- Email: [email protected]
Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique
YIJOM-2952; No of Pages 3
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.07.005, available online at http://www.sciencedirect.com
Case Report Pre-Implant Surgery
Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique
C. Bouchard, P.-E´. Landry, V.Goodyer Centre Hospitalier Universitaire (CHU) de Que´bec, Universite´ Laval, Hoˆpital de l’Enfant-Je´sus, Que´bec, Canada
C. Bouchard, P.-E´. Landry, V. Goodyer: Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Nowadays, upper denture instability secondary to severe maxillary atrophy is treated, in most cases, with dental implants. However, a significant number of patients cannot afford this procedure. Palatal bone deepening through a U-shaped osteotomy has been described previously. The procedure increases retention by improving the suction effect of the palate and prevents anteroposterior and lateral movement of the denture. By combining this procedure with a secondary epithelialization vestibuloplasty, the labial aspect of the ridge is also extended and it does not require a skin graft. This article describes a modification of the palatal vault osteotomy through the presentation of a case.
Severe maxillary atrophy affecting denture stability causes masticatory, aesthetic, and psychosocial problems. Implant placement to treat this condition is today’s standard of care, however, a significant number of patients cannot undergo this procedure for pecuniary reasons or have medical co-morbidities contraindicating complex bone grafting interventions. Soft tissue procedures, such as submucous vestibuloplasty, mostly prevent lateral movement of the denture. Bone grafting operations (onlay, inlay, or interpositional) carry morbidity, and without implant placement, they resorb quickly. In 1976, the team reported a technique to increase palatal depth based on the 0901-5027/000001+03
original description by Wassmund.1,2 This simple technique involves a deepening of the palatal vault by elevation of a bone segment towards the nasal cavity. The procedure allows a significant improvement in denture stability by reducing anteroposterior movement of the prosthesis and by increasing the suction effect of the palate. This operation has been performed on over a hundred patients through the years, with good results, no relapse, and few complications. More recently, the authors have modified the original technique to improve denture retention by combining the palatal osteotomy with a secondary epithelialization vestibuloplasty (sometimes called a
Keywords: maxillary atrophy; preprosthetic surgery; palate; osteotomy. Accepted for publication 15 July 2014
lipswitch or Kazanjian vestibuloplasty).3,4 This modification has the advantage of indirectly increasing the alveolar crest height on the palatal and the labial aspect of the ridge and it does not require a skin graft. It also facilitates soft tissue closure. The purpose of this article is to describe a modified palatal vault osteotomy technique through the presentation of a case. Case presentation
A 62-year-old female patient was referred to the department of oral and maxillofacial surgery of hospital with a chief complaint of upper denture instability. The patient was unable to chew or speak with the
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005
YIJOM-2952; No of Pages 3
2
Bouchard et al.
denture in place and did not wear the prosthesis most of the time. Her past medical history was significant for schizophrenia and depression, for which she was taking quetiapine, olanzapine, clonazepam, and paroxetine. On physical exam, it was noticed that her upper prosthesis was unstable and was dislodged every time the patient made an effort to speak. Vestibular and palatal vault depths were significantly reduced (Fig. 1). The ridge was flat and most of the alveolar process was resorbed. The patient was diagnosed with a class V Cawood and Howell maxillary resorption.5 Reconstruction with a bone graft with subsequent implant placement was proposed to the patient, but she refused this therapeutic option for pecuniary reasons. The decision was made to perform a palatal osteotomy with a secondary epithelialization vestibuloplasty under general anaesthesia. The patient was brought to the operating theatre, placed under general anaesthesia, and intubated nasally. She was given 2 mg of cephazolin intravenous (IV) and 80 mg of methylprednisolone IV 30 min before the start of the operation. Methylprednisolone was repeated every 4 h postoperatively for a total of four doses. The buccal vestibule was infiltrated with 10 ml of mepivacaine with epinephrine 1:200,000. A vestibular incision approximately 1 cm superior to the mucogingival junction was performed. In the middle, the incision was kept almost at the mucogingival junction because it was impossible to gain vertical height due to the presence of the anterior nasal spine. A supraperiosteal dissection was carried out superiorly to the level of the infraorbital nerves anteriorly and to the zygomatic buttresses posteriorly. Inferiorly, the flap was also dissected supraperiosteally to the summit of the remaining alveolar process and then the periosteum was incised. The palatal mucosa was carefully elevated so as to preserve both greater palatine arteries (Fig. 2). The nasopalatine neurovascular bundle was sectioned.
