Surgical correction of bone and soft alterations of the alveolar ridge, managing its atrophy and height reduction

Bone irregularities of the alveolar ridge and the jawbone can be acquired and congenital. Acquired irregularities can be result of:

  • Individual and multiple teeth extractions performed in large time intervals, leading to uneven atrophy of the alveolar ridge;
  • Not removed interdental or interradicular septum, after teeth extraction;
  • Not made reposition of the walls of the alveolus, after tooth extraction;
  • Fracture of the vestibular or oral cortical lamina as a result of applied inadequate technique of extraction;
  • Surgical interventions of the alveolar ridge;
  • Injury of the alveolar ridge, fracture of the jawbone, acute and chronic osteomyelitis.

Congenital alterations include torus palatinus and torus mandibullae.


The bone irregularities of the alveolar ridge are corrected with a surgical procedure called alveoloplasty, which can be partial or total. Partial alveoloplasty is a leveling of a part of the alveolar ridge and it is more commonly applied. Total alveoloplasty is a leveling of the entire alveolar ridge and it is rarely applied. Alveoloplasty can be madeafter single or multiple tooth extraction and the technique of the intervention pretty much the same.


In conditions of missing teeth antagonists in one jaw, elongation of the alveolar ridge in the other jaw occurs, and the teeth get superposition. The elongation can be so much expressed that the teeth or the alveolar ridge of one jaw, can make a contact with the alveolar ridge of the other jaw. In this case it is practically impossible to make a prosthetic device, therefore, after the extraction of the tooth, we approach to the process of remodeling the alveolar ridge.

Technique: after the extraction of the tooth, a mucoperiosteal flap is made. When performing alveoloplasty, it is particularly important to maintain the depth (height) of the labial and buccal sulcus. This is achieved with making short incisions in the fornix and elevating small mucoperiosteal flap. We raise the flap and using bone plier we remove the serrated parts of the alveolus. Afterwards, we use a milling cutter to flatten the bone surface, but it is important to preserve the cortical lamina (as much as possible), which prevents occurrence of more pronounced resorption of the alveolar ridge, in the following period. The excess gingiva is cut off with scissors, the operative zone is washed abundantly with NaCl and the operative wound is closed with individual sutures.

Surgical correction of torus palatinus

When the torus palatines is discretely expressed (with a small dimension), it is not necessary to undertake surgical correction of the alteration, because in the preparation of the prosthesis, this area can be covered with foil on the working model. In this way the prosthesis does not directly press against it and it has good sability. If the torus is larger, it should be surgically removed because the prosthesis will be unstable and it may cause painful decubituses to appear. The best option in correction of palatinal torus is to do the intervention before pre-planned teeth extraction for making a total prosthesis. The presence of individual teeth, enables the preparation of palatinal plate, modified by a thermoplastic substance, which is applied in the patient’s mouth for a period of 7 to 10 days. It improves the comfort of the patient in the postoperative period, allows an intimate adaptation of the mucous flap to the bone tissue, prevents the emergence of pronounced postoperative hematoma, and a possible injury of the operative wound during mastication.

torus palatinus reduction

Technique: an initial incision is made along the middle palatinal line, with additional relaxation incisions at both ends. Such a designed incision prevents possible damage of the blood vessels (a. palatina major), provides adequate visualization and access, an operational field without tension. After rising the mucosa, it is fixed with traction sutures or with a wide periosteal elevator. If the present torus is small, the incision is made along the medial line with only one additional, anterior, relaxation incision (Y form). Such a torus can be removed using a large drill (with a pear-shaped form) or a milling cutter. When removing a larger torus, often lobulated, it is best to first make a groove along the center line, using a fissure drill. Then, the separation is made with additional, transverse sections through the torus. Further, the additional segments are removed with chisel or with bone pliers. The bone surface is flattened with a milling machine, the operative field is irrigated with NaCl and the wound is closed with individual sutures.

