5. Vestibuloplasty.pptx

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1. VESTIBULOPLASTY CHANDINI RAVIKUMAR

2. OUTLINE Introduction Indications III. OBJECTIVES IV. Vestibuloplasty techniques 1. Submucosal vestibuloplasty (Closed and OPEN method) 2. Secondary epithelialization (Kazanjian, Lipswitch , Godwin, Clark’s, Obwegeser , Lingual vestibuloplasty - Trauner’s , Caldwell, Obwegeser’s technique) Grafting vestibuloplasty V. RECENT ADVANCES- GEISTLICH MUCOGRAFT

3. INTRODUCTION DEFINITION: “ Vestibuloplasty is a procedure to increase the depth by uncovering the existing basal bone of the jaws surgically and by repositioning the overlying mucosa, muscle attachments to a lower position in the mandible/superior position in the maxilla”. Deepening of the vestibule without any addition of the bone is termed as vestibuloplasty / sulcoplasty / sulcus deepening procedure .

4. Indications of Vestibuloplasty Shallow buccal vestibule Presence of adequate bone Insufficient keratinized mucosa Shallow lingual vestibule with raised floor of the mouth Objectives of Vestibuloplasty To increase the size of denture bearing area To increase the height of the residual alveolar ridge To prepare the mouth for dentures and to improve its retention To maintain oral hygiene effectively

5. TYPES OF VESTIBULOPLASTY Neelima Anil Malik, Textbook of Oral and maxillofacial surgery, 4 th edition.

6. I. Submucosal vestibuloplasty technique MacIntosh and Obwegeser (1967). Indication- Unstable dentures Mouth mirror test determines the adequacy of mucosa available.

7. Closed submucous vestibuloplasty Objectives To extend the vestibule for providing additional ridge height. To prevent relapse by excising or transferring sub-mucous tissue and the muscles to a position farther from the crestal ridge.

8. Open submucous vestibuloplasty Wallenius (1963) ‘ Open view ’ procedure instead of a ‘tunneling’ technique. Procedure Horizontal incision is made along the mucogingival junction Supraperiosteal dissection is performed, without tearing the periosteum. A thin mucosal flap is elevated by submucosal dissection Excision of muscle and subcutaneous tissue Stay suture are used to fix the flap to the periosteum deep in vestibule Free margin of the flap is then returned to its original position and sutured

9. Maxillary pocket inlay vestibuloplasty Pockets created surgically in maxillary buttress and piriform aperture region Denture flanges extended into these pockets Total denture retention improved Deficiency in the nasolabial fold can be improved

10. Bilateral anterior pockets developed surgically Midpoint of anterior pockets Denture modified with acrylic resin and modelling compound Split thickness skin graft applied to denture Cast made from modified denture 2 ½ years postoperatively Bob D. Gross, D.D.S., M.S.,* Randal B. James, D.D.S.,** and Jeffrey Fister , D.M.D. Use of pocket inlay grafts and tuberoplasty in maxillary prosthetic construction. The Journal of Prosthetic Dentistry, 1980.

11. II. SECONDARY EPIT HE LI ALI ZATION VESTIBULOPLASTY Inflammatory hyperplasia and scar tissue are present. Should be considered as the first alternative. Raw surface is healed by secondary epithelialization.

12. KAZANJIAN TECHNIQUE (1924) Uses mucosal flap from inner aspect of lower lip . Raw area on the lip side heals by secondary intention. Drawback : Severe scarring of the lip mucosa

13. GODWINS MODIFICATION Similar to kazanjian technique V estibule is deepened by means of sub- periosteal stripping instead of supraperiosteal dissection . The periosteum is excised or pushed downwards . DISADVANTAGE Scar on labial side of sulcus. Bone resorption

14. LIPSWITCH/ TRANSPOSITIONAL FLAP VESTIBULOPLASTY Kethley & gamble. Mucosal flap containing labial mucosa similar to Kazanjian’s and Godwin’s technique Minimum bone height of 15 mm between mental foramen areas.

15. CLARK’S TECHNIQUE (1953) Reverse of Kazanjian technique Incision started labial to the crest along the alveolar ridge. Mucosal flap on inner aspect of lip is undermined, till vermilion border. As the alveolar bone is covered by periosteal layer, it heals quickly by granulation.

16. LINGUAL VESTIBULOPLASTY Also called floor-of-the-mouth- plasty . Techniques: Anterior- Cooley Posterior Trauner Caldwell’s Obwegeser’s (combination of buccal and lingual vestibuloplasty )

17. 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

18. Genial tubercles removed if too large Heavy nylon sutures attached to the muscles and pulled thr o u gh the skin under the chin and repositioned inferiorly using buttons 18

19. 1. Trauner’s technique Trauner in 1952 Supra-periosteal procedur e Indications M ucosa of floor of mouth is as high as the mandibular ridge Mylohyoid muscle attached at the level of residual alveolar ridge POSTERIOR LINGUAL VESTIBULOPLASTY

20. Long crestal incision, supraperiosteal dissection done close to 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 .