Fig. 1. Preoperative intraoral photograph showing the severe maxillary alveolar atrophy.
Fig. 2. Intraoperative photograph showing the design of the incision and the osteotomized palatal bone after its upward repositioning. The incision is located at the mucogingival junction and the dissection supraperiosteal to the summit of the alveolar ridge.
A U-shaped osteotomy along the palatal side of the alveolar ridge from the nasopalatine canal to the posterior part of the hard palate was done with a carbide-cutting bur under copious saline irrigation (Fig. 2). The osteotomy was maintained medially to the greater palatine canals posteriorly to preserve the vascular supply to the mucosa. Once the osteotomy was completed, the palatal bone segment was moved inferiorly and the nasal septum sectioned, freeing it completely. A septoplasty and bilateral inferior turbinectomies were done to position the palatal bone superiorly without interfering with nasal structures. The free palatal bone was elevated until it was in contact with the nasal mucosa and the depth of the palate judged adequate (Fig. 2). Two transalveolar wires were inserted in the premolar area. These wires serve the dual purpose of maintaining the palatal bone and denture in position during healing (Fig. 3). The palatal mucosa was sutured to the periosteum with 4–0 Vicryl sutures on top of the alveolar process. The palatal portion of the patient’s own prosthesis was augmented with a thick layer of rigid impression compound (Kerr Corporation, Romulus, MI, USA). The peripheral
Fig. 3. Two transalveolar wires were inserted in the premolar areas from the lateral aspect of the ridge to the osteotomy line medially to maintain the palatal bone in its position and the denture in place during the healing period.
Fig. 4. Four months postoperative intraoral photograph.
margin of the prosthesis was also augmented with orthodontic resin (Dentsply Caulk, Milford, DE, USA) to allow an increased vestibular depth by secondary healing of this area. The modified denture was put back in place and secured with the two previously inserted stainless-steel wires (Fig. 3). Six weeks postoperatively, the denture was removed and relined with resilient acrylic material (Bosworth Trusoft, Skokie, IL, USA) and the final prosthesis delivered 3 months later. The depth of the vestibule and palate were significantly increased and excellent denture stability was achieved (Fig. 4). No postoperative complications were noted. Discussion
The palatal osteotomy was developed to improve denture stability in the extremely resorbed maxilla at a time when dental implants did not exist.2 Preprosthetic procedures were the only available option to treat extreme maxillary atrophy. Today, these procedures have fallen out of fashion due to advances in implant dentistry. It is now possible to place dental implants even in the severely atrophic maxilla. The use of modern imaging techniques allows clinicians to carefully select implant locations and in many cases, bone grafting is not even necessary. However, these treatments are expensive and most dental insurance companies will not cover the expenses related to this type of reconstruction. Palatal vault deepening offers an alternative for those patients who cannot undergo implant placement. With the modification described, denture stability is greatly improved and the cost of the operation is minimal. When initially described, the incision for the palatal osteotomy was placed on top of the alveolar ridge.1 It had to be undermined on the vestibular aspect to enable closure of the incision once the palatal bone was in its new position. This made closure difficult and it reduced the vestibular depth by moving the mucosa
Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005
YIJOM-2952; No of Pages 3
Palatal osteotomy with vestibuloplasty towards the palate. By combining the palatal osteotomy with a vestibuloplasty, vestibular depth is increased and there is no tension on the incision. This combined approach has the inconvenience of leaving a large area of soft tissue to heal secondarily and requires that the patient’s denture be rigidly fixated for 4–6 weeks. The prosthesis offers a protection to the exposed tissues and our experience is that pain is kept to a minimum during that period. Also, the extended flanges of the denture reduce relapse by preventing contracture in the healing phase. Donor site morbidity of a skin graft is avoided and denture retention is superior on