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VestibuloplastyVestibuloplasty with with SplitSplit--thickness Skin thickness Skin

Grafting and Lowering of Grafting and Lowering of the Floor of the Mouththe Floor of the Mouth

DG DG –– 51 51 y.oy.o. female. female0101--0404--0707

Combined Hospital Dental Staff Meeting16 January 2007Dr. Mark Ellison

ReasonsReasons

Primary reasons for altering the soft tissue of the Primary reasons for altering the soft tissue of the denturedenture--seating areaseating area

Allow deepening of the flange area to increase Allow deepening of the flange area to increase resistance to displacement forcesresistance to displacement forcesTo provide stable soft tissue upon which dentures To provide stable soft tissue upon which dentures can restcan rest

AdvantagesAdvantages

Possible lifelong benefit of the procedurePossible lifelong benefit of the procedureIncreased denture retentionIncreased denture retentionPossible diminution of rate of Possible diminution of rate of mandibularmandibularresorptionresorption ((LandesmanLandesman Study with serial Study with serial radiographs)radiographs)

DisadvantagesDisadvantages

Possible damage to the mental nervePossible damage to the mental nervePostPost--operative discomfort at the donor and operative discomfort at the donor and recipient sitesrecipient sitesUnestheticUnesthetic donor sitedonor site

Types of Types of VestibuloplastyVestibuloplasty

Mucosal Advancement (Mucosal Advancement (submucosalsubmucosal) ) VestibuloplastyVestibuloplastySecondary Secondary EpithelializationEpithelialization VestibuloplastyVestibuloplasty ––KazanjianKazanjian and Clark Techniquesand Clark TechniquesGrafting Grafting VestibuloplastyVestibuloplasty –– Mucosal vs. Skin Mucosal vs. Skin Graft vs. Graft vs. AllodermAlloderm

MUCOSAL ADVANCEMENT MUCOSAL ADVANCEMENT ((submucosalsubmucosal) )

VESTIBULOPLASTYVESTIBULOPLASTY

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KAZANJIAN’SKAZANJIAN’S TECHNIQUETECHNIQUE ––(modification (modification -- lipswitchlipswitch)) CLARK’SCLARK’S TECHNIQUETECHNIQUE

Grafting Grafting VestibuloplastyVestibuloplasty SplitSplit--thickness Skin Graftthickness Skin Graft

Advantage of SplitAdvantage of Split--thickness Skin Graftthickness Skin GraftHyperkeratosis (similar to callus on hand) whereas Hyperkeratosis (similar to callus on hand) whereas mucosa will ulceratemucosa will ulceratePatients usually more comfortable with skin graftPatients usually more comfortable with skin graftGreater amount of tissue availableGreater amount of tissue availableLower costLower cost

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ProcedureProcedure

Operating roomOperating roomSupine Supine Nasal IntubationNasal IntubationPatient Preparation Patient Preparation –– Donor and Recipient SitesDonor and Recipient SitesLocal Anesthetic Local Anesthetic –– Lidocaine with Epinephrine Lidocaine with Epinephrine for for HemostasisHemostasis

SplitSplit--thickness Skin Graftthickness Skin Graft

Harvest graft using dermatome Harvest graft using dermatome –– (.012(.012--.015 in.).015 in.)

VestibuloplastyVestibuloplasty

Initial incision just lateral to Initial incision just lateral to retromolarretromolar padpadFollow lateral Follow lateral mucogingivalmucogingival junctionjunctionCut to opposite canine areaCut to opposite canine areaTrasnverseTrasnverse incisionsincisionsSupraperiostealSupraperiosteal dissectiondissectionRemove excess soft tissue from Remove excess soft tissue from periosteumperiosteumDissect just below external oblique line on mandibleDissect just below external oblique line on mandibleContinue incision from canine area to lateral Continue incision from canine area to lateral retromolarretromolarareaarea

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Lowering the Floor of the MouthLowering the Floor of the Mouth

Start lingual Start lingual retromolarretromolar pad area at pad area at mucogingivalmucogingivaljunctionjunctionIncise to opposite canine areaIncise to opposite canine areaSupraperiostealSupraperiosteal dissectiondissectionThumb pressure or gauze on hemostats to pry away Thumb pressure or gauze on hemostats to pry away Floor of MouthFloor of MouthSection Section mylohyoidmylohyoid muscle at mandible in posterior muscle at mandible in posterior areasareasFinger dissection to inferior border Finger dissection to inferior border borderborder of mandibleof mandibleSection half of Section half of genioglossusgenioglossus muscle at genial tuberclesmuscle at genial tubercles

SubmandibularSubmandibular SuturesSutures

Pass awl through skin on inferior border of Pass awl through skin on inferior border of mandiblemandibleBring suture material from lingual to Bring suture material from lingual to buccalbuccalposition walking along inferior border of position walking along inferior border of mandiblemandible

Circumferential/Circumferential/SubmandibularSubmandibular SuturesSutures

Placing Skin GraftPlacing Skin Graft

StentStentSoft liner (CoSoft liner (Co--Soft)Soft)Skin can be adapted with accuracy to any contour of Skin can be adapted with accuracy to any contour of the labial and the labial and buccalbuccal mucosamucosa

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Place Skin on Place Skin on StentStent

Dermal side exposedDermal side exposedAdapt to Adapt to stentstent and trim away excessand trim away excessPlace Place stentstent and secure with and secure with circummandibularcircummandibularsuturessutures

CircummandibularCircummandibular LigaturesLigatures

Use awl in similar Use awl in similar fassionfassion as beforeas beforeUse Nylon sutureUse Nylon suturePass one just anterior to mental nerve and one Pass one just anterior to mental nerve and one posteriorposterior

ComplicationsComplications

Mental or lingual nerve Mental or lingual nerve paresthesiaparesthesiaLingual/Sublingual swelling or Lingual/Sublingual swelling or hematomahematoma ––compromised respiration and difficulty placing compromised respiration and difficulty placing stentstentComplete Complete genioglossusgenioglossus muscle detachment muscle detachment –– difficulty difficulty swallowingswallowingSuture abscessesSuture abscessesRelapse and lose vestibular depthRelapse and lose vestibular depthDrooping chin Drooping chin –– over dissection of over dissection of mentalismentalis musclemuscleHair in graftHair in graft

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AdditionalAdditional

Patient to be on antibiotics and steroidsPatient to be on antibiotics and steroidsNo pressure or extensive forces on the No pressure or extensive forces on the stentstent or or graftgraftRemove Remove stentstent after 7after 7--10 days10 daysCleanse area with antiseptic agent and swabsCleanse area with antiseptic agent and swabsRemove excess tissueRemove excess tissue

11 days post11 days post--opop