In totally toothless people, the incision is made along the alveolar ridge and the entire mucoperiosteal flap is lifted. Such a formed flap allows the setting of the sutures to be on a healthy bone base, away from the zone of removed palatinal torus.

Possible complications during the intervention: a fracture of the palatinal bone (when removing an unseparated large torus using a chisel), breakage of the thin palatinal mucosa and its consecutive necrosis (inadequate flap lifting), oronasal fistula (extremely rare complication).

Surgical correction of torus mandibullae

This bony protrusion, depending on its expression, can cause an injury of the mucous membrane during mastication, or lead to painful decubituses when the prosthesis is pressing against the mucous membrane of the torus.

Technique: After the mandibular anesthetic is given, we make an initial incision depending on the size of the torus and the presence or absence of teeth. In toothless patients the incision is made along the alveolar ridge and an additional, relaxation incision lingually, in front of the frontline of the torus. If teeth are present, then an envelope flap is performed around the necks of the teeth, and also we make a relaxation incision lingually, in order to achieve complete exposure of the bone exostosis. A piece of sterile gauze is placed under the torus, which prevents falling of small bone fragments between the tissues from the floor of the oral cavity, and the subsequent surgical procedure is identical to the one for torus palatinus.

Possible complications during this intervention are the breakage of the thin lingual mucosa and the possible occurrence of a postoperative hematoma.

Prosthetic fibrous hyperplasia of the mucosa

This condition is known as epulis fissuratum and it is most often localized in the vestibulum, in the area of the upper frontal teeth. Causes leading to this prosthetic hyperplasia are: trauma of badly made prosthesis, or in patients who have an upper total prosthesis and their natural teeth in the lower front. Namely, one or more folds are observed clinically, among which there are cuts in the mucosa that correspond to the prosthesis edges. The mucosa may be inflamed, in some places necrotic and painful on palpation and mastication. These hyperplastic creations reduce the retention and stabilization of the prosthesis, because they are mobile and in contact with the prosthetic edge. If epulis fissuratum is detected in the early stage when it is built from granulation tissue, removing the chronic irritation (non-usage of the prosthesis), may lead to its reduction or complete disappearance. In a later stage, when the granulation tissue has been transformed into fibrous, the condition is irreversible.

Surgical removal of the prosthetic hyperplasia is not performed at the first meeting with the patient, but the intervention is delayed for a period of 2 to 3 weeks, during which period the patient must not wear his prosthesis and must flash the oral cavity with oral antiseptic. During this period, the hyperplastic mucous membrane is reduced by 30% to 50%, which is much more convenient for surgical intervention compared to the initial condition.

Depending on the localization of the prosthetic hyperplasia, it is classified into 3 classes:

  • I class – when it is located on the solid wall of vestibular fornix;
  • II class – when it is located on the soft wall of vestibular fornix;
  • III class – when it is located on the both walls, thus fulfilling the whole fornix.

Operational technique – I class

  • After the application of local anesthesia, the epulis is fixed with surgical tweezers and then completely removed with a scalpel. In addition, the upper marginal part of the lesion are sutured with the exposed periosteum, so in this way, the height of the vestibular fornix is not reduced. The bare periosteum is covered with a prosthetic plate coated with zink-oxide impregnating paste, which the patient carries for the next 7 postoperative days.

Operational technique – II class

  • The easiest class to remove. The epulis is removed with a scalpel and the lesion is directly sutured.

Operational technique – III class (for removing III-class lesion we use a combination of the two previous techniques)

Atrophy of the alveolar ridge and jawbone

Loss of teeth and absence of physiological stimulations in the act of mastication, leads to atrophy of the alveolar ridge, which may be present along the entire ridge or only in individual parts. Deficient alveolar ridge may be compensated by implantation of a graft material, which can have a natural or artificial origin. Some of these materials also have an osteoinductive effect, they induce the growth of bone tissue through the porous material.

