A modied approach for vestibuloplasty in severely resorbed mandible using an implant-retained postoperative stent: a case report

Luiz Gustavo N. Melo, DDS, PhD,a,b,c Ana Lcia P. F. Almeida, DDS, PhD,a Jos Fernando Scarelli Lopes,a Maria Lcia R. Rezende, DDS, PhD,d Jos Srgio M. Neto, DDS, MS,a Frederico Ciporkin, DDS,a and Maria Jos Hitomi Nagata,b Bauru, Araatuba, and Gois, Brazil
UNIVERSITY OF SAO PAULO (USP), STATE UNIVERSITY OF SAO PAULO (UNESP), AND SCHOOL OF PROFESSIONAL IMPROVEMENT (EAPGOIS)

Background. Severely resorbed mandibles often present a short band of keratinized tissue associated with a shallow vestibule. As a result, prominent muscle insertions are present, especially in the mental region of the mandible. This case report describes the deepening of the vestibular sulcus in an atrophic mandible by combining free gingival grafts harvested from the palate and a postoperative acrylic resin stent screwed on osseointegrated implants placed at the anterior region of the mandible. Study design. During the second-stage surgery, a split-thickness labial ap was reected and apically sutured onto the periosteum. Two free gingival grafts were obtained and then sutured at this recipient site. A previously custom-made acrylic stent was then screwed onto the most distally positioned implants. To document the procedures stability over time, a metal ball was placed in the most apical part of the vestibule and standardized cephalometric radiographs were taken before and 6 months after the procedure. Linear measurements of vestibular depths over the observation time were realized using specic software for radiographic analysis. Results. The proposed technique augmented the band of attached masticatory mucosa, deepened the vestibule and prevented the muscle reinsertion. The difference between the 2 measurements of vestibular depths was 9.39 mm (initial 20.88 mm, nal 11.49 mm) after a 6-month postoperative period. Conclusion. The technique, in combination with palatal mucosal graft and use of a postoperative stent, decreased the pull of mentalis muscle and provided a peri-implantally stable soft tissue around implants. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e7-e14)

Several authors suggest that there is no correlation between implant success rate and presence of keratinized tissue in peri-implant masticatory mucosa.1-5 Other studies, however, have demonstrated that the presence of an adequate band of keratinized tissue surrounding implant abutments is essential to prevent development of inammation,6,7 hyperplasias,8,9 and retraction of the peri-implant marginal soft tis-

Division of Implantology, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo (HRAC-USP). b Division of Periodontics, Department of Surgery and Integrated Clinic, Dental School of Araatuba, State University of Sao Paulo Jlio de Mesquita Filho (FOA-UNESP). c Division of Implantology, School of Professional Improvement (EAPGOIS). d Department of Periodontology, Faculty of Dentistry of Bauru, University of So Paulo (FOB-USP). Received for publication May 3, 2007; returned for revision Apr 18, 2008; accepted for publication May 13, 2008. 1079-2104/$ - see front matter 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2008.05.029

sues.1,7,8,10-12 According to Sclar,13 there is a lack of consensus in the literature regarding this issue because there are many different factors that may affect the health of the peri-implant soft tissues (Table I). Because so many factors can inuence the health of the peri-implant soft tissues and the long-term success of an osseointegrated implant, it is difcult to design a study isolating the effects that attached tissues may have on the health or longevity of an implant restoration. Therefore, for the present time, the conclusion as to whether attached tissues are necessary must be based on clinical observations rather than on scientic studies.14,15 In general, the sealing ability of the peri-implant non keratinized mucosa15 and the critical role played by bacterial plaque control in some patients are the main arguments for justifying gingival grafts at the implant sites.9 Moreover, a critical factor that must be considered regarding the need of an adequate zone of attached tissue with intimate adaptation to the emerging implant structures is the presence of tissue mobility adjacent to implant abutments, caused by frenum or muscle traction.7,13 Such anatomic alterations have been conside7

