Vestibuloplasty- ridge extension procedures

©M. S. Ramaiah University of Applied Sciences

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RIDGE EXTENSION PROCEDURES

- ZEESHAN ARIF


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INTRODUCTION

• The size and shape of the denture bearing area affects the outcome for

the conventional complete denture

• An overlooked prognostic factor is the nature of the denture bearing

surface mucosa

• Following extractions, there is progressive resorption of bone along with

general deterioration of the quality and amount of attached mucosa

that remains.


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• As the alveolar process decreases in size, adjacent muscles are found to

attach at or near the crest of the residual ridges.

• The residual gingiva becomes diminished and the labiobuccal vestibule

and lingual sulcus becomes shallow

• An adequate amount of bone must remain to develop a new vestibule

mandible – 12 to 15 mm

maxilla – reduction of nasal spine


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• Definition– surgical procedure whereby the oral vestibule is deepened

changing the soft tissue attachments and thus increasing the size of the

denture bearing area and height of the residual alveolar ridge

• Deepening of the vestibule without any addition of the bone is termed

as vestibuloplasty or sulcoplasty or sulcus deepening procedure


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class definition

I The alveolar ridge is adequate in height but shows significant undercut areas and insufficient width

II The alveolar ridge is deficient in both height and width and presents as a knife edge appearance

III The alveolar ridge has been resorbed to the level of the basal bone

IV The mandible or the maxilla presents with severe resorption; there is impending pathological fracture


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TECHNIQUES

1)MUCOSAL ADVANCEMENT VESTIBULOPLASTY

2)SECONDARY EPITHILIZATION VESTIBULOPLASTY

3)GRAFTING VESTIBULOPLASTY


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MUCOSAL ADVANCEMENT VESTIBULOPLASTY

• When the vestibule is extended, the first choice of procedures should be

the one where-by the neighbouring mucosa can be advanced to line

both sides of the sulcus.

• The prime criterion for this type of procedure is the presence of an

adequate amount of bone and healthy mucosa.


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Clinical test- with the lips in a relaxed

position, a mouth mirror is inserted into

the vestibule to the depth required

prosthetically. If the lip is not displaced

upward or drawn inward, it can be

assumed that there is sufficient mucosa

for advancement procedures


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CLOSED SUBMUCOUS VESTIBULOPLASTY

OBJECTIVES

• To extend the vestibule to provide additional ridge height

• To excise or transfer the submucous connective tissue and adjacent

muscles to a position farther from the crest of the ridge to prevent

relapse of the vestibule to its preoperative condition

• Generally done in the maxilla where better results are obtained


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MAXILLARY VESTIBULOPLASTY

• Obwegeser described this procedure in 1958

• 1)SUBMUCOSAL TUNNEL

• Vertical incision made in the midline of vestibule from the crest of the ridge proceeding superiorly approximately 15 mm.

• Metzenbaum scissors introduced through the incision and blunt dissection done to separate mucosa from the submucosa on the right and left sides to create a submucosal tunnel


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2) SUPRA-PERIOSTEAL TUNNEL

• Supra-periosteal tunnel made with the

scissors, separating the connective

tissue and muscles from the periosteum

(parallel and below the submucosal

tunnel) till the zygomatic butress

• If anterior nasal spine is prominent, it is

reduced at this point


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3) EXCISION

• The wedge shaped strip of connective

tissue that remains between the two

tunnels is excised

• The freely movable mucosa is adapted

to the deepened sulcus with finger

pressure and the vertical incision is

sutured

• A roll guaze is placed into the vestibule

to support the mucosa temporarily


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• A compound impression is made of the extended vestibule by using the

patients denture or a splint

• The denture/splint with extended flanges is sutured to the maxilla with

peralveolar wires or pins or circumzygomatic wires for 10-15 days

• A new denture is made in 3-4 weeks


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MANDIBULAR VESTIBULOPLASTY

• Boering 1979

• Not commonly done

• Similar to maxillary

vestibuloplasty

• Extra incision is given in

the premolar region to

prevent damage to the

neurovascular bundle


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MODIFIED MAXILLARY SUBMUCOSAL VESTIBULOPLASTYGeorge a. Wessberg, stephen a. Schendel and bruce n. Epker- 1980

OBJECTIVES

• To create increased exposure

of the operative site

• To decrease the vertical

midline scar

• To more predictably deepen

the anterior vestibular sulcus

ADVANTAGES

• Excellent surgical access and visualization of

the operative site.

