YIJOM-2952; No of Pages 3

Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2014.07.005, available online at http://www.sciencedirect.com

Case Report
Pre-Implant Surgery

Palatal osteotomy with C. Bouchard, P.-É. Landry,

V.Goodyer
Centre Hospitalier Universitaire (CHU) de

vestibuloplasty for the treatment Québec, Université Laval, Hôpital de

l’Enfant-Jésus, Québec, Canada

of severe maxillary atrophy: a

new twist on an old technique
C. Bouchard, P.-É. Landry, V. Goodyer: Palatal osteotomy with vestibuloplasty for
the treatment of severe maxillary atrophy: a new twist on an old technique. Int. J. Oral
Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Nowadays, upper denture instability secondary to severe maxillary atrophy

is treated, in most cases, with dental implants. However, a significant number of
patients cannot afford this procedure. Palatal bone deepening through a U-shaped
osteotomy has been described previously. The procedure increases retention by
improving the suction effect of the palate and prevents anteroposterior and lateral
movement of the denture. By combining this procedure with a secondary Keywords: maxillary atrophy; preprosthetic
epithelialization vestibuloplasty, the labial aspect of the ridge is also extended and it surgery; palate; osteotomy.
does not require a skin graft. This article describes a modification of the palatal vault
osteotomy through the presentation of a case. Accepted for publication 15 July 2014

Severe maxillary atrophy affecting den-
ture stability causes masticatory, aesthetic,
and psychosocial problems. Implant
placement to treat this condition is today’s
standard of care, however, a significant
number of patients cannot undergo this
procedure for pecuniary reasons or have
medical co-morbidities contraindicating
complex bone grafting interventions. Soft
tissue procedures, such as submucous ves-
tibuloplasty, mostly prevent lateral move-
ment of the denture. Bone grafting
operations (onlay, inlay, or interposi-
tional) carry morbidity, and without im-
plant placement, they resorb quickly.
In 1976, the team reported a technique
to increase palatal depth based on the
original description by Wassmund.1,2 This
simple technique involves a deepening of
the palatal vault by elevation of a bone
segment towards the nasal cavity. The
procedure allows a significant improve-
ment in denture stability by reducing ante-
roposterior movement of the prosthesis
and by increasing the suction effect of
the palate. This operation has been per-
formed on over a hundred patients through
the years, with good results, no relapse,
and few complications.
More recently, the authors have modi-
fied the original technique to improve
denture retention by combining the palatal
osteotomy with a secondary epithelializa-
tion vestibuloplasty (sometimes called a
lipswitch or Kazanjian vestibuloplasty).3,4
This modification has the advantage of
indirectly increasing the alveolar crest
height on the palatal and the labial aspect
of the ridge and it does not require a skin
graft. It also facilitates soft tissue closure.
The purpose of this article is to describe a
modified palatal vault osteotomy tech-
nique through the presentation of a case.
Case presentation
A 62-year-old female patient was referred
to the department of oral and maxillofacial
surgery of hospital with a chief complaint
of upper denture instability. The patient
was unable to chew or speak with the

