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Stimulation of new tissue growth as an adjunct to alveoplasty
STIMULATION
It.
OF NEW TISSUE GROWTH AS AN ADJUNCT TO ALVEOPLASTY
dsr) Q. AZ. SMITH, J_).1).S.,3”;* STATEN H. MOORE, D.D.S., F.A.C.U).,* N. Y., AND .J. L. FIELI), I>.l).S.,*“* NEW TORK, ,lur IT.
ISLAND,
MOST
undercuts of the alveolar processes must be eliminated to produc,e satisfactory denture-bearing ridges. In accomplishing this desired result, it has been necessary in many cases to sacrifice sound bone which we would prefer not to remove. The narrow ridges thus produced are not desirable for stable and retentive dentures. With natural resorption some of these become the even more undesirable “knife edge” ridges. (lonservation of this bone to produce broader and stronger ridges for denture bearing is the aim of the procedure to be described. In a preliminary study at this Uinic, 36 cases treated in 1950 to 1951 were considered in which various degrees of undercut of the al\-eolar processes were eliminated by filling in subperiostcally with gelatin sponge material, thereby stimulating the tissue to obliterate these areas by the formation ol fibrous tissue or perhaps bonc~. It was theorized that the gelatin sponge material held the subpcriosteal space until a blood clot had organized and granulation had begun. The material was then removed by a foreign body reaction and replaced gradually by connective tissuch. Following this evolution, the previous undercuts ww absent. Clinically the area was very firm, and it. was believed that at least, in some cases boric had been produced. Further work clinically and experimentally has gi\-ch11us more inforniatioll concerning the techniques, values, and limitations of this procedure>.
Gelatin Sponge to Eliminate Undercuts in Edentulous Mouths The gelatin sponge is inserted through small vertical incisions, tuadc beyond each end of the undercut area. Using a periosteal elevator, the Cssues are carefully detarhed from the bone. Thus a tunnel is created beneath the Inside the tunnel, care shonld hc periosteum connecting 1he two incisions. taken that the periosteum is elevated up to the crest of the ridge and down t,o the lowest portion of the undercut in so far as is practical. The gelatin sponge, 20 mm. by 6 mm. by 7 mm., which is standard size for oral surgery, is then soaked in a solution of penicillin containing 5,000 units per cubic centimeter. It is squeezed and rcsoaked. The piece is then folded double and inserted T-Fthe undercut is long enough, it may be necessary lengthwise into the tnnncl. to insert a piece from each side, and in more sevcrc undercuts additional pieces N. Y.
*Dental
Director.
T-nit4
States Public, Hc.alth Service Hospital,
**Senior Assistant Dental Stapleton, Staten Island, N. Y. ***Senior Assistant Dental Clinic, New York, N. Y.
Surgeon,
I’nitcd
States
Surgeon,
Lvnited
States
Public Public
Stapleton, Health Health
Staten Island,
Service Service
Hospital, Outpatient
NEW
TISSUE
GROWTH
AS
ADJUNCT
TO
813
ALVEOPLASTY
may be necessary (Fig. 1). The area should be overfilled, 50 per cent beyond the desired contour. The incisions are then closed with one or two silk sutures. A modification of this technique is to make a single incision in the center of
Fig.
l.-Left
to
right,
Procedure
in
which described
gelatin sponge in text.
is
inserted
from
each
side
as
the undercut area and to raise the pcriosteum to the right and left. This is sometimes a satisfactory method but may cause a dimpling scar at the site of incision.
Fix.
:3-
-iUo,lel
showin::
postogenrtive
hmling
result
on
above
case.
in normal positioll. Xaintaining thca position of the implant while is somctimcs difficult. It has been found that a suture placed in the the flap first will aid in maintaining position of the implant, while sutures are placed. Sutures should not be removed for six to eight
suturing center of the other days, de-
XEW
TISSUE
GROWTH
AS ADJUTNCT
TO ALVEOPLASTP
815
pending upon the appearance of the tissues. Usually, healing time of the soft tissue edges is prolonged by the presence of t,he gclat,in material beneath the suture line.
