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Asutural maxillary vestibuloplasty
Asutural maxillary vestibuloplasty Philip L. Maloney, D.M.D., * Norman X. Shepherd, D.M.D.,*+ and H. C. Doku, D.M.D., M.X.D.,*“” Boston, Mass. TUFTS
UNIVFXWITY
SCHOOL
OF DENTAL
MEDICINE
On the basis of our experience with twelve patients, a technique for maxillary vestibuloplasty without the use of sutures is presented. This technique saves considerable operating time, and the result is more natural in contour in comparison to previously reported techniques. Postoperative injections of corticosteroids inhibits regression and keeps the fold soft and supple.
M
ost techniques currently proposed for maxillary vestibuloplasty advocate the suturing of the margin of the undermined mucosal Aap to the periosteum at the depth of the surgically developed sulcus. This step has been deemed to be necessary in the secondary epithelization, skin grafting, and mucosal grafting techniques. The exception to this procedure has been the buccal inlay (buccal sulcus skin grafting) technique, which has been recommended for patients with marked deficiency of bone height of the maxil1a.l Accordingly, after the supraperiosteal dissection, the margin of the undermined labial mucosa is not sutured to the periosteum; instead, multiple interrupted sutures are passed through the mucosal margin and are left untied. An impression of the wound is taken with a prefabricated splint. The skin grafts are placed over the flange of the splint, the splint is reinserted, and the previously placed interrupted sutures are tied to the palatal mucosa, drawing the margin of the labial mucosa over the splint. The ensuing postoperative contracture results in a sphincter type of entrance into the vestibule. The shrinkage is so drastic that the patient must wear the splint or his new denture continuously for one year. The technique has not become popular because of its inherent limitations. We previously introduced the free buccal mucosal graft technique for vestibuloplasty.2 After supraperiosteal dissection, the free mucosal margin was sutured and Professor of Oral Surgery, Tufts *Director of Oral Surgery, Boston City Hospital; University School of Dental Medicine. **Associate Clinical Professor of Oral Surgery. ***Professor and Chairman or Oral Surgery and Assistant Dean for Hospital Affairs.
858
Asutural maxilEary vestibubplasty
Volume 37 Number 6
Fig. 1. Preoperative
atrophic
edentulous
maxillary
859
ridge with epulis fissurata.
to the height of the new vestibule of the maxilla. This technique is successful in maintaining sulcus depth. However, we were concerned with two aspects: first, the suturing of the free mucosal margin to the periosteum was tedious and time-consuming; and secondly, the graft-mucosal junction was located at the apex of the vestibule. Although this junction consisted of only a fine scar, it did create a sharply pointed, firm vestibule instead of a smooth, inverted-U-shaped, soft vestibule. These two factors prompted us to make modifications in our original maxillary vestibuloplasty technique. This modified asutural technique has been used over a period of 18 months on twelve patients (Fig. 1). The initial phase of our technique is as previously described, namely, a mucosal incision at the mucogingival junction followed by a supraperiosteal dissection to the desired height. Any epithelial hyperplastic tissue, when present, is usually excised. The pcriosteal bed is carefully prepared by removing any remaining muscle fibers or submucosal tissue. A prefabricated acrylic splint lined with Veltec’ is inserted, muscle trimmed and removed. Inspection is then made in order to ascertain that the flange has a smooth, rounded contour. The free split-thickness buccal mucosal strips arc taken in the usual manner with a Castroviejo ElectroKeratot0me.t The Veltec-lined splint is painted with tincture of benzoin, and the mucosal strips are placed over the flange so that the mucosa will cover the receptor site when the splint is inserted. The strips are arranged in vertical fashion over the flange of the splint (Fig. 2). The splint is fixed to the maxilla with two v&inch Vitallium screws placed in the midline of the hard palate. The splint is removed on the fifth postoperative day; however, we instruct the patient to continue to wear the splint for 2 hours every morning and 2 hours every afternoon until a permanent denture is constructed. *Veltec D-P Company, Glendale, tCastrovieJo Electra-Keratotome, St. Louis, MO.
Calif. Storez Instrument
Co., 3365 Tree Court Industrial
Blvd.,
Fig. 9. Split-thickness inner nspcct, of tlw splint. screws.
