Referat Vestibuloplasty

Pebrian Diki Prestya

Pembimbing:
drg. Melita Sylvyana, Sp.BMM., Subsp., COMF(K)

Oral and Maxillofacial Surgery Resident

Department of Oral and Maxillofacial Surgery
Faculty of Dentistry Universitas Padjadjaran | Hasan Sadikin General Hospital, Bandung
“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.
Vestibuloplasty

Prosedur flap transposisional vestibuloplasty atau 

prosedur lip switch

Pada prosedur ini jaringan lunak dari bagian dalam

bibir digeser ke zona favorable pada tulang alveolar,
sehingga terjadi peningkatan di area bantalan gigi
tiruan

Neelima Anil Malik. Textbook of Oral And Maxillofacial Surgery. 3rd Edition 2021.
 Prosedur

Insisi pada alveolar ridge dimulai ke arah sedikit ke labial

Flap mukosa pada bagian dalam bibir dilonggarkan sampai

perbatasan vermilion, untuk memastikan mobilitas memadai

Diseksi supraperiosteal dilakukan, sepanjang permukaan labial

tulang alveolar sampai kedalaman vestibulum yang diinginkan

Tepi flap yang mobile didorong ke area kedalaman vestibular

dan dipertahankan posisinya dengan jahitan

Neelima Anil Malik. Textbook of Oral And Maxillofacial Surgery.5 th Edition 2021.
Neelima Anil Malik. Textbook of Oral And Maxillofacial Surgery.5 th Edition 2021.
 Vestibuloplasty pada bagian lingual
1. Insisi dibuat berjalan dari retromolar pad ke pertemuan free dan attached
gingiva gingiva pada bidang supraperiosteal
2. Kemudian dilakukan diseksi hingga ke dasar mulut secara hati hati
3. Jika ada tonjolan tulang yang tajam, jaringan lunak di atas area ini harus
dihilangkan
4. Dilakukan submandibular (hammock sutures)
5. Penempatan skin graft pada bukal dan lingual
6. Penempatan stent/modified denture diatas graft

Deepak K, Paul Tiwana. Atlas of Oral and Maxillofacial Surgery. 2015

Deepak K, Paul Tiwana. Atlas of Oral and Maxillofacial Surgery. 2015
Deepak K, Paul Tiwana. Atlas of Oral and Maxillofacial Surgery. 2015
 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
TYPES OF VESTIBULOPLASTY

Neelima Anil Malik,

Textbook of Oral and
maxillofacial surgery,
4th edition.
I. Submucosal vestibuloplasty technique

 MacIntosh and Obwegeser (1967).

 Indication- Unstable dentures

 Mouth mirror test determines the adequacy of mucosa available.

 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.
 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
 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
 Bilateral anterior pockets Denture modified with acrylic resin and
developed surgically Midpoint of anterior pockets modelling compound

Split thickness skin graft applied Cast made from

to denture 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.
 II. SECONDARY EPITHELIALIZATION
VESTIBULOPLASTY
 Inflammatory hyperplasia and scar tissue are present.

 Should be considered as the first alternative.

 Raw surface is healed by secondary epithelialization.

 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

 GODWINS MODIFICATION
 Similar to kazanjian technique

 Vestibule 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
 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.

 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.

 LINGUAL VESTIBULOPLASTY
 Also called floor-of-the-mouth-plasty.

 Techniques:
 Anterior- Cooley
 Posterior
• Trauner
• Caldwell’s
• Obwegeser’s (combination of buccal and lingual vestibuloplasty)
 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
• Genial tubercles removed if too large
• Heavy nylon sutures attached to the muscles and pulled through the skin
under the chin and repositioned inferiorly using buttons
23
 POSTERIOR LINGUAL VESTIBULOPLASTY

1. Trauner’s technique
• Trauner in 1952

• Supra-periosteal procedure

 Indications

• Mucosa of floor of mouth is as high as the mandibular ridge

• Mylohyoid muscle attached at the level of residual alveolar ridge

• 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.
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
Obwegeser’s technique (1963)
(A) Incision sparing mucosa at crest of

ridge

(B) Labial and lingual ridge extensions

(C) Raw bone is skin grafted and

covered with surgical stent

(D) Final result

 Other
modifications
A. Normal
B. Trauner
C. Brown
D. Caldwell
E. Hopkins
F. Edlan
  GRAFTING VESTIBULOPLASTY
 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

 DISADVANTAGES
 GRAFTS USED
 ADVANTAGES  Donor site morbidity
 Skin graft
 Less relapse  Skin grafts may not take up
 Mucosal graft (palatal and
 Early covering of surgical well on exposed bone
buccal mucosa)
defect  Hair growth if graft is thick
 Xenograft
 Reduced secretory capacity,
 Amnion  Rapid healing
colour and surface consistency
 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.
 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.
 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 Treatment concepts for soft tissue regeneration with
Geistlich Mucograft®. Geistlich biomaterials.

  How does Geistlich mucograft act ?
 Advantages
 Promotes migration of connective tissue cells by signaling for keratinized tissue
 Easy handling
 2 components of the graft
 Good adherence • Compact layer- Protects the wound during open healing and allows suturing

 Easy to suture • Spongy layer- Stabilizes blood clot and enables soft-tissue ingrowth

 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)