Fig. 4.-Models most satisfactorily
showing show
five cases before and after the implant the buccolingual thickening and undercut
procedure. elimination
These models accomplished.
Gelatin Sponge for Repair of Extraction Defects In our opinion, the use of gelatin sponge to prevent depressions and irregularities of the alveolar ridges is of equal importance as the procedure of eliminating undercuts. Frequently the fracture or surgical removal of the
816
RIOORE,
SJLITII,
.
HIELL)
buccal or labial plate ot’ lwno awornpanics the removal of teeth. This may produce a defect sufficient to allow the gingival niu~~sa to collapse into the socket or sockets no mat,tclr hog carcl’ully thcsc tissws are sutured to p‘law. If such areas are loosely Ijacked with gelatin sponge, the> soft tissues may then be brought together and sut,ured to their f’ormcr position as if no bone had been removed. When resorption and hcalin g take place, the amount of de]prcssion or irregularity will be considerably less than would be espc~ctcedif nc) implant were used. It is only occasionally, however, that the entire dcht’ect CilIl 1)~eliminated in this manner.
The introduction of any foreign body into the tissues prod~~ces various Some individuals tolerate such substances well and others do not. reactions. Also, contaminated objects arc more poorly tolerated t,han are clean objects. For these ‘reasons it is felt that this procedure should be used only on healthy iridividu&ls and in areas which arc not extensively infected. At, least half of the patients will have a moderate &ma on the first postoperative day. There is no accompanying pain, how-ever, and by the second In a postoperative day this tr;tnsicnt (>dt’nla usually subsides complctcly. few casrs, five to six days following the implant, a purulcnt c3udate forms, the gelatin material begins to liyucl’y, and there is some drainage, apparcnt.l> until all of the implant has been removed. Such cases are few and t,he occurrence of this phenomenon does not necessarily mean that t,hc procedure has
NEW
TISSUE
GROWTH
AS
ADJUXCT
TO
AI,VEOPIASTY
817
failed, for in most such cases the material
has apparently been in place long enough to serve its purpose and after healing there is st,ill a favorable result. In a few such cases, however, the desired results will not be obtained. Furthermore, in some individuals the foreign body reaction will be too efficient and a portion of the undercut may remain after complete resorption. There were two such cases in our series. This will emphasize the importance of overfilling the undercut. Generally, gelatin sponge is well tolerated by the tissues and the use of penicillin solution as recommended in the technique seems to aid in minimizing unfavorable reactions.
Experimental
Studies
Subperiosteal implants were made in the mouths of 4 dogs which were undergoing a series of abdominal operations. Two of these animals were lost in only a few days. A specimen was obtained on the third dog at thirty-two days and on the fourth dog at seventy-two days. These specimens showed only 11; is hoped t,hat further experimental fibrous tissue at the site of the implant. study on a more extensive scale can be accomplished at a later time.
Results To date over 120 patients have been treated in this Clinic by these techniques. Elimination of undercuts and irregularities has been highly successful; however, there has been no success in increasing the vertical height of the ridge. Narrow ridges have been thickened buccolingually, but we have had little success in improving the frequently seen low “knife edge” ridges without undercut. Following surgery, the average time required for healing before denture impressions was thirty days. A large number of these patients have been wearing dentures for several months with no noticeable change in the alveolar contour. The areas of previous undercut are very firm to palpation. It is felt that in some cases new bone has been formed even though ra.diographic and experimental evidence are inconclusive.
Summary A technique has been presented to aid in the elimination and prevention of undesirable undercuts and contour defects in the alveolar ridges. Whether new bone formation has been stimulated or merely the formation of a firm subperiosteal scar, clinically the result is the same. Better alveolar ridges are produced without extensive bone removal giving more stable and comfortable denture-bearing areas.
