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Reverse visor osteotomy for augmentation of the atrophic edentulous mandible
BODNER ET AL
that caused entrapment of epithelium at the fracture line, with subsequent proliferation.
patient such an exvagination became separated from the main body of the sinus and subsequently started to grow.
References
Summary
1. Stafne EC: Possible role of retained deciduous roots in etiology of cyst of the jaw. J Am Dent Assoc 24:1488, 1937 2. Gorlin RJ: Potentialities of oral epithelium manifest by mandibular dentigerous cysts. Oral Surg 10:271, 1957 3. Shear M: Secretory epithelium in the lining of dental cysts. J Dent Assoc S Afr 15:117, 1960 4. Shear M: Cysts of the Oral Regions. Bristol, John Wright & Sons Ltd, 1976, p 170 5. Killey HC. Kay LW, Seward GR: Benign Cystic Lesions of the Jaws: Their Diagnosis and Treatment. Ed. 3. New York, Churchill Livingstone, 1977, p 173 6. Sperber GH: Craniofacial Embryology. Ed. 2. Bristol, John Wright & Sons Ltd, 1976, p 163 7. Gregory GT, Shafer WG: Surgical ciliated cysts of the maxilla. J Oral Surg 16:251, 253, 1958
An unusual cyst of the zygoma is described. Three patterns of development of the cyst are suggested, namely: 1. Residual cyst of retained deciduous roots with metaplasia of the odontogenic epithelium into resniratory epithelium. 2. Fissural cyst of the zygomatico-maxillary suture. 3. Connection to the maxillary sinus, by a developmental exvagination or trauma to the sinus
Reverse Visor Osteotomy for Augmentation of the Atrophic Eden tulous Mandible GEORGE T. STRATIGOS, DDS, MSD,* ALAN CASSARA, AND MARK BIRNBAUM, DDSS The atrophic edentulous mandible has long been a problem to patients and practitioners. The inability to control a prosthesis, pain and discomfort due to the small basal seat for denture support, direct pressure on the inferior alveolar nerve, poor dietary intake, improper mastication, and the associated physiologic and social difficulties are all problems to be dealt with. l Methods of treatment include meticulous prosthesis construction, soft tissue surgical procedures, and ridge augmentation.‘-‘” This paper reports a case in which a new surgical treatment for the atrophic edentulous mandible, a reverse visor osteotomy, is used for osseous augmentation. This procedure, as with other visor augmentations, is possible because the atrophic edentulous mandible is frequently greater in its medial-lateral dimension than in its superior-inferior dimension.16 The osteotomy is made so that the buccal aspect is slid
DMDJ
superiorly and posteriorly along the sagittal bony cut. Because all soft tissue attachments are removed, the buccal segment is actually a free graft. The procedure avoids injury to the inferior alveolar nerve, does not require a distant donor site with its associated problems, and provides a graft of almost ideal mandibular contour. An incidental result is that it helps correct facial and interarch pseudoprognathism. Case Report A 59-year-old woman came to our department with a chief complaint of not being able to wear her lower denture. The patient had had this difficulty for many years and had originally lost her dentition at the age of 25. Her medical history included long-standing advanced osteoarthritis, which had been treated SymptomaticaIly, and a right total hip replacement secondary to the degenerative arthritis in 1972. On physical examination she appeared older than 59 and had a slight pseudoprognathic facial appearance (Fig. 1). Intraoral findings included an atrophic mandible, prominent genial tubercles, decreased vestibular depth with a lack of attached mucosa, and a relatively wide mandible in relation to its height (Fig. 2). Because of the apparent advanced age of the patient, and the history of long-standing osteoarthritis and total hip replacement, it was decided that the modified reverse visor osteotomy could provide a greater and more stable base for a mandibular prosthesis while helping to eliminate both the facial and the interarch pseudoprognathism.
