DEPARTMENT OF ORAL AND

MAXILLOFACIAL SURGERY
GOVERMENT DENTAL COLLEGE &
HOSPITAL, AHMEDABAD.

Ridge Extension and Ridge Augmentation

Procedure

Presented by :- Akshay B. Chaudhari

Intern Batch :- 2014 15.
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[ RIDGE EXTENSION PROCEDURES ]

The goal of ridge extension is to uncover existing basal bone of
Jaw Surgically by repositioning the overlying mucosa, mucosal
attachments & muscle to lowered position in mandible or to superior
position in the maxilla.
The resultant advantage is that a larger flange can be
accommodated thus contributing to greater denture stability & retention.
There must be adequate alveolar bone with sufficient hight
remaining to allow for repositioning of mental nerve &baccinator &
mylohyoid muscle in mandible in the maxilla the anterior nasal spine,
nasal cartilage & molar buttresses may interfere with repositioning the
swcus superiorly.
There are mathods for ridge extension for maxilla & mandible in
maxilla, buccal approach & in mandible, Buccal & lingual approach.

Maxillary Procedures :-

Submucosal vestibuloplasty.
Indication ;
This procedure is indicated for patient with a small clinical ridge & healthy
overlying mucosa & without excessive submucosal fibrosis, hyperplasia or
scarring.
Submucosal vestibuloplasty should be pertoemed with use of general
anaesthesia.

Technique ;
A midline vertical incision is made from nasal spine to incisive papilla
from this incision, dissection of submucosa proceeds distally on either side,
separating the tissue inferiorly to the crest of ridge & superiorly to restore good
vestibuler hight.
The next dissection trees the submucosal connective tissue from the
periosteum. This is done by establishing a supraperiosteal plan & is best
accomplished with curved scissors. This freed tissue now can either be
repositioned superiorly to fill in a detect in canine fossa or resected.
The anterior nasal Spine, it prominent or interfering with denture seating, is
approached by same vertical incision & resected with osteoteme.
Incision closed with 3-0 Dexon.
The splint is fixed to the maxilla with peralveolar wires or nylon sutures.
The stent is removed in one week, at which time impressions are made for
immediate relining of denture.

Secondary epithelisation vestibuloplasty.

Indication ;
Patient with extensive scarring or epulis fissuratum in the swcus or who
have good quality of mucosa cover available without sufficient hight.
Secondary epithelisation vestibuloplasty require supra periosteal
dissection of mucosa to form a flap & Superior repositioning by suturing the flap
hight on to periosteum. The exposed periosteum. The exposed periosteum is
allowed to granulate & reepithelize without benefit of cover from a denture.

 Buccal mucosa graft vestibuloplasty.

Technique ;
In buccal mucosa graft vestibuloplasty incision made through the mucosa
at Junction of attached & non attached mucosa from molar buttress to molar
butteress.
A supra periosteal flap is developed by sharp dissection.
It is carried superiorly & laterally from the canine fossa to region of infra
orbital nerve.
Anteriorly at midline the dissection approaches the pyriform aperture
without perterating the nasal mucosa.
The margin of freed flap is sutured superiorly to periosteum with 4.0
Dexon so as to delineate the new vestibular hight.
This would normally complete the procedure for secondary epithelisation
vestibuloplasty, bt the placing of denture over this raw tissue tend to accelerate
secondary granulation & contribute to relapse.
The procedure to obtain the donor mucosa graft is as follows;
The size of donor mucosa is measured on recipient site, using sterilized toil.
The toil adapted to plate .
The outline of graft is incised down to submucosa above periosteum. The
submucosa dissection is started by mobilizing an end of graft with a scalpel &
maintaining it under tension with a skin hook.
Once the graft is mobilized, mucosa removal procedure rapidly using
periodontal kinives & strabismus scissors.
After graft is tried & measured to cover the recipient bed, it trimmed &
than tacked to periosteum with 6-0 Dermalon suture.

The graft is further covered with an acrylic splint lined with Dental
compound & quttaterm.

Mandibular Procedures.

Buccal mucosa graft vestibuloplasty.

Buccal mucosa graft vestibuloplasty is the procedure of choice in
avulsive or severly traumatized patient in whom the swcus is entirely obliterated
by scarring or by bone graft reconstructive procedure.