It.
OF NEW TISSUE GROWTH AS AN ADJUNCT TO ALVEOPLASTY
dsr) Q. AZ. SMITH, J_).1).S.,3”;* STATEN H. MOORE, D.D.S., F.A.C.U).,* N. Y., AND .J. L. FIELI), I>.l).S.,*“* NEW TORK, ,lur IT.
ISLAND,
MOST
undercuts of the alveolar processes must be eliminated to produc,e satisfactory denture-bearing ridges. In accomplishing this desired result, it has been necessary in many cases to sacrifice sound bone which we would prefer not to remove. The narrow ridges thus produced are not desirable for stable and retentive dentures. With natural resorption some of these become the even more undesirable “knife edge” ridges. (lonservation of this bone to produce broader and stronger ridges for denture bearing is the aim of the procedure to be described. In a preliminary study at this Uinic, 36 cases treated in 1950 to 1951 were considered in which various degrees of undercut of the al\-eolar processes were eliminated by filling in subperiostcally with gelatin sponge material, thereby stimulating the tissue to obliterate these areas by the formation ol fibrous tissue or perhaps bonc~. It was theorized that the gelatin sponge material held the subpcriosteal space until a blood clot had organized and granulation had begun. The material was then removed by a foreign body reaction and replaced gradually by connective tissuch. Following this evolution, the previous undercuts ww absent. Clinically the area was very firm, and it. was believed that at least, in some cases boric had been produced. Further work clinically and experimentally has gi\-ch11us more inforniatioll concerning the techniques, values, and limitations of this procedure>.
Gelatin Sponge to Eliminate Undercuts in Edentulous Mouths The gelatin sponge is inserted through small vertical incisions, tuadc beyond each end of the undercut area. Using a periosteal elevator, the Cssues are carefully detarhed from the bone. Thus a tunnel is created beneath the Inside the tunnel, care shonld hc periosteum connecting 1he two incisions. taken that the periosteum is elevated up to the crest of the ridge and down t,o the lowest portion of the undercut in so far as is practical. The gelatin sponge, 20 mm. by 6 mm. by 7 mm., which is standard size for oral surgery, is then soaked in a solution of penicillin containing 5,000 units per cubic centimeter. It is squeezed and rcsoaked. The piece is then folded double and inserted T-Fthe undercut is long enough, it may be necessary lengthwise into the tnnncl. to insert a piece from each side, and in more sevcrc undercuts additional pieces N. Y.
*Dental
Director.
T-nit4
States Public, Hc.alth Service Hospital,
**Senior Assistant Dental Stapleton, Staten Island, N. Y. ***Senior Assistant Dental Clinic, New York, N. Y.
Surgeon,
I’nitcd
States
Surgeon,
Lvnited
States
Public Public
Stapleton, Health Health
Staten Island,
Service Service
Hospital, Outpatient
NEW
TISSUE
GROWTH
AS
ADJUNCT
TO
813
ALVEOPLASTY
may be necessary (Fig. 1). The area should be overfilled, 50 per cent beyond the desired contour. The incisions are then closed with one or two silk sutures. A modification of this technique is to make a single incision in the center of
Fig.
l.-Left
to
right,
Procedure
in
which described
gelatin sponge in text.
is
inserted
from
each
side
as
the undercut area and to raise the pcriosteum to the right and left. This is sometimes a satisfactory method but may cause a dimpling scar at the site of incision.
Fix.
:3-
-iUo,lel
showin::
postogenrtive
hmling
result
on
above
case.
in normal positioll. Xaintaining thca position of the implant while is somctimcs difficult. It has been found that a suture placed in the the flap first will aid in maintaining position of the implant, while sutures are placed. Sutures should not be removed for six to eight
suturing center of the other days, de-
XEW
TISSUE
GROWTH
AS ADJUTNCT
TO ALVEOPLASTP
815
pending upon the appearance of the tissues. Usually, healing time of the soft tissue edges is prolonged by the presence of t,he gclat,in material beneath the suture line.