* Director, Department of Oral and Maxillofacial Surgery and Dentistry, Lincoln Hospital, Professor, New York Medical College. t Chief Resident, Department of Oral and Maxillofacial Surgery and Dentistry, Lincoln Hospital. Senior Resident, Department of Oral and Maxillofacial Surgery and Dentistry, Lincoln Hospital. Received from the Department of Oral and Maxillofacial Surgery and Dentistry, Lincoln Medical and Mental Health Center, 234 E. 149th Street, Bronx, New York, 10451. Address correspondence and reprint requests to Dr. Stratigos.
0278-2391/82/0400/0231 $00.60 Q American Association of Oral and Maxillofacial Surgeons
231
232
REVERSE VISOR OSTEOTOMY
FIGURE 3. Leff, the osteotomy cut. FIGURE 4. Right, The position of the free bony graft and of the circummandibular wires.
The patient was admitted to the hospital. Her vital signs and the results of operative blood studies, urinalysis, chest radiograph, and electrocardiograph were essentially within normal limits. Under nasotracheal general anesthesia, and after administration of a local anesthetic into the mucobuccal tissues, an incision was made in the lateral aspect of the vestibule from one retromolar region to the other. The mandible was degloved and the major flap developed lingually. The mental nerves were identified and retracted with the lingual flap. The genial muscles were severed, and tubercle reduction was performed. A bony cut was made from right to left, buccal to the mental foramen and tapering buccally in the molar regions (Fig. 3). The sagittal osteotomy allowed the entire buccal segment (free from all soft tissue attachments) to be positioned superiorly and posteriorly to augment mandibular height. The graft was ligated in position with one interosseous and two circummandibular wires (Fig. 4). After copious irrigation, the site was closed with 3-O chromic sutures in deeper layers and 3-O continuous silk sutures for watertight closure and to aid in oral hygiene (a minimum of suture material being present intraorally).
Intravenous aqueous penicillin was administered preoperatively, intraoperatively, and postoperatively. No corticosteroids were used. The patient had an unremarkable postoperative course, with moderate swelling and altered sensation of the lower lip. She was discharged two days postoperatively and was followed up closely for signs of sepsis and dehiscence. Antibiotics were continued orally for two weeks, and sutures were removed
FIGURE 5.
Postoperative
radiograph of graft.
233
STRATIGOS ET AL.
FIGURE 7.
Ri&t.
Postbperative
_
facial profile.
on the fourteenth day. There was no sepsis or opening of the operative site. The altered lip sensation has been steadily diminishing. The only noticeable physical finding was the loss of weight during the postoperative period. Radiographically, there was an evident increase in mandibular height (Fig. 5). Although long-term follow-up of this procedure has not yet occurred, the skin graft vestibuloplasty was performed at six months. At the time of surgery, we found literally no bone resorption; the circummandibular wires placed at initial surgery were firm and showed no signs of loosening. The six-month radiograph confirmed these observations (Fig. 6). Discussion
The indications for reverse visor osteotomy include a wide buccal-lingual mandibular width, interarch and facial pseudoprognathism, adequate posterior ridge height, and medical problems making it impossible for the patient to tolerate a hip or rib graft procedure. There are many possible advantages to the technique. By moving the buccal segment superiorly and posteriorly, facial and interarch pseudoprognathism can be decreased (Fig. 7). Morbidity to the inferior alveolar nerve is eliminated, although the possibility of mental nerve paresthesia is present. A separate donor site is also avoided and, by using known stress-bearing bone, we believe that resorption secondary to wearing a prosthesis may be decreased. Contraindications to the reverse visor osteotomy include thin buccal-lingual width of the mandible and an overall thin mandible with little medullary bone. Also, if the patient is unable or unwilling to undergo two surgical procedures and to be without a mandibular prosthesis for approximately six to eight months, this procedure is not indicated.
