Vestibuloplasty with Split-thickness Skin Grafting and Lowering of the Floor of the Mouth

Combined Hospital Dental Staff Meeting 16 January 2007 Dr. Mark Ellison DG 51 y.o. y.o. female 0101-0404-07

Reasons

Primary reasons for altering the soft tissue of the denturedenture-seating area
Allow deepening of the flange area to increase resistance to displacement forces To provide stable soft tissue upon which dentures can rest

Advantages

Disadvantages

Possible lifelong benefit of the procedure Increased denture retention Possible diminution of rate of mandibular resorption (Landesman Study with serial radiographs)

Possible damage to the mental nerve PostPost-operative discomfort at the donor and recipient sites Unesthetic donor site

Types of Vestibuloplasty

Mucosal Advancement (submucosal ) (submucosal) Vestibuloplasty Secondary Epithelialization Vestibuloplasty Kazanjian and Clark Techniques Grafting Vestibuloplasty Mucosal vs. Skin Graft vs. Alloderm

MUCOSAL ADVANCEMENT (submucosal) submucosal) VESTIBULOPLASTY

KAZANJIANS TECHNIQUE (modification - lipswitch) lipswitch)

CLARKS TECHNIQUE

Grafting Vestibuloplasty

SplitSplit-thickness Skin Graft

Advantage of SplitSplit-thickness Skin Graft
Hyperkeratosis (similar to callus on hand) whereas mucosa will ulcerate Patients usually more comfortable with skin graft Greater amount of tissue available Lower cost

Procedure

Operating room Supine Nasal Intubation Patient Preparation Donor and Recipient Sites Local Anesthetic Lidocaine with Epinephrine for Hemostasis

SplitSplit-thickness Skin Graft

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

Vestibuloplasty

Initial incision just lateral to retromolar pad Follow lateral mucogingival junction Cut to opposite canine area Trasnverse incisions Supraperiosteal dissection Remove excess soft tissue from periosteum Dissect just below external oblique line on mandible Continue incision from canine area to lateral retromolar area

Lowering the Floor of the Mouth

Start lingual retromolar pad area at mucogingival junction Incise to opposite canine area Supraperiosteal dissection Thumb pressure or gauze on hemostats to pry away Floor of Mouth Section mylohyoid muscle at mandible in posterior areas Finger dissection to inferior border border of mandible Section half of genioglossus muscle at genial tubercles

Submandibular Sutures

Circumferential/ Submandibular Sutures

Pass awl through skin on inferior border of mandible Bring suture material from lingual to buccal position walking along inferior border of mandible

Placing Skin Graft

Stent

Soft liner (Co(Co-Soft) Skin can be adapted with accuracy to any contour of the labial and buccal mucosa

Place Skin on Stent

Dermal side exposed Adapt to stent and trim away excess Place stent and secure with circummandibular sutures

Circummandibular Ligatures

Use awl in similar fassion as before Use Nylon suture Pass one just anterior to mental nerve and one posterior

Complications

Mental or lingual nerve paresthesia Lingual/Sublingual swelling or hematoma compromised respiration and difficulty placing stent Complete genioglossus muscle detachment difficulty swallowing Suture abscesses Relapse and lose vestibular depth Drooping chin over dissection of mentalis muscle Hair in graft

Additional

Patient to be on antibiotics and steroids No pressure or extensive forces on the stent or graft Remove stent after 77-10 days Cleanse area with antiseptic agent and swabs Remove excess tissue

11 days post-op