non-keratinized mucosa.3 Leonard and Howe reported a series of five cases treated by conventional palatal vault osteotomy in 1978.6 The mean increase in palatal depth obtained in the coronal plane was 5.4 mm. The authors mentioned that they performed a submucous vestibuloplasty 3 weeks after the palatal osteotomy because they were dissatisfied with the single-stage operation, but no further explanation was given. In 1986, Tiner et al. described a modification of the technique by avoiding total reflection of the palatal flap.7 Soft tissues are elevated only to the level of the osteotomy, maintaining the vascular supply to the osteotomized segment. While this is in theory an advantage, we believe that this has no effect on postoperative results and we have never experienced bone necrosis or sequestrum formation. Hori et al. also reported two cases of palatal osteotomy with excellent results and no complications.8 They avoided a complete descent of the palatal vault by making a midsagittal osteotomy at the suture line. Each bone section was then pushed superiorly and the nasal septum exposed and trimmed. Kitayama et al.,9 Steinha¨user,10 and Yoshizama et al.,11 all proposed similar modifications of the osteotomy. The authors believe that a complete exposure of the nasal septum and inferior turbinates is necessary to modify these structures as necessary
and allow an unrestricted movement of the palate upward. According to author’s experience, a U-shaped osteotomy with complete downward fracture of the palatal segment is the easiest way to obtain this. Possible complications of this procedure include loss of vascular supply to the palate with subsequent necrosis of the soft tissue, oro-nasal communication, nasal septum deviation, obstruction of nasal airflow, and relapse. Because of the natural tongue position and the lack of any muscular attachment in the area of the osteotomy, this last complication is seldom encountered. As for nasal complications such as snoring due to narrowing of the nasal cavity, these can easily be avoided by carefully trimming excess septal cartilage and performing inferior turbinectomies when necessary. The blood supply is easily maintained by placing the osteotomy medial to the greater palatine foramens and with careful soft tissue dissection and manipulation. Excess pressure on soft tissues by the modified prosthesis has to be avoided to prevent compression of the vascular supply. The palatal osteotomy combined with vestibuloplasty improves vestibular and palatal depth and prevents anteroposterior and lateral movement of upper dentures in the extremely resorbed maxilla. The procedure is relatively easy to perform and complications are rare. Although indications for this operation are rare, it could be offered to patients who cannot undergo implant placement. Funding
None. Competing interests
None. Ethical approval
Not required. Patient consent
Not required.
3
References 1. Charest A, Goodyer V. Palatal osteotomy: a simple approach to maxillary alveolar atrophy. J Oral Surg 1976;34:442–4. 2. Wassmund M. Uber chirurgishe formgestaltung des astrophischen kiefers zum zwecke prothetischer versorgung. Vierteljahresschrift Zahnheildke 1931;47:305. 3. Kethley Jr JL, Gamble JW. The lipswitch: a modification of Kazanjian’s labial vestibuloplasty. J Oral Surg 1978;36:701–5. 4. Kazanjian VH. Surgery as an aid to more efficient service with prosthetic dentures. J Am Dent Assoc 1935;22:566. 5. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg 1988;17:232–6. 6. Leonard M, Howe GL. Palatal vault osteotomy. Oral Surg Oral Med Oral Pathol 1978;46:344–8. 7. Tiner BD, Aragon SB, McAnear JT. Modification of the palatal vault osteotomy. J Oral Maxillofac Surg 1986;44:489–91. 8. Hori M, Okaue M, Matsunaga S, Iwanari S, Matsumoto M, Tanaka H, et al. Preprosthetic surgery for severely atrophic maxilla with poor palatal vault form; report of two cases treated by hard palate compression through palatal vault osteotomy. J Nihon Univ Sch Dent 1993;35:186–91. 9. Kitayama S, Oda S, Nagano T, Shibata Y, Kondu K, Toyoda T. A modification of hard palate compression for marked atrophic maxilla. Jpn J Oral Maxillofac Surg 1987;33: 791–6. 10. Steinha¨user EW. Methods for operative improvements of the palatal arch. Zahnarztl Prax 1978;29:50–4. [in German]. 11. Yoshizawa N, Shimada K, Yanai T, Shibata H, Yamada M, Kawashima Y, et al. Hard palate compression for greatly reduced alveolar ridge of the maxilla. Jpn J Oral Maxillofac Surg 1981;27:1602–8.