References 1. Kratochvil FJ et al: Rehabilitation of grossly deficient mandibles with combined subperiosteal implants and bone grafts. J Prosthet Dent 35:452, 1976 2. Baker RD, Connole PW: Pre-prosthetic augmentation grafting-autogenous bone. J Oral Surg 35:541, 1977 3. Steinhauser E, Obwegeser HL: Second International Conference on Oral Surgery-1965. Copengagen, Munksgaard, 1976,pp 203 4. Baker RD et al: Long term results of alveolar ridge augmentation. J Oral Surg 37:486, 1979 5. Bunte M et al: Ceramic augmentation of the lower jaw. J Maxillofac Surg 5:303, 1977 6. Constantinides J et al: Homogenous bone grafts to the mandible. J Oral Surg 36:599, 1978 7. Harashina T et al: Reconstruction of mandibular defects with revascularized free rib grafts. Plast Reconstruct Surg 621514, 1978 8. Gazili M et al: Follow-up investigation of reconstruction of the alveolar process in the atrophic mandible. Int J Oral Surg 7:400, 1978 9. De Koomen HA et al: Interposed bone-graft augmentation of the atrophic mandible (a progress report). J Maxillofac Surg 7: 129, 1979 10. Ridley MT et al: Resorption of rib graft to inferior border of the mandible. J Oral Surg 36:546, 1978 11. Curtis TA et al: Autogenous bone graft procedures for atrophic endentulous mandibles. J Prosthet Dent 38:366. 1977 12. Leake DL: Contouring split ribs for correction of severe mandibular atrophy. J Oral Surg 34:940, 1976 13. Sanders B eta]: Inferior-border rib grafting for augmentation of the atrophic endentulous mandible. J Oral Surg 34:897, 1976 14. Davis WH et al: Transoral bone graft for atrophy of the mandible. J Oral Surg 28:760, 1970 15. Harle F: Visor osteotomy to increase the absolute height of the atrophied mandible: A preliminary report. J Maxillofac Surg 3:257, 1975 16. Peterson LJ Slade EW Jr: Mandibular ridge augmentation by a modified visor osteotomy: Preliminary report. J Oral Surg 35:999, 1977 17. Fitzpatrick B: Current concepts in the surgical management of the atrophic mandible. Aust Dent J 23:344, 1978
that caused entrapment of epithelium at the fracture line, with subsequent proliferation.
patient such an exvagination became separated from the main body of the sinus and subsequently started to grow.
References
Summary
1. Stafne EC: Possible role of retained deciduous roots in etiology of cyst of the jaw. J Am Dent Assoc 24:1488, 1937 2. Gorlin RJ: Potentialities of oral epithelium manifest by mandibular dentigerous cysts. Oral Surg 10:271, 1957 3. Shear M: Secretory epithelium in the lining of dental cysts. J Dent Assoc S Afr 15:117, 1960 4. Shear M: Cysts of the Oral Regions. Bristol, John Wright & Sons Ltd, 1976, p 170 5. Killey HC. Kay LW, Seward GR: Benign Cystic Lesions of the Jaws: Their Diagnosis and Treatment. Ed. 3. New York, Churchill Livingstone, 1977, p 173 6. Sperber GH: Craniofacial Embryology. Ed. 2. Bristol, John Wright & Sons Ltd, 1976, p 163 7. Gregory GT, Shafer WG: Surgical ciliated cysts of the maxilla. J Oral Surg 16:251, 253, 1958
An unusual cyst of the zygoma is described. Three patterns of development of the cyst are suggested, namely: 1. Residual cyst of retained deciduous roots with metaplasia of the odontogenic epithelium into resniratory epithelium. 2. Fissural cyst of the zygomatico-maxillary suture. 3. Connection to the maxillary sinus, by a developmental exvagination or trauma to the sinus
Reverse Visor Osteotomy for Augmentation of the Atrophic Eden tulous Mandible GEORGE T. STRATIGOS, DDS, MSD,* ALAN CASSARA, AND MARK BIRNBAUM, DDSS The atrophic edentulous mandible has long been a problem to patients and practitioners. The inability to control a prosthesis, pain and discomfort due to the small basal seat for denture support, direct pressure on the inferior alveolar nerve, poor dietary intake, improper mastication, and the associated physiologic and social difficulties are all problems to be dealt with. l Methods of treatment include meticulous prosthesis construction, soft tissue surgical procedures, and ridge augmentation.‘-‘” This paper reports a case in which a new surgical treatment for the atrophic edentulous mandible, a reverse visor osteotomy, is used for osseous augmentation. This procedure, as with other visor augmentations, is possible because the atrophic edentulous mandible is frequently greater in its medial-lateral dimension than in its superior-inferior dimension.16 The osteotomy is made so that the buccal aspect is slid