The technique of incorporating hydroxylapatite (alloplastic material) is relatively easy, and in some cases with two small vertical cuts, the entire alveolar ridge can be upgraded. In doing so, a subperiosteal tunnel is formed on the top of the alveolar ridge, which usually has a gully shape and it is suitable for application of the implant material using a specially designed syringe. The syringe is drawn in the tunnel and the area over the alveolar ridge is filled, starting from the most distant part of the tunnel to the vertical cut through which the syringe is drawn. In conditions of present extreme atrophy of the alveolar ridge, the only possibility is bone transplantation in combination with enosseal implants.

Surgical correction of the height of the alveolar ridge

The height of atrophic alveolar ridge can be surgically corrected in two ways: a relative increase and absolute increase. A relative increase of the height of the alveolar ridge is the usage of soft tissue surgery, most often in the vestibular fornix. An absolute increase is the usage of surgical bone transplantation procedures that increase or form a new alveolar ridge.

A relative increase in the height of the alveolar ridge is achieved by a procedure called vestibuloplasy. There are three techniques of vestibuloplasy:

  1. Deepening of the fornix with covering the two surfaces of the fornix with mucosa. From this group of operating procedures, the most commonly used is the submucosal vestibuloplasty (Obwegeser), which can be performed in the ambulance, with local anesthesia. The main indication for using this method is the presence of a healthy, flexible vestibular mucosa and a mild atrophy of the alveolar ridge. In doing so, we remove the excess submucosal tissue and do a reposition of the mucosa from the initial to a new (higher, deeper) level.
  2. Deepening of the fornix with secondary epithelization (two techniques)
    – Deepening of fornix with secondary epithelization of the soft tissue surface of vestibular fornix (the surface of the alveolar ridge is covered with mucosa) – Kazanjian.
    – Deepening of fornix with secondary epithelization on the surface of the alveolar ridge (the soft tissue area of the vestibular fornix is covered with mucosa) – Clark.
  3. Deepening of the fornix by covering the operative lesion with a free graft (mucosa/skin). This operative technique is identical to the method of deepening the fornix with secondary epithelization of the soft tissue area of vestibular fornix – Kazanjian, with the difference that the operative lesion of the alveolar ridge is covered with a free mucous or skin graft. The basic indication for the usage of this method is partial deepening of the fornix, only on a certain part of the alveolar ridge.

Locator attachments

Locator abutment overdentures: Better, Simpler and Stronger design with practical benefits

It is almost impossible to imagine the advanced field on a dental industry that represents the implant systems which come as a restoration treatment of dental aesthetics and health. Most of the patients are not familiar with this procedure until they face this type of necessity for having optimal dental health. Sometimes, it is very difficult to make a proper decision because of the new and modern dental implants solutions the manufacturers offer to their dental professionals.
Patients, who are interested in gaining knowledge about dental implants, have the right to know that the abutment is a kind of connector between the denture and the implant which is inserted in the patient’s bone. There are so many different types of implant abutments which could be found on the market and each of them provides specific function while forming more individual approach to the right dental solution. Locator abutment is one of the previously mentioned abutment systems which provide a specific function in the field of dental implantology.