• Increases anterior labial vestibular depth

and eliminates a low frenum attachment or

vertical midline scar.

• Permits the extension of the incision beyond

the ANS into the lip mucosa without fear of

creating a fibrous frenula


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SECONDARY EPITILIZATION VESTIBULOPLASTY

INDICATION

• Sufficient bone is present, but mucosa is either insufficient in quantity or

quality(inflammatory hyperplasia, ulceration or scar tissue)

• The mucosa of the vestibule is used to line one side of the extended vestibule,

and the other side heals by growing a new epithelial surface


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Secondary epithelization

vestibuloplasty

Kazanjian

Godwinsmodification

Lipswitch

Bipedicled

Clark

Obwegesersmodification

Tortorellis periosteal fenestration


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KAZANJIAN TECHNIQUE

• Incision made in the

mucosa(premolar to premolar) of the

lip and a large flap of labial and

vestibular mucosa is reflected

• Supraperiosteal dissection done to

deepen the vestibule

• Flap of mucosa is turned downward

from the alveolar ridge and sutured

against the periosteum


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• Rubber catheter stent placed into deepened sulcus and fixed through the lip to the

outer surface with percutaneous sutures

• The catheter holds the flap in its new position and maintains the depth of vestibule

during the initial stages of healing.

• Catheter is removed after 7 days

• Labial donor site coated with tincture benzoin and left to granulate by secondary

epithelisation

• Drawback – severe scarring of the lip is seen which will further restrict the

movements of the lower lip


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GODWINS MODIFICATION

• Similar to kazanjian technique

• Mucosal incision on the inner aspect of the lip is designed longer than the proposed

vestibular depth to be achieved

• Flap of labial mucosa is elevated but the vestibule is deepened by means of sub-

periosteal stripping instead of supraperiosteal dissection

• The periosteum is either excised or pushed downwards

• The labial and vestibular flap is placed directly against the bone and sutured

DISADVANTAGE – Scar contracture with a loss in sulcus depth


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LIPSWITCH TECHNIQUE

• Variation of Kazanjian's technique

• Keithly and gambly (1978) – lipswitch technique to be more successful in mandible


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Mandibular Anterior Ridge Extension: A Modification of the Kazanjian Vestibuloplasty Technique

BIPEDICLED FLAPmucosal incision is made approximately 10 to 12 mm in the mucosa

incision down to periosteum is made at the junction of the attached mucosa on the ridge

bi-pedicled mucosal flap is carefully elevated


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• The flap is advanced and secured to the

depth of the vestibule with a polyethylene

tube fixed through the lip with

percutaneous sutures are placed.

• The labial and alveolar sides of the flap

are sutured to the lip and periosteum,

respectively, using horizontal mattress

sutures


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Edlan Mejchar An Underestimated Tool For Vestibuloplasty - A Case Report

• Described as a modification of Kazanjian in 1924 for deepening the mandibular

labial vestibule in edentulous patient’s .

• Lipswitch modification done in the mandibular anterior region

ADVANTAGES –

• Healing occurs by first intention and no bone is left exposed, thereby minimizing

the chances of bone resorption and further recession.

• More practical and less technique sensitive

EDLAN MEJCHAR MODIFICATION


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vertical incision mesial to the

mandibular canines ; distance of 10

to 12 mm extending on to the lower

lip


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CLARKS TECHNIQUE

• Reverse of Kazanjian's technique

• Based on 4 principles

1. Raw surfaces of connective tissue contract whereas the same surfaces undergo

minimal contraction when covered with epithelium

2. Raw surfaces overlying bone cannot contract

3. Epithelial flaps must be undermined sufficiently to permit repositioning and

fixation without tension

4. Soft tissues undergoing plastic revision have a tendency to return to their former

position, so over correction and firm fixation are necessary


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PROCEDURE

• Incision is made on the alveolar ridge and a supraperiosteal dissection is done to the desired depth

• Mucosa of the lip is undermined till the vermillion border

• Non absorbable percutaneous sutures are placed in the free margin and are carried through the skin and tied over the cotton roll

• Soft tissue side of the vestibule is covered with mucosa, whereas on the osseous side the raw periosteal surface is left to granulate and epithelise


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OBWEGESER’S MODIFICATION

• Similar to Clark’s method

• The area of the alveolar bone with it‘s periosteal attachment is covered with a split

thickness skin graft and held in position by sutures or stent constructed

preoperatively.

