conservative alveoloplasty should be done if prominent areas exist on the alveolar bone after single-tooth extraction. An incision is made along the free gingival margin and is extended to one tooth on either side. A full-thick mucoperiosteal envelope flap exposes the buccal and palatal cortical plates supporting the tooth. The projecting bone or bony irregularity is removed with a bur or a rongeur. The area is smoothed and irrigated well prior to closure.
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After Multiple Teeth Extraction - In this, an initial incision is made along the free gingival margin. Reflection of the flap should provide:
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Good visualization.
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Access to the bony structures.
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Protection to the soft tissues adjacent to this area.
The irregular bone formation is removed with a bur, rongeur, or bone file under profuse saline irrigation. Then, the ridge should be palpated to ensure that all irregularities are removed and then the flap is replaced with digital pressure. Edges of the flap may be trimmed to remove excessive tissues and then sutured.
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Edentulous Patients - After total extraction, the alveolar ridge should be allowed to heal sufficiently for a period of at least six to eight weeks. During this period, the patient should be advised to gently massage the ridge. This will help prevent the development of small sharp bony prominences. Sharp bony projections may make denture wearing very painful. Hence, alveoloplasty is required in such patients.
Local anesthesia is given, and a crestal incision is made. Further, relieving incisions may be placed depending upon the amount of reflection required. A rongeur or bone file may be used to smoothen the sharp edges that are seen after flap reflection. Sometimes a large round bur may be used to round off the bony prominence. Finally, the wound is irrigated well prior to closure.
3. Dean’s Interseptal Alveoloplasty (Intracortical Alveoloplasty):
Dean's concept of alveoloplasty differs from routine procedures in that he advocated that the cortical plate towards the cheeks could be preserved, and instead, the interseptal bone (within the ridge) could be sacrificed. This procedure is mostly done in people who had proclined teeth previously, and the construction of a denture on such ridge can again produce the effect of proclination of the denture teeth. An alveoloplasty done to correct this deformity can be done in the following ways:
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The procedure can be done at the time of extraction or in the initial post-operative healing period.
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The ridge is exposed by reflecting a mucoperiosteal flap.
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A small rongeur or bur may be used to remove the interseptal part of the alveolar bone.
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After adequate bone removal, the cortical plates have to be compressed (towards the cheek and tongue).
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If there are small areas of bony irregularity, they may be removed using a bone file. Then the alveolar mucosa is reapproximated and sutured.
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An immediate denture lined with a soft liner may be placed to maintain the position until initial healing occurs.
4. Obwegeser's Modification of Dean's Technique:
A further modification of Dean's technique is suggested in cases of extreme premaxillary protrusion. In this technique, the teeth are removed as usual, and a rongeur or bur is used to remove the interseptal bone. The bone or plate towards the cheek and tongue is cut vertically with burs at the canine region to weaken the bone. A small mounted disc may be inserted into the sockets to add strength horizontally to the bone or plate towards the cheek and tongue, thereby weakening them along the proposed fracture line.
A broad, flat elevator such as a periosteal elevator is inserted into the socket to fracture the bone towards the cheek and tongue. The ridge is then compressed using digital pressure to obtain the desired shape and contour. The ridge can be molded as desired since the bone towards the cheek and tongue are mobile. Then, sutures are placed to close the gingiva over the sockets. A denture is placed to stabilize the fractured alveolar process, and it heals in about four to six weeks.
What Is the Post-operative Advice to Be Followed After an Alveoloplasty Procedure?
The following are the post-operative care to be followed:
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After alveoloplasty, pain may be experienced by the patient in the area for approximately a week. Painkillers such as Acetaminophen, Tylenol, and Ibuprofen may be prescribed during that period.
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Swelling may occur in the first 24 hours, and it may subside later. Ice pack compression can be kept on the face to suppress swelling in such cases.
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One may be prescribed antibiotics and an antibacterial rinse to prevent infection of the area, especially if one is old and has had many teeth removed.
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Until the stitches have been fully removed, it is advisable to eat soft and liquid foods. Also, using a straw should be avoided since sucking pressure can result in bleeding.
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After a week, a follow-up consultation with the dentist is needed.
What Are the Risks of Alveoloplasty?
The risks of alveoloplasty are:
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Excessive bleeding is a rare complication, and it eventually tapers off.
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Wounds can open if the stitch gets removed or becomes loose.
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Infection may occur due to the presence of bacteria in the mouth. In order to avoid it, antibiotics are prescribed.
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Accidental trauma to the nerve causes numbness in the lips and the chin. In rare cases, the nerves may be permanently damaged.
Conclusion:
Alveoloplasty is most often done in elderly patients who require complete or removable partial dentures. It is done to smoothen and contour the bones of the jaw so that a denture or a dental implant that is placed will have good retention, stability, comfort, and eventually a higher success rate. Alveoloplasty procedure takes about an hour to complete. This is a relatively safe procedure, but when there is excessive bleeding, increased swelling for more than three days, signs of inflammation, chills, and fever, one must contact the dentist to avoid unwanted complications.