DMDJ
superiorly and posteriorly along the sagittal bony cut. Because all soft tissue attachments are removed, the buccal segment is actually a free graft. The procedure avoids injury to the inferior alveolar nerve, does not require a distant donor site with its associated problems, and provides a graft of almost ideal mandibular contour. An incidental result is that it helps correct facial and interarch pseudoprognathism. Case Report A 59-year-old woman came to our department with a chief complaint of not being able to wear her lower denture. The patient had had this difficulty for many years and had originally lost her dentition at the age of 25. Her medical history included long-standing advanced osteoarthritis, which had been treated SymptomaticaIly, and a right total hip replacement secondary to the degenerative arthritis in 1972. On physical examination she appeared older than 59 and had a slight pseudoprognathic facial appearance (Fig. 1). Intraoral findings included an atrophic mandible, prominent genial tubercles, decreased vestibular depth with a lack of attached mucosa, and a relatively wide mandible in relation to its height (Fig. 2). Because of the apparent advanced age of the patient, and the history of long-standing osteoarthritis and total hip replacement, it was decided that the modified reverse visor osteotomy could provide a greater and more stable base for a mandibular prosthesis while helping to eliminate both the facial and the interarch pseudoprognathism.
* Director, Department of Oral and Maxillofacial Surgery and Dentistry, Lincoln Hospital, Professor, New York Medical College. t Chief Resident, Department of Oral and Maxillofacial Surgery and Dentistry, Lincoln Hospital. Senior Resident, Department of Oral and Maxillofacial Surgery and Dentistry, Lincoln Hospital. Received from the Department of Oral and Maxillofacial Surgery and Dentistry, Lincoln Medical and Mental Health Center, 234 E. 149th Street, Bronx, New York, 10451. Address correspondence and reprint requests to Dr. Stratigos.
0278-2391/82/0400/0231 $00.60 Q American Association of Oral and Maxillofacial Surgeons
231
232
REVERSE VISOR OSTEOTOMY
FIGURE 3. Leff, the osteotomy cut. FIGURE 4. Right, The position of the free bony graft and of the circummandibular wires.
The patient was admitted to the hospital. Her vital signs and the results of operative blood studies, urinalysis, chest radiograph, and electrocardiograph were essentially within normal limits. Under nasotracheal general anesthesia, and after administration of a local anesthetic into the mucobuccal tissues, an incision was made in the lateral aspect of the vestibule from one retromolar region to the other. The mandible was degloved and the major flap developed lingually. The mental nerves were identified and retracted with the lingual flap. The genial muscles were severed, and tubercle reduction was performed. A bony cut was made from right to left, buccal to the mental foramen and tapering buccally in the molar regions (Fig. 3). The sagittal osteotomy allowed the entire buccal segment (free from all soft tissue attachments) to be positioned superiorly and posteriorly to augment mandibular height. The graft was ligated in position with one interosseous and two circummandibular wires (Fig. 4). After copious irrigation, the site was closed with 3-O chromic sutures in deeper layers and 3-O continuous silk sutures for watertight closure and to aid in oral hygiene (a minimum of suture material being present intraorally).
Intravenous aqueous penicillin was administered preoperatively, intraoperatively, and postoperatively. No corticosteroids were used. The patient had an unremarkable postoperative course, with moderate swelling and altered sensation of the lower lip. She was discharged two days postoperatively and was followed up closely for signs of sepsis and dehiscence. Antibiotics were continued orally for two weeks, and sutures were removed
FIGURE 5.