Indication ;
Patient with high muscle attachment, extensive local scarring, extensive
Mandibular bone atrophy with the mental nerve emerging at the crest of ridge or
extension of normal swcus from canine to resulting from premature tooth loss
caused by odontal disese.

Technique ;
The procedure is identical to that of maxillary mucosa graft, except in
manner of treating lingual swcus.
Use of splints a full palatal acrylic splint is used to cover the donor site
in palate. For the mandible for partially edentulous one, an overextended splint
relived at mental nerve is use.
The splint is used to take a compound impression of extended vestibule
& is relieved to accommodate a graft from liner. Graft is immobilized.

Buccal skin graft vestibuloplasty with complete lowering of floor of

mouth.
Indication ;
Indication for this procedure include an atrophic, but not pencil thin,
mandible with high buccinator, frenum & mylohyoid attachment overed by thin
movable atrophic non keratinizing mucosa.

Technique ;
Donor skin Procedure;
The area of lateral thigh is prepared & draped. A 4 by 10 cm split
thickness piece of skin is procured with Brown dermatome.
Donor site is immediately dressed with fine mesh gauze & covered with
temporary pressure dressing throughout the remainder of operation.
Floor of mouth procedure:
A mucosal incision is mad just medially to the crest of ridge from
retramolar pad to retromolar pad.
The tenque is retracted laterally for dissection.
By alternating sharp & blunt dissection the muscle fiber can be made to
buiqe into incision. The curved Kelly haemostat is threaded under muscle which is
cut with scissors near the mandible without injury to periostem or the lingual nerve
in the posterior portion of incision.
A Similar dissection is performed on other side at an angle to symphysis area In the
midline. The lateral & superior fibers of genioglossus muscle are sectioned.
The periosteum over the tubercle is incised vertically & attached muscle insertions
are identified a gut suture is tied to bundle.
Ridge preaparation & skin grafting procedure;
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A superficial mucosal incision is made from retramolar pad to retramolar pad.

Two lateral relaxing incision are made posteriorly.
Through this incision Superaperiosteal flap is develop laterally & inferiorly.
If lowering is needed to eliminate undue nerve pressure that could be expected
under the skin graft than nerve is retracted with blut nerve hook while for came is
lowered & through is made in bone with round bur.
The anterior swcus between mental foramina is dissected laterally & inferiorly
enough to sever part.
The freed mucosal edges obtain by means of lingual & buccal flap dissection need
to reposition & stabilized. At their most inferior position.
Impression of recipient site by acrylic tray filled with dental compound.
Final preparation of recipient Bed by Hemostasis by electro cautery of bleeders
pressure & application of ice water. While setisfactery Hemostat splint position
over recipient site.

[RIDGE AUGMENTATION PROCEDURES]

Ridge augmentation is common procedure performed to help recreate
the natural contour of gums.
After tooth is removed, the bone in jaw will begin to deroriorate &
recade.
The hight & width of socket which was supported by tooth is removed.
Many patient will eventually develop an indentation in gum or jawbone where
tooth used to be.
When the alveolar ridge rescrption is so extreme, that the alveolar
bone has completly disappeared & in maxilla, the hight has been reduced to point
that a nearly flat sutures exists between vestibule & palate & perform aperture lies
just beneath gingival.
And the mandible, the basal bone has shown consideration amount of rescp with
mental nerve positioned almost at crest & very thin mandibular alveolar ridge
exists which can end up in fracture easily.

Two approaches;
Augmentation of alveolar bone place the implants.

Aims;
- Restoration of optimum/ near optimum ridge hight & width, ridge form
vestibular depth & optimum denture bearing area.
- Protection of neurovascular bundle.
- Establishment of proper interarch relationship.
- Improvement of retention & stabilityof denture.
- Improve the patient comfort for wear ling denture.
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Mandibular Augmentation
In mandibular ridge Augmentation use two 15cm autogenous rib graft. One rib is
scored at cortex, followed by contouring the same rib in shape of mandible.
The rib graft is fixed to mandible, either with transosseous wiring or circum
mandibular wiring.
The other rib graft is made into corticocancellous particle & moulded around first
rib graft.
Surgical flap is than closed.