• Instead of skin, mucosal graft has also been tried.

• ADVANTAGES

• Covers the bone and ensures faster healing

• Reduces chances of postoperative infection

• Less bone loss and scarring


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PERIOSTEAL FENESTRATION

• Periosteum at the base of newly created vestibule is fenestrated/incised

horizontally , parallel with muco-gingival junction

• The inferior periosteal margin is sutured to the free margin of the mucosal flap


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• When the periosteum is fenestrated, healing of the denuded bone is delayed by 2-3 weeks.

• By the time the denuded boned begins to granulate, the periosteum covered bone

will already have grown a new epithelial surface

• This differential rates of healing could account for the reduction of relapse at the line of fenestration


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INDICATIONS

• Inadequate amount of bone to compensate for relapse after vestibuloplasty

• When a bone graft has been placed before in the surgical site

• Large surgical defect

ADVANTAGES

Less relapse

Early covering of surgical defect

Rapid healing

DISADVANTAGESDonor site morbiditySkin grafts may not take up well on exposed boneHair growth if graft is thickReduced secretory capacity, colour and surface consistency

GRAFTING VESTIBULOPLASTY


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PRINCIPLES OF GRAFTING

1. Skin grafts to be removed from a relatively hairless area.(upper thigh, inner surface

of arm)

2. Thin split thickness grafts are less likely to have hair follicles in the dermis

3. Split thickness graft will give better results than full thickness, but a full thickness

graft contracts less

4. Recipient site should be free of infection and have good blood supply

5. Graft should cover the entire raw area


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6. Haemostasis should be obtained in the recipient site before graft placement

7. Graft should be placed over periosteum and not cortical bone

8. Graft should be immobilised until healing has occurred(7 to10 days) by either by

stent or suturing

9. If palatal mucosa used, it should be defatted to make it as thin as possible


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GRAFTING VESTIBULOPLASTY

SKIN GRAFT

MAXILLARY

Pocket inlay

Macintosh modification

Wallenus modification

MANDIBULAR

DERMIS GRAFT

MUCOSAL

PALATAL MUCOSA

BUCCAL MUCOSA


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SKIN GRAFT VESTIBULOPLASTY

STAGE I - DONOR SITE SURGERY

• Patients thigh is prepared with a surgical soap and Skin lubricated with mineral oil

• Graft width depends on the height of body of mandible(5 to 6 cms) and thickness being about 0.012 inch(0.3mm)

• Dermatome used to prepare skin graft


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• The skin graft is kept moist and rolled in gauze

• Donor site is covered with fibre mesh gauze and pressure dressing


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STAGE II - RECIPIENT SITE SURGERY

• Mucosa infiltrated with local anaesthesia and crestal incision given from lateral margin of one retromolar pad to the other

• Mandibular labio-buccal, submucosal and supra-periosteal dissections done, mucosal flap reflected and sutured to the desired vestibular depth


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STAGE III – GRAFT SECURED TO THE RECIPIENT SITE

1. STENT – dermatome cement is

used to attach the graft to the stent such that the raw side is in contact with the periosteum

2. SUTURES


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DERMAL GRAFTING

• Introduced by smiler et al

Advantages

• Readily available in sufficient quantity

• Easily re-vascularised

• Viable and immuno-compatible transplants

• Inhibit wound margin contracture

• Ability to take on the characteristics of surrounding mucosa


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SURGICAL PROCEDURE

• Thin split thickness graft (0.012 – 0.014 inch),

is raised with a dermatome, but the skin is not

removed and left pedicled at one end.