21. 2. Caldwell’s technique (1955) Incision - crest of posterior mandibular ridge from molar to molar region Mylohyoid muscle and mylohyoid ridge removed along with reduction of genial tubercle Mylohyoid muscle and superficial fibers of genioglossus muscles are pushed inferiorly Sutured with percutaneous suture Left in place for 7-10 days

22. Obwegeser’s technique (1963) Incision sparing mucosa at crest of ridge Labial and lingual ridge extensions Raw bone is skin grafted and covered with surgical stent Final result

23. Other modifications Normal Trauner Brown Caldwell Hopkins Edlan

24. 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 GRAFTING VESTIBULOPLASTY ADVANTAGES Less relapse Early covering of surgical defect Rapid healing DISADVANTAGES Donor site morbidity Skin grafts may not take up well on exposed bone Hair growth if graft is thick Reduced secretory capacity, colour and surface consistency GRAFTS USED Skin graft Mucosal graft (palatal and buccal mucosa) Xenograft Amnion

25. INTRODUCTION Autogenous soft tissue grafts such as dermis, reversed dermis, full-thickness skin, meshed skin, and palatal mucosa were used as graft materials for vestibuloplasty . PROCEDURE Intra-oral incision at the mucogingival junction Supraperiosteal dissection to the desired vestibular depth. Incision margin sutured to the periosteum at the bottom of new vestibular depth. The graft was cut to the correct shape, sutured in place on the periosteum, and stabilized using a relined custom-made acrylic stent. The stent was removed 7 days after the operation. RESULTS Healing of all graft types was successfully achieved with no complications. Palatal mucosal grafts - satisfactory mucosal colour , moistening and contraction. Full-thickness grafts - good original characteristics, healing with minimal contraction occurring in the long term. Dermal grafts - appearance close to mucosa, hair growth observed at 3 month post-operative visit. Reversed dermal grafts - nearest in appearance to mucosa; no problems with hair growth. Meshed skin grafts - better in terms of colour and moistening than full-thickness skin grafts. Contraction of dermal and reversed dermal grafts was excessive.

26. DISCUSSION AND CONCLUSION Full-thickness grafts : hair growth and poor adhesive quality. Sanders and Starshak have claimed that palatal mucosal grafts are the ideal grafts for the oral cavity. In areas that require smaller grafts, palatal mucosal graft can be successfully applied. Major disadvantage is donor area morbidity and limited size. Reversed dermal grafts had advantages over dermal grafts in the reconstruction of large mucosal defects. Meshed skin grafts can be obtained from smaller donor areas. In terms of mucosal appearance and functioning, the order from best to worst was palatal mucosal, reversed dermal, meshed skin, dermal, and full-thickness skin grafts. In terms of least contraction, the order was full-thickness skin, palatal mucosal, meshed skin, dermal, and reversed dermal grafts. The results of the study showed that, for vestibuloplasty , the best alternative to a palatal mucosal graft is a meshed skin graft .

27. RECENT ADVANCES GEISTLICH MUCOGRAFT Highly bio-functional collagen matrix (porcine) Autologous soft tissue graft alternative Off-the-shelf soft tissue graft avoids harvest-site morbidity Supports good integration and soft tissue regeneration Indications Gingival recession Socket seal following atraumatic tooth extraction Lack of keratinized tissue Shallow vestibule Treatment concepts for soft tissue regeneration with Geistlich Mucograft ®. Geistlich biomaterials.

28. Advantages Easy handling Good adherence Easy to suture Less pain and morbidity Less surgical chair time Faster soft tissue healing Natural soft tissue colour and structure Higher treatment safety compared to Connective tissue graft (CTG) and Free gingival graft (FGG) How does Geistlich mucograft act ? Promotes migration of connective tissue cells by signaling for keratinized tissue 2 components of the graft Compact layer- Protects the wound during open healing and allows suturing Spongy layer- Stabilizes blood clot and enables soft-tissue ingrowth

29. REF E RENCES Neelima Anil Malik, Textbook of Oral and Maxillofacial Surgery, 4 th edition. SM Balaji, Textbook of Oral and Maxillofacial Surgery, 3 rd edition. The Association of Oral and Maxillofacial Surgeons of India 2021, Oral and Maxillofacial Surgery for the clinician. Thomas. J. Starshak , Bruce Sanders, Preprosthetic oral and maxillofacial surgery Fonseca, Oral and maxillofacial surgery, Reconstructive and Implant surgery. Vol 7.

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