0901-5027/000001+03 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary
atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005
YIJOM-2952; No of Pages 3
2 Bouchard et al.
denture in place and did not wear the
prosthesis most of the time. Her past med-
ical history was significant for schizophre-
nia and depression, for which she was
taking quetiapine, olanzapine, clonaze-
pam, and paroxetine. On physical exam,
it was noticed that her upper prosthesis
was unstable and was dislodged every
time the patient made an effort to speak.
Vestibular and palatal vault depths were
significantly reduced (Fig. 1). The ridge
was flat and most of the alveolar process
was resorbed. The patient was diagnosed
with a class V Cawood and Howell max-
illary resorption.5 Reconstruction with a
bone graft with subsequent implant place-
ment was proposed to the patient, but she
refused this therapeutic option for pecuni-
ary reasons. The decision was made to
perform a palatal osteotomy with a sec-
ondary epithelialization vestibuloplasty
under general anaesthesia.
The patient was brought to the operating
theatre, placed under general anaesthesia,
and intubated nasally. She was given 2 mg
of cephazolin intravenous (IV) and 80 mg
of methylprednisolone IV 30 min before
the start of the operation.
Methylprednisolone was repeated every
4 h postoperatively for a total of four
doses. The buccal vestibule was infiltrated
with 10 ml of mepivacaine with epineph-
rine 1:200,000. A vestibular incision ap-
proximately 1 cm superior to the
mucogingival junction was performed.
In the middle, the incision was kept almost
at the mucogingival junction because it
was impossible to gain vertical height due
to the presence of the anterior nasal spine.
A supraperiosteal dissection was carried
out superiorly to the level of the infraor-
bital nerves anteriorly and to the zygomat-
ic buttresses posteriorly. Inferiorly, the
flap was also dissected supraperiosteally
to the summit of the remaining alveolar
process and then the periosteum was in-
cised. The palatal mucosa was carefully
elevated so as to preserve both greater
palatine arteries (Fig. 2). The nasopalatine
neurovascular bundle was sectioned.
Fig. 1. Preoperative intraoral photograph
showing the severe maxillary alveolar atro-
phy.
Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary
atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005
Fig. 2. Intraoperative photograph showing
the design of the incision and the osteoto-
mized palatal bone after its upward reposition-
ing. The incision is located at the
mucogingival junction and the dissection
supraperiosteal to the summit of the alveolar
ridge.
A U-shaped osteotomy along the palatal
side of the alveolar ridge from the naso-
palatine canal to the posterior part of the
hard palate was done with a carbide-cut-
ting bur under copious saline irrigation
(Fig. 2). The osteotomy was maintained
medially to the greater palatine canals
posteriorly to preserve the vascular supply
to the mucosa. Once the osteotomy was
completed, the palatal bone segment was
moved inferiorly and the nasal septum
sectioned, freeing it completely. A septo-
plasty and bilateral inferior turbinectomies
were done to position the palatal bone
superiorly without interfering with nasal
structures.
The free palatal bone was elevated until it
was in contact with the nasal mucosa and
the depth of the palate judged adequate
(Fig. 2). Two transalveolar wires were
inserted in the premolar area. These wires
serve the dual purpose of maintaining the
palatal bone and denture in position during
healing (Fig. 3). The palatal mucosa was
sutured to the periosteum with 4–0 Vicryl
sutures on top of the alveolar process. The
palatal portion of the patient’s own pros-
thesis was augmented with a thick layer of
rigid impression compound (Kerr Corpora-
tion, Romulus, MI, USA). The peripheral
Fig. 3. Two transalveolar wires were inserted
in the premolar areas from the lateral aspect of
the ridge to the osteotomy line medially to
maintain the palatal bone in its position and
the denture in place during the healing period.
Fig. 4. Four months postoperative intraoral
photograph.
margin of the prosthesis was also augment-
ed with orthodontic resin (Dentsply Caulk,
Milford, DE, USA) to allow an increased
vestibular depth by secondary healing of
this area. The modified denture was put
back in place and secured with the two
previously inserted stainless-steel wires
(Fig. 3). Six weeks postoperatively, the
denture was removed and relined with re-
silient acrylic material (Bosworth Trusoft,
Skokie, IL, USA) and the final prosthesis
delivered 3 months later. The depth of the
vestibule and palate were significantly in-
creased and excellent denture stability was
achieved (Fig. 4). No postoperative com-
plications were noted.
Discussion
The palatal osteotomy was developed to
improve denture stability in the extremely
resorbed maxilla at a time when dental
implants did not exist.2 Preprosthetic pro-
cedures were the only available option to
treat extreme maxillary atrophy. Today,
these procedures have fallen out of fashion
due to advances in implant dentistry. It is
now possible to place dental implants even
in the severely atrophic maxilla. The use
of modern imaging techniques allows clin-
icians to carefully select implant locations
and in many cases, bone grafting is not
even necessary. However, these treat-
ments are expensive and most dental in-
surance companies will not cover the
expenses related to this type of reconstruc-
tion. Palatal vault deepening offers an