Address: Carl Bouchard Centre Hospitalier Universitaire (CHU) de Que´bec Universite´ Laval Hoˆpital de l’Enfant-Je´sus 1401 18e rue Que´bec G1J 1Z4 Canada Tel.: +1 418 265 8744; Fax: +1 418 624 3338 E-mail: [email protected]
Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.07.005, available online at http://www.sciencedirect.com
Case Report Pre-Implant Surgery
Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique
C. Bouchard, P.-E´. Landry, V.Goodyer Centre Hospitalier Universitaire (CHU) de Que´bec, Universite´ Laval, Hoˆpital de l’Enfant-Je´sus, Que´bec, Canada
C. Bouchard, P.-E´. Landry, V. Goodyer: Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Nowadays, upper denture instability secondary to severe maxillary atrophy is treated, in most cases, with dental implants. However, a significant number of patients cannot afford this procedure. Palatal bone deepening through a U-shaped osteotomy has been described previously. The procedure increases retention by improving the suction effect of the palate and prevents anteroposterior and lateral movement of the denture. By combining this procedure with a secondary epithelialization vestibuloplasty, the labial aspect of the ridge is also extended and it does not require a skin graft. This article describes a modification of the palatal vault osteotomy through the presentation of a case.
Severe maxillary atrophy affecting denture stability causes masticatory, aesthetic, and psychosocial problems. Implant placement to treat this condition is today’s standard of care, however, a significant number of patients cannot undergo this procedure for pecuniary reasons or have medical co-morbidities contraindicating complex bone grafting interventions. Soft tissue procedures, such as submucous vestibuloplasty, mostly prevent lateral movement of the denture. Bone grafting operations (onlay, inlay, or interpositional) carry morbidity, and without implant placement, they resorb quickly. In 1976, the team reported a technique to increase palatal depth based on the 0901-5027/000001+03
original description by Wassmund.1,2 This simple technique involves a deepening of the palatal vault by elevation of a bone segment towards the nasal cavity. The procedure allows a significant improvement in denture stability by reducing anteroposterior movement of the prosthesis and by increasing the suction effect of the palate. This operation has been performed on over a hundred patients through the years, with good results, no relapse, and few complications. More recently, the authors have modified the original technique to improve denture retention by combining the palatal osteotomy with a secondary epithelialization vestibuloplasty (sometimes called a
Keywords: maxillary atrophy; preprosthetic surgery; palate; osteotomy. Accepted for publication 15 July 2014
lipswitch or Kazanjian vestibuloplasty).3,4 This modification has the advantage of indirectly increasing the alveolar crest height on the palatal and the labial aspect of the ridge and it does not require a skin graft. It also facilitates soft tissue closure. The purpose of this article is to describe a modified palatal vault osteotomy technique through the presentation of a case. Case presentation
A 62-year-old female patient was referred to the department of oral and maxillofacial surgery of hospital with a chief complaint of upper denture instability. The patient was unable to chew or speak with the
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005
YIJOM-2952; No of Pages 3
2
Bouchard et al.
denture in place and did not wear the prosthesis most of the time. Her past medical history was significant for schizophrenia and depression, for which she was taking quetiapine, olanzapine, clonazepam, and paroxetine. On physical exam, it was noticed that her upper prosthesis was unstable and was dislodged every time the patient made an effort to speak. Vestibular and palatal vault depths were significantly reduced (Fig. 1). The ridge was flat and most of the alveolar process was resorbed. The patient was diagnosed with a class V Cawood and Howell maxillary resorption.5 Reconstruction with a bone graft with subsequent implant placement was proposed to the patient, but she refused this therapeutic option for pecuniary reasons. The decision was made to perform a palatal osteotomy with a secondary epithelialization vestibuloplasty under general anaesthesia. The patient was brought to the operating theatre, placed under general anaesthesia, and intubated nasally. She was given 2 mg of cephazolin intravenous (IV) and 80 mg of methylprednisolone IV 30 min before the start of the operation. Methylprednisolone was repeated every 4 h postoperatively for a total of four doses. The buccal vestibule was infiltrated with 10 ml of mepivacaine with epinephrine 1:200,000. A vestibular incision approximately 1 cm superior to the mucogingival junction was performed. In the middle, the incision was kept almost at the mucogingival junction because it was impossible to gain vertical height due to the presence of the anterior nasal spine. A supraperiosteal dissection was carried out superiorly to the level of the infraorbital nerves anteriorly and to the zygomatic buttresses posteriorly. Inferiorly, the flap was also dissected supraperiosteally to the summit of the remaining alveolar process and then the periosteum was incised. The palatal mucosa was carefully elevated so as to preserve both greater palatine arteries (Fig. 2). The nasopalatine neurovascular bundle was sectioned.