• Dermatome is again used to get a slightly

narrower strip of only dermis (0.015 – 0.022

inch) thick (below the skin pedicle)

• The pedicled skin flap is returned to its bed

and sutured in place


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MUCOSAL GRAFT VESTIBULOPLASTY

• BUCCAL MUCOSA GRAFT

Incion given from 1st premolar to 1st

premolar, at the alveolar crest

Supraperiosteal dissection done to reflect a labial flap, which is sutured till the desired vestibular depth


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Buccal mucosal graft harvested using arhenmretractors; 5mm longer than the recipient size required

Primary sutured and stent placed

Post stent removal (7 to 10 days) Post op (3months)


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• Supraperiosteal dissection done in

vestibule and desired height is

achieved

• 2 spilt thickness strips of mucosa

taken from right and left side of

palate

• The 2 grafts are then placed on the

recipient site and sutured, followed

by stent placement.

PALATAL MUCOSAL GRAFT (sanders and starshak 1975)


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LINGUAL VESTIBULOPLASTY

• Also called floor-of-the-mouth-plasty

• Extension of the lingual sulci or lowering of the floor of the mouth

• It extends the denture bearing surface and improve stability and retention of the

mandibular denture

• Eliminates the muscle attachments that dislodge the prosthesis.

• Used in the mandible, when the mylohyoid and genioglossus attachments are close

to the alveolar ridge.


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Lingual sulcoplasty

anterior

posterior

Caldwell

Trauner

obwegeser


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ANTERIOR LINGUAL SULCOPLASTY

• Cooley 1952

• Often combined with reduction of genial

tubercles

• Crestal incision given to expose the upper genial

tubercle and to detach the genioglossus muscle

(only lateral and superior fibres to prevent post

operative complaints of swallowing and speech)


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• Genial tubercles removed if too large

• Heavy nylon sutures attached to the muscles and pulled thru the skin under the chin

and repositioned inferiorly using buttons


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POSTERIOR LINGUAL SULCOPLASTY

CALDWELL PROCEDURE

• It is a subperiosteal procedure

• Suggested method when mylohyoid ridge reduction is recommended along with the

sulcoplasty

COMPLICATIONS

• Haematoma and edema of the sublingual tissues

• Difficulty in swallowing and speech for few days


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• Crestal incision given(molar to molar) and subperiosteal dissection done to reflect a full thickness periosteal flap

• Mylohyoid muscle stripped away to expose the prominent ridge which is reduced with a chisel or rounger

• Flap is sutured back to the ridge• Denture or splint with an elongated flange is used to hold the lingual tissues down to the required depth

and held in place with circummandibular wiring


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TRAUNERS PROCEDURE

• Trauner in 1952

• Supra-periosteal procedure

INDICATIONS

• If mucosa of floor of mouth rises as high as the mandibular ridge

• When the tongue is elevated

• Mylohyoid muscle is attached at the level of the residual alveolar ridge


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• Long crestal incision given , supraperiosteal dissection done using gloved finger or haemostat as close to the mandible to detach the muscle

• Heavy nylon sutures placed and mylohyoid muscle pulled down to desired depth• Held in place with buttons• Stent placed with split thickness graft to enhance healing


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OBWEGESERS PROCEDURE

• Macintosh and obwegeser in 1967

• Method of combining skin graft vestibuloplasty along with lowering of the floor of the mouth

• Lingual sulcus deepening followed by buccal/labial vestibuloplasty


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REFRENCES

• Preprosthetic oral and maxillofacial surgery-Thomas j. Starshak, bruce sanders

• Reconstructive preprosthetic oral and maxillofacial surgery-Fonseca and davis, 2nd

edition

• Reconstructive preprosthetic surgery – john f helfrick and Daniel e waite

• Edlan Mejchar An Underestimated Tool For Vestibuloplasty - A Case Report , Indian Journal of Dental Sciences, September 2015, Issue:3, Vol.:7

• Vestibular Extension By Edlan-Mejchar Technique Followed By Permanent Fibre Splinting - A Case Report-Dr. Harinder Gupta, Dr. Pulkit Kinra, Vol .2, Issue 2 March 2010

• Modified maxillary submucosal vestibuloplasty George a. Wessberg, stephen a. Schendel and bruce n. Epker, Int. J. Oral Surg. 1980: 9: 74-78

Vestibuloplasty- ridge extension procedures

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