alternative for those patients who cannot
undergo implant placement. With the
modification described, denture stability
is greatly improved and the cost of the
operation is minimal.
When initially described, the incision
for the palatal osteotomy was placed on
top of the alveolar ridge.1 It had to be
undermined on the vestibular aspect to
enable closure of the incision once the
palatal bone was in its new position. This
made closure difficult and it reduced the
vestibular depth by moving the mucosa
YIJOM-2952; No of Pages 3
towards the palate. By combining the pal-
atal osteotomy with a vestibuloplasty, ves-
tibular depth is increased and there is no
tension on the incision. This combined
approach has the inconvenience of leaving
a large area of soft tissue to heal second-
arily and requires that the patient’s denture
be rigidly fixated for 4–6 weeks. The
prosthesis offers a protection to the ex-
posed tissues and our experience is that
pain is kept to a minimum during that
period.
Also, the extended flanges of the den-
ture reduce relapse by preventing contrac-
ture in the healing phase. Donor site
morbidity of a skin graft is avoided and
denture retention is superior on non-kera-
tinized mucosa.3
Leonard and Howe reported a series of
five cases treated by conventional palatal
vault osteotomy in 1978.6 The mean
increase in palatal depth obtained in
the coronal plane was 5.4 mm. The
authors mentioned that they performed
a submucous vestibuloplasty 3 weeks
after the palatal osteotomy because they
were dissatisfied with the single-stage
operation, but no further explanation
was given. In 1986, Tiner et al. de-
scribed a modification of the technique
by avoiding total reflection of the palatal
flap.7 Soft tissues are elevated only to
the level of the osteotomy, maintaining
the vascular supply to the osteotomized
segment. While this is in theory an ad-
vantage, we believe that this has no
effect on postoperative results and we
have never experienced bone necrosis or
sequestrum formation. Hori et al. also
reported two cases of palatal osteotomy
with excellent results and no complica-
tions.8 They avoided a complete descent
of the palatal vault by making a mid-
sagittal osteotomy at the suture line.
Each bone section was then pushed su-
periorly and the nasal septum exposed
and trimmed. Kitayama et al.,9 Steinhäu-
ser,10 and Yoshizama et al.,11 all pro-
posed similar modifications of the
osteotomy. The authors believe that a
complete exposure of the nasal septum
and inferior turbinates is necessary to
modify these structures as necessary
Please cite this article in press as: Bouchard C, et al. Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary
atrophy: a new twist on an old technique, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.07.005
Palatal osteotomy with vestibuloplasty
and allow an unrestricted movement of
the palate upward. According to author’s
experience, a U-shaped osteotomy with
complete downward fracture of the pal-
atal segment is the easiest way to obtain
this.
Possible complications of this proce-
dure include loss of vascular supply to
the palate with subsequent necrosis of
the soft tissue, oro-nasal communication,
nasal septum deviation, obstruction of na-
sal airflow, and relapse. Because of the
natural tongue position and the lack of any
muscular attachment in the area of the
osteotomy, this last complication is sel-
dom encountered. As for nasal complica-
tions such as snoring due to narrowing of
the nasal cavity, these can easily be
avoided by carefully trimming excess sep-
tal cartilage and performing inferior tur-
binectomies when necessary. The blood
supply is easily maintained by placing the
osteotomy medial to the greater palatine
foramens and with careful soft tissue dis-
section and manipulation. Excess pressure
on soft tissues by the modified prosthesis
has to be avoided to prevent compression
of the vascular supply.
The palatal osteotomy combined with
vestibuloplasty improves vestibular and
palatal depth and prevents anteroposterior
and lateral movement of upper dentures in
the extremely resorbed maxilla. The pro-
cedure is relatively easy to perform and
complications are rare. Although indica-
tions for this operation are rare, it could be
offered to patients who cannot undergo
implant placement.
Funding
None.
Competing interests
None.
Ethical approval
Not required.
Patient consent
Not required.
3
References
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2. Wassmund M. Uber chirurgishe formgestal-
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prothetischer versorgung. Vierteljahress-
chrift Zahnheildke 1931;47:305.
3. Kethley Jr JL, Gamble JW. The lipswitch: a
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4. Kazanjian VH. Surgery as an aid to more
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Maxillofac Surg 1986;44:489–91.
8. Hori M, Okaue M, Matsunaga S, Iwanari S,
Matsumoto M, Tanaka H, et al. Preprosthetic
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Dent 1993;35:186–91.
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Kondu K, Toyoda T. A modification of hard
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10. Steinhäuser EW. Methods for operative
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Prax 1978;29:50–4. [in German].
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Address:
Carl Bouchard
Centre Hospitalier Universitaire (CHU)
de Québec
Université Laval
Hôpital de l’Enfant-Jésus 1401
18e rue
Québec G1J 1Z4
Canada
Tel.: +1 418 265 8744; Fax: +1 418 624 3338
E-mail: carl.bouchard@fmd.ulaval.ca