Postoperative
radiograph of graft.
233
STRATIGOS ET AL.
FIGURE 7.
Ri&t.
Postbperative
_
facial profile.
on the fourteenth day. There was no sepsis or opening of the operative site. The altered lip sensation has been steadily diminishing. The only noticeable physical finding was the loss of weight during the postoperative period. Radiographically, there was an evident increase in mandibular height (Fig. 5). Although long-term follow-up of this procedure has not yet occurred, the skin graft vestibuloplasty was performed at six months. At the time of surgery, we found literally no bone resorption; the circummandibular wires placed at initial surgery were firm and showed no signs of loosening. The six-month radiograph confirmed these observations (Fig. 6). Discussion
The indications for reverse visor osteotomy include a wide buccal-lingual mandibular width, interarch and facial pseudoprognathism, adequate posterior ridge height, and medical problems making it impossible for the patient to tolerate a hip or rib graft procedure. There are many possible advantages to the technique. By moving the buccal segment superiorly and posteriorly, facial and interarch pseudoprognathism can be decreased (Fig. 7). Morbidity to the inferior alveolar nerve is eliminated, although the possibility of mental nerve paresthesia is present. A separate donor site is also avoided and, by using known stress-bearing bone, we believe that resorption secondary to wearing a prosthesis may be decreased. Contraindications to the reverse visor osteotomy include thin buccal-lingual width of the mandible and an overall thin mandible with little medullary bone. Also, if the patient is unable or unwilling to undergo two surgical procedures and to be without a mandibular prosthesis for approximately six to eight months, this procedure is not indicated.
References 1. Kratochvil FJ et al: Rehabilitation of grossly deficient mandibles with combined subperiosteal implants and bone grafts. J Prosthet Dent 35:452, 1976 2. Baker RD, Connole PW: Pre-prosthetic augmentation grafting-autogenous bone. J Oral Surg 35:541, 1977 3. Steinhauser E, Obwegeser HL: Second International Conference on Oral Surgery-1965. Copengagen, Munksgaard, 1976,pp 203 4. Baker RD et al: Long term results of alveolar ridge augmentation. J Oral Surg 37:486, 1979 5. Bunte M et al: Ceramic augmentation of the lower jaw. J Maxillofac Surg 5:303, 1977 6. Constantinides J et al: Homogenous bone grafts to the mandible. J Oral Surg 36:599, 1978 7. Harashina T et al: Reconstruction of mandibular defects with revascularized free rib grafts. Plast Reconstruct Surg 621514, 1978 8. Gazili M et al: Follow-up investigation of reconstruction of the alveolar process in the atrophic mandible. Int J Oral Surg 7:400, 1978 9. De Koomen HA et al: Interposed bone-graft augmentation of the atrophic mandible (a progress report). J Maxillofac Surg 7: 129, 1979 10. Ridley MT et al: Resorption of rib graft to inferior border of the mandible. J Oral Surg 36:546, 1978 11. Curtis TA et al: Autogenous bone graft procedures for atrophic endentulous mandibles. J Prosthet Dent 38:366. 1977 12. Leake DL: Contouring split ribs for correction of severe mandibular atrophy. J Oral Surg 34:940, 1976 13. Sanders B eta]: Inferior-border rib grafting for augmentation of the atrophic endentulous mandible. J Oral Surg 34:897, 1976 14. Davis WH et al: Transoral bone graft for atrophy of the mandible. J Oral Surg 28:760, 1970 15. Harle F: Visor osteotomy to increase the absolute height of the atrophied mandible: A preliminary report. J Maxillofac Surg 3:257, 1975 16. Peterson LJ Slade EW Jr: Mandibular ridge augmentation by a modified visor osteotomy: Preliminary report. J Oral Surg 35:999, 1977 17. Fitzpatrick B: Current concepts in the surgical management of the atrophic mandible. Aust Dent J 23:344, 1978