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Table I. Internal and external factors that affect the health of the peri-implant soft tissues*
Internal factors Age of patient General health Periodontal status of remaining dentition Host resistance Systemic resistance Periodontal phenotype Pre-existing bony dehiscence Vestibular depth Aberrant frenum Thickness of attached tissue Apicocoronal dimension of attached tissue, if present External factors Tobacco use Use of medications Oral hygiene Implant design and surface characteristics Submerged vs. nonsubmerged technique Surgical approach Location of implant Depth of implant placement Prominence of implant position in the alveolus Restorative technique Restorative materials Restorative margin vis--vis biologic width *Based on Sclar.13

ered to be one of the main risk factors for development of mucogingival complications. Schroeder et al.16 and Listgarten et al.17 related that the presence of a loose mucosa adjacent to dental implants may favor the mobility of the implant-epithelium junction and increase peri-implant mucosa susceptibility to inammation. In addition, when this type of alteration is associated with other factors as a shallow vestibule, hygiene procedures may become more difcult and there may be an increased plaque accumulation. Resorbed mandibles often present alterations in anatomic characteristics, and the approach of an implant therapy should be differentiated.13 Arnoux et al.12 believed that there is a direct relation between the extent of resorbed mandibular bone and width of keratinized gingiva. In cases of advanced resorption, a short band of keratinized tissue (1 to 2 mm) is often associated with a shallow vestibule. As a result, there are prominent muscle attachments on the vestibular side (especially the mentalis muscle), the lingual attachment (especially the genioglossus and the posterior bers of the mylohyoid) is very close to the future implant sites, and the oor of the mouth is mobile.12 A variety of techniques have been used to extend the labiobuccal vestibule and the lingual sulcus and to provide an immobile soft tissue covering for the resid-

ual ridge. Vestibuloplasty is the surgical procedure whereby the oral vestibule is deepened by changing the soft tissue attachments.18 A mandibular labial vestibuloplasty combined with lowering of the oor of the mouth was also indicated by MacIntosh and Obwegeser19 to increase the relative height of the residual ridge on the lingual side. During this procedure, the posterior portion of the mylohyoid is detached and allowed to reattach at a lower level, thus deepening the posterior lingual sulcus. The authors, however, cautioned against severing both the mylohyoid and the genioglossus-geniohyoid muscles, because of the resulting total loss of tongue control and swallowing difculty.19 Arnoux et al.12 also stated that when the lingual ap is fully elevated the entire oor of the mouth becomes extremely mobile with every movement of the tongue (a situation that is difcult to control). The most popular procedure in an edentulous mandible is vestibule deepening associated with palatal mucosal grafts around the implants.7,11,13,20-25 However, classic clinical articles on healing after vestibuloplasty procedures demonstrate a rapid loss of the immediate surgical result in the rst few weeks after surgery.26-28 Arnoux et al.,12 based on Corn,29 stated that the previsibility of vestibule deepening is achieved with the use of postoperative stents as adjuncts with the appropriate surgical technique. Although the use of postoperative stents has been proposed as a way to provide protection to the grafted area in vestibuloplasty procedures,30-37 its use to prevent the reattachment of the muscle bers, based on the biologic rationality proposed by Corn,29 has not yet been reported. Based on related arguments, the objective of the present case report was to describe a new technique involving a combination of vestibule deepening associated with palatal mucosal graft and use of postoperative stent in a severely resorbed mandible. CASE REPORT
A 53-year-old female patient who had received 5 screwshaped titanium implants (3.75 15 mm) (Titamax Ti Cortical; Neodent, Curitiba, Brazil) in the anterior mandible presented to the Division of Implantology of the Hospital for Rehabilitation of Craniofacial Anomalies, University of So Paulo, for second-stage surgery procedure of the implanted area. Clinical examination revealed severe atrophy of the mandibular bone, presence of alveolar mucosa covering the implants, and a shallow vestibule (Figs. 1 and 2). A signicant strain of the mental muscle existed on implant area. An incision in the mucogingival line was made as proposed by Arnoux et al.,12 keeping a thin band of keratinized tissue as a part of the lingual ap. This partial-thickness ap was raised just enough to expose the implants to maintain its attachment to the mandibular bone at the lingual side (Fig. 3). At the buccal side, a partial-thickness ap was made to

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Fig. 1. Severe resorption of the mandibular ridge, presence of alveolar mucosa over implants, and a shallow vestibule.

Fig. 3. Incision in the mucogingival line.