huccal mucos:d strips have becln positioned over the flange and Note thcx two mitllinc~ pxlxtnl holw to awommotlatc the Vitallium
RESULTS Healing was excellent in all twelve patients. The maxillary vestibules of the patients were smooth and shaped like an inverted U. Moderate submucosal firmness was noticed in four patients. The submucosal tissues of these patients were injected locally with 30.0 mg. of trimacinolone acetonide at 21 and 42 days. These tissues gradually became soft and supple. Patients who were observed over a period of 12 months have not shown any significant regression in the depth of the vcstibulc ( tl’ig. 3). All patients have been fittetl with satisfactory dentures. DISCUSSION The modifications that we have introduced into the technique for vestibuloplasty with buccal mucosal grafts have been rewarding. The complete elimination of any suturing has saved considerable operating time, and the resultant vestibule is more natural in eoutour. The local injection of corticosteroids has added another dimension to the treatment of the patient requiring ridge extension, since contracturc and regression after vcstihuloplastp are of prime concern to the oral surgeon. The treatment of keloids with locally injected trimacinolone acetonide has been widely applied in both Negro and Caucasian patients.3 A keloid arises from an abundant production of fibrous tissue as a response to skin injury. Patients with keloids lack the ability to arrest the process of fibroplasia after sufficient healing has occurred. The mechanism of the steroids is believed to be an interference with the production of fibroblasts and, in turn, the production of colloid. This explains the prevention after excision of keloids but does not account for the softening process by mere injection of the keloid. The explanation offered is that the kcloid rqwcscnts a dynamic situation. Excessive atrophy of the skin has been
Asutural maxillary
Volume 37 Number 6
vestibuloplasty
861
Fig. PI. Maxillary vestibuloplasty one year after operation. There has been minimal regression. The mucobuccal fold is soft and shaped like an inverted U.
reported, as well as occasional cases of local depigmentation of the skin in Negroes. We think that injections of triamcinoline acetonide at 3-week intervals can modify the development of scar tissue in the area of the vestibuloplasty. This not only inhibits contracture and regression but also keeps the area soft and supple. Our modified asutural maxillary vestibuloplasty technique does result in a considerable portion of the receptor site being submucosal tissue rather than periosteal surface. Despite the fact that the submucosal tissue is covered with the graft, it is more prone to contracture and regression than a receptor site composed entirely of periosteum. The local injection of corticosteroids does provide a useful adjunct when deemed to be advisa.ble in the judgment of the surgeon. We are presently conducting animal studies in which corticosteroids are used with vestibuloplasty. It should be stated categorically that the practice of discontinuance of suturing the mucosal margin to the periosteum will stand on its own merit and does not rely upon the use of corticosteroids. This modified maxillary technique is distinct from the buccal inlay technique and offers numerous advantages over the
latter
technique plasty.
procedure.
merits
We
sclcrtion
think
that
the
as the primar)
results
indicate
method
that
this
for maxillary
asutural
vestibulo-
SUMMARY 1. Presented is a technique for maxillary vestibuloplasty with murosal grafts which eliminates all suturing. 2. Twelve patients who underwent asutural maxillary vestibuloplasty with mucosal grafts have been observed for as long as 12 months, without any significant regression in t,hc depth of t,he rcst,ihulc.
UNIVFXWITY
SCHOOL
OF DENTAL
MEDICINE
On the basis of our experience with twelve patients, a technique for maxillary vestibuloplasty without the use of sutures is presented. This technique saves considerable operating time, and the result is more natural in contour in comparison to previously reported techniques. Postoperative injections of corticosteroids inhibits regression and keeps the fold soft and supple.
M
ost techniques currently proposed for maxillary vestibuloplasty advocate the suturing of the margin of the undermined mucosal Aap to the periosteum at the depth of the surgically developed sulcus. This step has been deemed to be necessary in the secondary epithelization, skin grafting, and mucosal grafting techniques. The exception to this procedure has been the buccal inlay (buccal sulcus skin grafting) technique, which has been recommended for patients with marked deficiency of bone height of the maxil1a.l Accordingly, after the supraperiosteal dissection, the margin of the undermined labial mucosa is not sutured to the periosteum; instead, multiple interrupted sutures are passed through the mucosal margin and are left untied. An impression of the wound is taken with a prefabricated splint. The skin grafts are placed over the flange of the splint, the splint is reinserted, and the previously placed interrupted sutures are tied to the palatal mucosa, drawing the margin of the labial mucosa over the splint. The ensuing postoperative contracture results in a sphincter type of entrance into the vestibule. The shrinkage is so drastic that the patient must wear the splint or his new denture continuously for one year. The technique has not become popular because of its inherent limitations. We previously introduced the free buccal mucosal graft technique for vestibuloplasty.2 After supraperiosteal dissection, the free mucosal margin was sutured and Professor of Oral Surgery, Tufts *Director of Oral Surgery, Boston City Hospital; University School of Dental Medicine. **Associate Clinical Professor of Oral Surgery. ***Professor and Chairman or Oral Surgery and Assistant Dean for Hospital Affairs.