Fig. 1. Preoperative intraoral photograph showing the severe maxillary alveolar atrophy.
Fig. 2. Intraoperative photograph showing the design of the incision and the osteotomized palatal bone after its upward repositioning. The incision is located at the mucogingival junction and the dissection supraperiosteal to the summit of the alveolar ridge.
A U-shaped osteotomy along the palatal side of the alveolar ridge from the nasopalatine canal to the posterior part of the hard palate was done with a carbide-cutting bur under copious saline irrigation (Fig. 2). The osteotomy was maintained medially to the greater palatine canals posteriorly to preserve the vascular supply to the mucosa. Once the osteotomy was completed, the palatal bone segment was moved inferiorly and the nasal septum sectioned, freeing it completely. A septoplasty and bilateral inferior turbinectomies were done to position the palatal bone superiorly without interfering with nasal structures. The free palatal bone was elevated until it was in contact with the nasal mucosa and the depth of the palate judged adequate (Fig. 2). Two transalveolar wires were inserted in the premolar area. These wires serve the dual purpose of maintaining the palatal bone and denture in position during healing (Fig. 3). The palatal mucosa was sutured to the periosteum with 4–0 Vicryl sutures on top of the alveolar process. The palatal portion of the patient’s own prosthesis was augmented with a thick layer of rigid impression compound (Kerr Corporation, Romulus, MI, USA). The peripheral
Fig. 3. Two transalveolar wires were inserted in the premolar areas from the lateral aspect of the ridge to the osteotomy line medially to maintain the palatal bone in its position and the denture in place during the healing period.
Fig. 4. Four months postoperative intraoral photograph.
margin of the prosthesis was also augmented with orthodontic resin (Dentsply Caulk, Milford, DE, USA) to allow an increased vestibular depth by secondary healing of this area. The modified denture was put back in place and secured with the two previously inserted stainless-steel wires (Fig. 3). Six weeks postoperatively, the denture was removed and relined with resilient acrylic material (Bosworth Trusoft, Skokie, IL, USA) and the final prosthesis delivered 3 months later. The depth of the vestibule and palate were significantly increased and excellent denture stability was achieved (Fig. 4). No postoperative complications were noted. Discussion
The palatal osteotomy was developed to improve denture stability in the extremely resorbed maxilla at a time when dental implants did not exist.2 Preprosthetic procedures were the only available option to treat extreme maxillary atrophy. Today, these procedures have fallen out of fashion due to advances in implant dentistry. It is now possible to place dental implants even in the severely atrophic maxilla. The use of modern imaging techniques allows clinicians to carefully select implant locations and in many cases, bone grafting is not even necessary. However, these treatments are expensive and most dental insurance companies will not cover the expenses related to this type of reconstruction. Palatal vault deepening offers an alternative for those patients who cannot undergo implant placement. With the modification described, denture stability is greatly improved and the cost of the operation is minimal. When initially described, the incision for the palatal osteotomy was placed on top of the alveolar ridge.1 It had to be undermined on the vestibular aspect to enable closure of the incision once the palatal bone was in its new position. This made closure difficult and it reduced the vestibular depth by moving the mucosa
Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005
YIJOM-2952; No of Pages 3
Palatal osteotomy with vestibuloplasty towards the palate. By combining the palatal osteotomy with a vestibuloplasty, vestibular depth is increased and there is no tension on the incision. This combined approach has the inconvenience of leaving a large area of soft tissue to heal secondarily and requires that the patient’s denture be rigidly fixated for 4–6 weeks. The prosthesis offers a protection to the exposed tissues and our experience is that pain is kept to a minimum during that period. Also, the extended flanges of the denture reduce relapse by preventing contracture in the healing phase. Donor site morbidity of a skin graft is avoided and denture retention is superior on non-keratinized mucosa.3 Leonard and Howe reported a series of five cases treated by conventional palatal vault osteotomy in 1978.6 The mean increase