Fig. 2. Severe resorption of the mandibular ridge, presence of alveolar mucosa over implants, and a shallow vestibule.

Fig. 4. Exposure of the implants. The lingual ap was not elevated, except around each implant.

provide blood supply coming to the periosteum for the gingival grafts. An incision was made in the periosteum, at the base of the recipient bed, as described by Corn,29 with an osseous exposure of 4-5 mm to minimize future muscle reinsertion over implant abutments during the postoperative period (Fig. 4). The cover screws were removed. Then the 3 central implants received healing abutments (3.75 6 mm) (Cicatrizadores Paralelos; Neodent), and the two most distally located implants received standart abutments (3.75 7 mm) (Pilar Trans-Epitelial; Neodent) (Figs. 5 and 6). Two fragments of keratinized connective tissue were harvested from both sides of the hard palate. The palatal donor areas were sutured (Polyvicril 5-0; Ethicon, So Paulo, Brazil) continuously for clot stabilization. Grafts were adapted in the receptor area and stabilized with horizontal mattress sutures (Fig. 7). A postoperative stent was made from acrylic resin before the surgical procedure (Fig. 8). Specic temporary titanium cylinders were bonded to the stent with acrylic resin. The

stent was xed to distal standard abutments through the temporary components for prosthetic abutments to avoid future muscle reinsertion over implant abutments (Figs. 9 and 10). The stent was maintained for at least 4 weeks, as suggested by Corn.29 The patient was instructed to clean the region underneath the stent using saline solution with the aid of a syringe. After 40 days, the stent was removed, and the patient attended to recall appointments for 6 months (Fig. 11) until the prosthetic procedures were completed. To document the stability of the results over time, a modication in the technique proposed by Bohannan26 was used. A metal ball was placed at the bottom of the vestibular sulcus, and standardized cephalometric radiographs were taken before and 6 months after the procedure. Linear measurements from the mandibular basis to the bottom of the vestibular sulcus were made on both radiographs by using specic software for radiographic tracing and treatment planning in implantology (RadioImp; Radiomemory, Belo Horizonte, Brazil) (Figs. 12 and 13). The difference between the 2

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Fig. 5. Cover screws removed and healing caps installed (3.75 6 mm). Standard abutments (3.75 7 mm) were placed in the distal implants.

Fig. 7. Grafts stabilized in the receptor area with horizontal mattress sutures

Fig. 8. Postoperative acrylic stent. Fig. 6. Schematic design showing standard abutment (3.75 7 mm) placed in the distal implants and the apical position of the alveolar mucosa.

measurements was 9.39 mm (initial 20.88 mm, nal 11.49 mm) after a 6-month postoperative period.

DISCUSSION According to several studies, in patients with minimal or no keratinized tissue, homeostasis of the periimplant tissues may be achieved if the patient is able to maintain adequate hygiene of the area.1-5 However, it has been observed clinically that a shallow vestibular sulcus associated with a narrow band of keratinized gingiva surrounding implant abutments may contribute to an impaired quality of oral hygiene. In those cases, a palatal mucosal graft in conjunction with a vestibuloplasty have been indicated.7,13 Soft tissue sealing around dental implants is formed by junctional epithelium, which adheres to the abut-

ment or the implant body through hemidesmosometype junctions. The surface of the implant does not present functional ber insertions such as Sharpey bers to the cement of a natural tooth. Thus, biologic sealing around the implant depends on a combination of the resistance of junctional epithelium insertion and mobility of peri-implant connective tissue. Such absence of mobility exists only with an appropriate amount of connective tissue adjacent to the implants. Moreover, this connective tissue must be closely adapted around the implant abutments. The muscle tone of the connective tissue circular bers around the implant and insertion of connective tissue bers from the alveolar crest to free gingiva provide the stability and structural support necessary for maintenance of the junctional epithelium sealing.38 According to some authors, the presence of an adequate amount of keratinized tissue around the implants supports the functional stress transmitted by mastication and oral hygiene procedures, because tissues with appropriate contours al-

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Fig. 9. Postoperative stent xed to distal standard abutments.

Fig. 11. Six months after surgery.