858
Asutural maxilEary vestibubplasty
Volume 37 Number 6
Fig. 1. Preoperative
atrophic
edentulous
maxillary
859
ridge with epulis fissurata.
to the height of the new vestibule of the maxilla. This technique is successful in maintaining sulcus depth. However, we were concerned with two aspects: first, the suturing of the free mucosal margin to the periosteum was tedious and time-consuming; and secondly, the graft-mucosal junction was located at the apex of the vestibule. Although this junction consisted of only a fine scar, it did create a sharply pointed, firm vestibule instead of a smooth, inverted-U-shaped, soft vestibule. These two factors prompted us to make modifications in our original maxillary vestibuloplasty technique. This modified asutural technique has been used over a period of 18 months on twelve patients (Fig. 1). The initial phase of our technique is as previously described, namely, a mucosal incision at the mucogingival junction followed by a supraperiosteal dissection to the desired height. Any epithelial hyperplastic tissue, when present, is usually excised. The pcriosteal bed is carefully prepared by removing any remaining muscle fibers or submucosal tissue. A prefabricated acrylic splint lined with Veltec’ is inserted, muscle trimmed and removed. Inspection is then made in order to ascertain that the flange has a smooth, rounded contour. The free split-thickness buccal mucosal strips arc taken in the usual manner with a Castroviejo ElectroKeratot0me.t The Veltec-lined splint is painted with tincture of benzoin, and the mucosal strips are placed over the flange so that the mucosa will cover the receptor site when the splint is inserted. The strips are arranged in vertical fashion over the flange of the splint (Fig. 2). The splint is fixed to the maxilla with two v&inch Vitallium screws placed in the midline of the hard palate. The splint is removed on the fifth postoperative day; however, we instruct the patient to continue to wear the splint for 2 hours every morning and 2 hours every afternoon until a permanent denture is constructed. *Veltec D-P Company, Glendale, tCastrovieJo Electra-Keratotome, St. Louis, MO.
Calif. Storez Instrument
Co., 3365 Tree Court Industrial
Blvd.,
Fig. 9. Split-thickness inner nspcct, of tlw splint. screws.
huccal mucos:d strips have becln positioned over the flange and Note thcx two mitllinc~ pxlxtnl holw to awommotlatc the Vitallium
RESULTS Healing was excellent in all twelve patients. The maxillary vestibules of the patients were smooth and shaped like an inverted U. Moderate submucosal firmness was noticed in four patients. The submucosal tissues of these patients were injected locally with 30.0 mg. of trimacinolone acetonide at 21 and 42 days. These tissues gradually became soft and supple. Patients who were observed over a period of 12 months have not shown any significant regression in the depth of the vcstibulc ( tl’ig. 3). All patients have been fittetl with satisfactory dentures. DISCUSSION The modifications that we have introduced into the technique for vestibuloplasty with buccal mucosal grafts have been rewarding. The complete elimination of any suturing has saved considerable operating time, and the resultant vestibule is more natural in eoutour. The local injection of corticosteroids has added another dimension to the treatment of the patient requiring ridge extension, since contracturc and regression after vcstihuloplastp are of prime concern to the oral surgeon. The treatment of keloids with locally injected trimacinolone acetonide has been widely applied in both Negro and Caucasian patients.3 A keloid arises from an abundant production of fibrous tissue as a response to skin injury. Patients with keloids lack the ability to arrest the process of fibroplasia after sufficient healing has occurred. The mechanism of the steroids is believed to be an interference with the production of fibroblasts and, in turn, the production of colloid. This explains the prevention after excision of keloids but does not account for the softening process by mere injection of the keloid. The explanation offered is that the kcloid rqwcscnts a dynamic situation. Excessive atrophy of the skin has been
Asutural maxillary
Volume 37 Number 6
vestibuloplasty
861
Fig. PI. Maxillary vestibuloplasty one year after operation. There has been minimal regression. The mucobuccal fold is soft and shaped like an inverted U.
reported, as well as occasional cases of local depigmentation of the skin in Negroes. We think that injections of triamcinoline acetonide at 3-week intervals can modify the development of scar tissue in the area of the vestibuloplasty. This not only inhibits contracture and regression but also keeps the area soft and supple. Our modified asutural maxillary vestibuloplasty technique does result in a considerable portion of the receptor site being submucosal tissue rather than periosteal surface. Despite the fact that the submucosal tissue is covered with the graft, it is more prone to contracture and regression than a receptor site composed entirely of periosteum. The local injection of corticosteroids does provide a useful adjunct when deemed to be advisa.ble in the judgment of the surgeon. We are presently conducting animal studies in which corticosteroids are used with vestibuloplasty. It should be stated categorically that the practice of discontinuance of suturing the mucosal margin to the periosteum will stand on its own merit and does not rely upon the use of corticosteroids. This modified maxillary technique is distinct from the buccal inlay technique and offers numerous advantages over the
latter
technique plasty.
procedure.
merits
We
sclcrtion
think
that
the
as the primar)
results
indicate
method
that
this
for maxillary
asutural
vestibulo-
SUMMARY 1. Presented is a technique for maxillary vestibuloplasty with murosal grafts which eliminates all suturing. 2. Twelve patients who underwent asutural maxillary vestibuloplasty with mucosal grafts have been observed for as long as 12 months, without any significant regression in t,hc depth of t,he rcst,ihulc.