It is specially designed to be used with partial dentures or overdentures dental-elementswhich are supported partially or completely by dental implants. The most important feature of locator abutment is the fact that it could solve the problem with removable overdentures in a specific way and at the same time, provide secure attachment of the denture supported by dental implants. Locator abutment could be used for all types of complete dentures because of their low vertical height. They are a good choice because they offer dual retention, self-correcting alignment, and tolerance for the implant divergence. These types of attachments are used to stabilize the complete dentures in the last few decades. They represent an affordable solution for those patients who wear dentures to improve their chewing quality and also the quality of their life. Locators are ideal for improving aesthetics and retention and they can be a perfect choice when an abutment tooth is removed or lost.
This type of abutment is indicated to be used with partial dentures or overdentures which are retained in part or in whole by endosseous dental implants in the upper or lower jaw. But, it is good to remember that locator abutment is not appropriate when a totally rigid contact is required. All implant abutments or elements and also the metal instruments should be sterilized according to the standard clinical protocols.
Another thing to consider is that locator males are single-use parts which when re-used may cause damage during removal or in most cases they may cause loss of retention for the denture. When it comes to locator abutments, when re-used they may also cause some problems especially they could have patient contamination or contain some particles which would affect the retention. The final result would be improper fit or inappropriate function which would lead to a loss of the retention of the denture.
Locator abutments offer the following advantages:
Dual retention, outside and inside: This unique and innovative feature of the locator allows greater retention than any other attachment before. The greater surface area that ensures better retention combined with the inside and outside surfaces provides the long-lasting performance.
Low vertical profile: The total height of this type of attachment for an externally hexed type of implant is 3.17 mm and for a non-hexed type of implant it is 2.73 mm.
Pivoting feature: The pivoting locator male has a special design which enables a resilient connection with the denture and without any negative result of losing retention. The nylon male part which is retentive, stay in contact with the other part more exactly with the female socket. Finally, the metal prosthesis cap has a full range of rotating movements over the male part.
Correction of the angle up to twenty degree
Easy maintenance because the overdenture and the locator abutment have to be cleaned every day.
Easy and very simple insertion: Its self-locating design permits a patient easy seating of the denture without the necessity for exact alignment of the other attachment elements.
Low cost
It is very important to follow the dental professional instructions after the successful placement of the dental implant and the advanced locator abutment in order to not cause any irritations because it may affect the durability of the whole construction as well. In the first days after the procedure, the patients should rinse their mouth with mouthwash and then they may clean it with a soft-bristle toothbrush but very carefully. This way, they would help in the healing process. Another thing to keep in mind is that pain or discomfort may also occur, but in a relatively short period, they will disappear with the termination of the healing process.

Special elements and metal instrument which would be needed during the procedure

With the usage of the locator, a dental professional could offer to its patient a great implant-supported solution for its denture. All cases with specific angulation and also limited occlusal space could be easily improved with the locator.

Elements and metal instruments


• Locator abutment (Available for connecting sizes: 3.5/4.0; 4.5/5.0 Height: 0.5-5 mm )

• Processing Cap

• Locator Inserts (They are produced in five different retentive holding force levels *designed for non-parallel implants)

• Locator Abutment Pick-up

• Locator Abutment Replica

• Block-out Spacer

• Locator Core Tool

• Locator Torque Wrench Bit

• Torque Wrench


Locator Abutment Impression technique
How to select the right abutmentselect-abutment
The height of the selected locator abutment needs to be based according to the highest position of the tissue when measured with the special instrument called Abutment Depth Gauge. This action is performed just to permit the retention groove to be at suitable supragingival height.

How to install the abutmentinstall-abutment
The locator abutment should be inserted manually into the implant.

The abutment should be seat manually utilizing the locator Abutment driver instrument from the locator care tool set.

Final tightening
Torque the locator Abutment utilizing the special instrument called Locator Torque Wrench Bit accordingly accompanied with the Torque Wrench used for the final tightening.

Creating the new overdenture

Placing the locator Abutment Pick-upplacing-locator-abutment-pickup
The dental professional should firmly attach the special component of the set more exactly, the Locator Abutment Pick-up to each of the Locator Abutments. The pick-up tool should establish stable friction retention.
Taking the impressionimpression
The impression from this situation should be taken in a specially customized tray with a specific elastomeric material for impressions. When the impression material is ready, the dental physician should remove the impression tray.
Impression Verification
Before sending the impression to the dental laboratory is has to be checked and classified as good one. When inspected, the dental professional should look for the black processing inserts and notice if they are clear and visible. If everything is okay, the impression should be well disinfected and ready to be sent to the proper dental laboratory.
Creating a working modelprocessing-model
The dental technician should place the locator Abutment Replica into the locator Abutment Pick-ups. He should create a model which would serve as a working one with the Locator Abutment Replica and some stone material with high-quality.
In this phase, the dental physician should position the spacer above each Locator Abutment Replica supplying primary soft tissue support and a great resilient condition. The dental worker should connect the Locator Processing Cap. Then it has to be processed and cured into the denture. After this, the processed prosthesis should be removed and the spacer should be discarded when the acrylic material has set.
Finishing Phase
The acrylic material should be added as necessary. The dental physician should utilize a burr in order to remove the excessive acrylic and later polish the base of the prosthesis. The final denture together with the Locator Processing Cap should be sent to the dental clinician.