Fig. 4.-Models most satisfactorily
showing show
five cases before and after the implant the buccolingual thickening and undercut
procedure. elimination
These models accomplished.
Gelatin Sponge for Repair of Extraction Defects In our opinion, the use of gelatin sponge to prevent depressions and irregularities of the alveolar ridges is of equal importance as the procedure of eliminating undercuts. Frequently the fracture or surgical removal of the
816
RIOORE,
SJLITII,
.
HIELL)
buccal or labial plate ot’ lwno awornpanics the removal of teeth. This may produce a defect sufficient to allow the gingival niu~~sa to collapse into the socket or sockets no mat,tclr hog carcl’ully thcsc tissws are sutured to p‘law. If such areas are loosely Ijacked with gelatin sponge, the> soft tissues may then be brought together and sut,ured to their f’ormcr position as if no bone had been removed. When resorption and hcalin g take place, the amount of de]prcssion or irregularity will be considerably less than would be espc~ctcedif nc) implant were used. It is only occasionally, however, that the entire dcht’ect CilIl 1)~eliminated in this manner.
The introduction of any foreign body into the tissues prod~~ces various Some individuals tolerate such substances well and others do not. reactions. Also, contaminated objects arc more poorly tolerated t,han are clean objects. For these ‘reasons it is felt that this procedure should be used only on healthy iridividu&ls and in areas which arc not extensively infected. At, least half of the patients will have a moderate &ma on the first postoperative day. There is no accompanying pain, how-ever, and by the second In a postoperative day this tr;tnsicnt (>dt’nla usually subsides complctcly. few casrs, five to six days following the implant, a purulcnt c3udate forms, the gelatin material begins to liyucl’y, and there is some drainage, apparcnt.l> until all of the implant has been removed. Such cases are few and t,he occurrence of this phenomenon does not necessarily mean that t,hc procedure has
NEW
TISSUE
GROWTH
AS
ADJUXCT
TO
AI,VEOPIASTY
817
failed, for in most such cases the material
has apparently been in place long enough to serve its purpose and after healing there is st,ill a favorable result. In a few such cases, however, the desired results will not be obtained. Furthermore, in some individuals the foreign body reaction will be too efficient and a portion of the undercut may remain after complete resorption. There were two such cases in our series. This will emphasize the importance of overfilling the undercut. Generally, gelatin sponge is well tolerated by the tissues and the use of penicillin solution as recommended in the technique seems to aid in minimizing unfavorable reactions.
Experimental
Studies
Subperiosteal implants were made in the mouths of 4 dogs which were undergoing a series of abdominal operations. Two of these animals were lost in only a few days. A specimen was obtained on the third dog at thirty-two days and on the fourth dog at seventy-two days. These specimens showed only 11; is hoped t,hat further experimental fibrous tissue at the site of the implant. study on a more extensive scale can be accomplished at a later time.
Results To date over 120 patients have been treated in this Clinic by these techniques. Elimination of undercuts and irregularities has been highly successful; however, there has been no success in increasing the vertical height of the ridge. Narrow ridges have been thickened buccolingually, but we have had little success in improving the frequently seen low “knife edge” ridges without undercut. Following surgery, the average time required for healing before denture impressions was thirty days. A large number of these patients have been wearing dentures for several months with no noticeable change in the alveolar contour. The areas of previous undercut are very firm to palpation. It is felt that in some cases new bone has been formed even though ra.diographic and experimental evidence are inconclusive.
Summary A technique has been presented to aid in the elimination and prevention of undesirable undercuts and contour defects in the alveolar ridges. Whether new bone formation has been stimulated or merely the formation of a firm subperiosteal scar, clinically the result is the same. Better alveolar ridges are produced without extensive bone removal giving more stable and comfortable denture-bearing areas.