in palatal depth obtained in the coronal plane was 5.4 mm. The authors mentioned that they performed a submucous vestibuloplasty 3 weeks after the palatal osteotomy because they were dissatisfied with the single-stage operation, but no further explanation was given. In 1986, Tiner et al. described a modification of the technique by avoiding total reflection of the palatal flap.7 Soft tissues are elevated only to the level of the osteotomy, maintaining the vascular supply to the osteotomized segment. While this is in theory an advantage, we believe that this has no effect on postoperative results and we have never experienced bone necrosis or sequestrum formation. Hori et al. also reported two cases of palatal osteotomy with excellent results and no complications.8 They avoided a complete descent of the palatal vault by making a midsagittal osteotomy at the suture line. Each bone section was then pushed superiorly and the nasal septum exposed and trimmed. Kitayama et al.,9 Steinha¨user,10 and Yoshizama et al.,11 all proposed similar modifications of the osteotomy. The authors believe that a complete exposure of the nasal septum and inferior turbinates is necessary to modify these structures as necessary
and allow an unrestricted movement of the palate upward. According to author’s experience, a U-shaped osteotomy with complete downward fracture of the palatal segment is the easiest way to obtain this. Possible complications of this procedure include loss of vascular supply to the palate with subsequent necrosis of the soft tissue, oro-nasal communication, nasal septum deviation, obstruction of nasal airflow, and relapse. Because of the natural tongue position and the lack of any muscular attachment in the area of the osteotomy, this last complication is seldom encountered. As for nasal complications such as snoring due to narrowing of the nasal cavity, these can easily be avoided by carefully trimming excess septal cartilage and performing inferior turbinectomies when necessary. The blood supply is easily maintained by placing the osteotomy medial to the greater palatine foramens and with careful soft tissue dissection and manipulation. Excess pressure on soft tissues by the modified prosthesis has to be avoided to prevent compression of the vascular supply. The palatal osteotomy combined with vestibuloplasty improves vestibular and palatal depth and prevents anteroposterior and lateral movement of upper dentures in the extremely resorbed maxilla. The procedure is relatively easy to perform and complications are rare. Although indications for this operation are rare, it could be offered to patients who cannot undergo implant placement. Funding
None. Competing interests
None. Ethical approval
Not required. Patient consent
Not required.
3
References 1. Charest A, Goodyer V. Palatal osteotomy: a simple approach to maxillary alveolar atrophy. J Oral Surg 1976;34:442–4. 2. Wassmund M. Uber chirurgishe formgestaltung des astrophischen kiefers zum zwecke prothetischer versorgung. Vierteljahresschrift Zahnheildke 1931;47:305. 3. Kethley Jr JL, Gamble JW. The lipswitch: a modification of Kazanjian’s labial vestibuloplasty. J Oral Surg 1978;36:701–5. 4. Kazanjian VH. Surgery as an aid to more efficient service with prosthetic dentures. J Am Dent Assoc 1935;22:566. 5. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg 1988;17:232–6. 6. Leonard M, Howe GL. Palatal vault osteotomy. Oral Surg Oral Med Oral Pathol 1978;46:344–8. 7. Tiner BD, Aragon SB, McAnear JT. Modification of the palatal vault osteotomy. J Oral Maxillofac Surg 1986;44:489–91. 8. Hori M, Okaue M, Matsunaga S, Iwanari S, Matsumoto M, Tanaka H, et al. Preprosthetic surgery for severely atrophic maxilla with poor palatal vault form; report of two cases treated by hard palate compression through palatal vault osteotomy. J Nihon Univ Sch Dent 1993;35:186–91. 9. Kitayama S, Oda S, Nagano T, Shibata Y, Kondu K, Toyoda T. A modification of hard palate compression for marked atrophic maxilla. Jpn J Oral Maxillofac Surg 1987;33: 791–6. 10. Steinha¨user EW. Methods for operative improvements of the palatal arch. Zahnarztl Prax 1978;29:50–4. [in German]. 11. Yoshizawa N, Shimada K, Yanai T, Shibata H, Yamada M, Kawashima Y, et al. Hard palate compression for greatly reduced alveolar ridge of the maxilla. Jpn J Oral Maxillofac Surg 1981;27:1602–8.
Address: Carl Bouchard Centre Hospitalier Universitaire (CHU) de Que´bec Universite´ Laval Hoˆpital de l’Enfant-Je´sus 1401 18e rue Que´bec G1J 1Z4 Canada Tel.: +1 418 265 8744; Fax: +1 418 624 3338 E-mail: [email protected]
Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005