Interior border graftting;

This surgical procedure is indicate when the alveolar ridge is less than 5 to 8mm in
hight & is at risk of pathologic fracture.

Technique ; A supraclavicular incision

Similar to the incision used in bilateral neck dissection is made, from
mastoid to mastoid region.
Subplarysmal dissection till the inferior border of mandible is done. Incision
throug periosteum is completed from angle to angle.
A freezed dried allogenic cadaver mandible is hollowed out & multiple perteration
made into 1 + +0allow for revascularization of packed can callous bone graft.
The can callous bone graft is harvested from iliac crest.
The cadaver mandible is than filled with auto genoas can cellos graft particies &
fixed to inferior border with vicryl suture by cirammandibular fixation.
The neck flap is closed in tension free manner.

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Inter positional bone graft;

(Sandwich grafting)
In this procedure, a horizontal osteotomy is performed. Splitting of residuce
maxilla or mandible & bone is grafted into this osteotomy gap.
In mandible, sandwich technique is mainly used for augmentation of anterior
mandible, between the mental foramina.
The autogenous or allogenic bone or hydroxyapatite graft can used successfully.
Secondary vestibuloplasty procedure may be necessary.

Onlay Grafting;
When adequate hight ispresent, but width is inadequate for prosthesis in maxilla or
mandible,
Hydroxyapatite is advocated by obwegeser via submucosal vestibule plasty
technique.
After creating a tunnel via midline, a putty is formed of hydroxyl apatite crystal,
mixed with saline/blood, & is injected via siring into submucosal tunnel.
Solid or porous blocks of hydroxyl apatite have been used as onlay or inter
positional graft to improve the bony detect.
A split thickness rib graft/iliac crest bone graft cam used, as an onlay graft in
maxilla or mandible. Rib is more uniform & can be placed in one pice. Iliac creast
place in block or pieces, not uniform.

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Technique ;
A high vestibular incision is taken to facilitate good water tight closure & achive
good under mining of the tissue for relaxation.
Mucoperiosteal flap is restarted to expose the detect . Small perteation are made in
external cortex by using small round bal to creat bleeding & promotion of clot
formation & neovascularisation.
The grafting material is placed over the external certex.
Placement of barrier membrane help in regeneration & presentation of graft.
Vlsor osteotomy;
The goal is to increase the hight of mandibular ridge for denture support.
In this central splitting of mandible which is wired in position. Cancullous bone
graft material is placed at outer certex over superior labial junction for improving
contour.

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Sinus lift Procedure or Sinus Grafting

(for maxilla)
It is mainly used to assist with placement of osseointe a rated implant in
posterior maxilla.
Due to pneumatization of maxilla Sinus & atrophy of ridge. The sinus
floor is lowered almost to the crest of alveolar ridge in posterior region.
In order to implant support the sinus lining at the floor is lifted up
surgically & bone graft is placed between the sinus lining & inner aspect of
alveolar crest of floor of maxillary sinus in posterior maxilla.

Technique ;
Intraoral incision is taken on maxillary crest or slightly on palatal aspect
with vertical releasing incision from canine to tuberoaiy area.
Anterolateral wall of maxilla is exposed by resieoting the mucoperiosteal
flap. A bony window is made with trap door type osteotomy just lateral & posterior
to canine fossa.
15 to 20 mm long interior horizontal osteotomy cut is placed 3 mm
above sinus floor. The anterior vertical osteotomy cut is placed perpendicular to
horizontal osteotomy & parallel to lateral nasal wall.
The posterior vertical cut is placed just at just at maxillary buttress the
vertical cut are joined superiorly by palcing small bur hall placed at small intervals
without completing the superior cut. The trap door type of bony window is than
gently lifted up superiorly to expose the schneiderian membrane, which is than
lifted up genraly from sinus floor & walls.
The gap between the lifted sinus membrane & floor is filled with the
graft material. For the one stage implant a corticocancellous illic crest bone block
used.

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Augmentation in Combination with orthognathic surgery.

1. Anterior maxillary
2. Total le fort I osteotomy
Total le fort I osteotomy can be used along with interpositioning of
graft total maxillary osteotomy with palatal vault osteotomy also can be used for
depening the palatal vault.

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