For this phase, the dental clinician should use the Locator Insert Removal Tool for removing the back processing insert.

The dental clinician should press the chosen locator and it should be inserted into the Processing Cap’s metal housing utilizing the Insert Seating Instrument.

Final outcome
When all the procedures are done, the dental clinician should seat the dental prosthesis over the Locator Abutments. The prosthodontist should verify that the necessary retention is completely obtained. When it comes to the retention, gradual increasing is always the best solution and the most suitable recommendation is to start with the low-level retention.

Patients should maintain proper oral health care

The great success of a long-lasting implant is definitely maintaining good oral health care habits. Patients have to be informed that the Locator Implant Abutment should be cleaned every day. They have to purchase a soft nylon bristle toothbrush and they have to teach how to polish and superfloss the abutments. The dental clinician would recommend a non-abrasive toothpaste or gel and also a rinsing mouthwash should be found in the oral health care kit. As an additional oral hygiene tool could be an irrigation system such as water floss just to maintain the Locator Abutment socket clean. Patients should not soak their dental prosthesis. Those people who clean their dentures this way, eat salads or spinach, and have some health problems such as acid reflux, should follow the instructions of their dental professional and brush the attachments with water and mild dish soap. This is especially helpful for the nylon attachments because it will keep them smooth and at the same time the solution would reduce the excessive particles on the implant abutments.
Another great idea about checking the patient’s maintenance of the oral health care habits is to schedule an appointment every three to four months for cleanings and the evaluation of the implant condition. This way, the dental clinician would replace the nylon males if abrasive calculus is accumulated because if it is not cleaned it may provoke premature wear on the abutment. In some cases, the dental worker should check and notice if a reline procedure should be done to the denture. When the prosthesis is relined, it gives dentures great stability and at the same time reduces the accumulation of wear on the attachment.
The most concerning area when implants are inserted in the patient’s mouth is the sulcus area. The dental clinician should use proper instruments for performing the scaling of the abutments. Plastic instruments are the first-line choice because metal instruments could leave scratches on the surface of the abutment. During the examination process, the dental professional should check if there are any signs of inflammation around the abutments. Another thing that should be examined is the implant mobility. The dental practitioner should utilize the locator Abutment Driver so he could become sure that the Locator Implant Abutment is well tight before dismissal.

The Future of Locator Abutments

As the medical technology rapidly grows and this allows manufacturers easily create new and advanced solutions for dental situations. The new

generation locator is the new and advanced Locator R-Tx Removable attachment system.
This method offers progressive outline features, new and stronger system simplicity so dental clinicians could quickly realize the practical advantages of upgrading the existing Locator Abutment system. The new methodology of the all-in-one package gives the necessary elements which are needed for the specific case with only one part number. The convenient all-in-one Package contains Locator R-Tx Abutment, Retention Inserts (Zero Retention Insert- Gray, Low Retention Insert- Blue, Medium Retention Insert-Pink, and High retention Insert – Clear), Denture Attachment Housing with Black Processing Insert, and Block Out Spacer.

  • This new, stronger, better and simpler locator provides:

– More wear resistant Duratec Coating
– Treats up to 60 Convergence/ Divergence between dental implants
– Increased pivot technology
– The alignment and seating are easier during the insertion process of the overdenture
– .050”/1.25” Hex Drive Mechanism
– Simple All-in-one Package
– The same restorative technique as the legacy LOCATOR
– The patient is more satisfied with this new method
This revolutionary system is great for both, the clinician and the patient. Looking forward to hearing from the manufacturers what would be their new invention.