Fig. 10. Postoperative stent xed to distal standard abutments.

low a self-cleaning environment with reduction in food debris accumulation.7,11,13,25 Sclar13 stated that the presence of keratinized tissue around the implants provides a favorable prosthetic environment, facilitating realization of specic prosthetic procedures. Peri-implant soft tissues are often submitted to mechanical trauma. Procedures such as placement of abutment connections, temporary abutment removal and replacement, impression procedures, preparation and delivery of subgingival restorations, framework try-ins, and movements allowed by resilient retention systems supporting overdentures represent challenges that could result in disruption of the junctional epithelium and the connective tissue sealing, further compromising the success of the implant therapy. In cases of severely atrophic mandibles, an absent or insufcient keratinized tissue may be observed in association with a shallow vestibule. Shallow or absent vestibules cause food retention, difculties in perform-

ing hygiene procedures, and mobility of the peri-implant mucosa.7,13 Therefore, considering all of these factors together may justify the surgical therapy proposed. An association of palatal masticatory mucosa graft and vestibule deepening was described. These techniques increase previsibility of postoperative results.39,40 Moreover, in the present study, the patient presented a prominent insertion of the muscles in the mental region of the mandible. The main obstacle that impairs the previsibility of mucogingival surgery in the severely resorbed mandible is the presence of the mental muscle insertion almost on the crest of the ridge. To avoid muscle reinsertion, a postoperative acrylic resin stent was connected to the distal implant abutments. The use of a device to prevent muscle reattachment in procedures of vestibule deepening was rst proposed by Corn.29 According to that author, when mental muscle was separated from its insertions by means of the periosteal incision, a careful treatment was necessary to avoid the rejoining of the bers at their previous level. Originally, the author suggested the application of a surgical dressing into the broad base of the newly established vestibule to restrain the muscle bers. Moreover, as proposed by Corn,29 the device retention period for muscle restraint should be a sufcient length of time to allow complete epithelialization of the area. As time goes by, the cut bers of the mental muscle are covered by mature epithelialized tissue, and cannot creep coronally, because of the periosteal separation. Four weeks should be the length of time required. Premature removal of the device, as stated by the author,29 may allow exposed muscle bers to become attached at a higher level, thus losing the vestibular fornix depth achieved. Therefore, based on Corns experience,29 we recommended the patient to use an acrylic stent screwed to distal standard abutments for at least 4 weeks.

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Fig. 12. Linear measurement of vestibular depth before the vestibuloplasty procedure.

Fig. 13. Linear measurement of vestibular depth 6 months after the vestibuloplasty procedure.

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12. Arnoux JP, Papasotiriou A, Weisgold AS. A revised technique for stage-two surgery in the severely resorbed mandible: a technical note. Int J Oral Maxillofac Implants 1998;13:565-8. 13. Sclar AG. Beyond osseointegration. In: Sclar AG, editor. Soft tissue and esthetic considerations in implant dentistry. Chicago: Quintessence; 2003. p. 1-12. 14. Prato GP, Clauser C, Cortellini P. Periodontal plastic and mucogingival surgery. Periodontology 2000 1995;9:90-105. 15. Ericsson I, Lindhe J. Probing at implants and teeth: An experimental study in the dog. J Clin Periodontol 1993;20:623-7. 16. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone, connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces. J Maxillofac Surg 1981;9:15-25. 17. Listgarten MA, Lang NP, Schroeder HE, Schroeder A. Periodontal tissues and their counterparts around endosseous implants. Clin Oral Implants Res 1991;2:1-19. 18. Sanders B, Starshak TJ. Vestibuloplasty. In. Starshak TJ, Sanders B, editors. Preprosthetic Oral and maxillofacial Surgery. St. Louis: Mosby; 1980. p. 165213. 19. MacIntosh RB, Obwegeser HL. Preprosthetic surgery: a scheme for its effective employment. J Oral Surg 1967;25:397-413. 20. Ten Bruggenkate CM, Krekeler G, van der Kwast WA, Oosterbeek HS. Palatal mucosa grafts for oral implant devices. Oral Surg Oral Med Oral Pathol Oral Radiol Endods 1991;72:154-8. 21. Sevor JJ. The use of free gingival grafts to improve the implant soft tissue interface: rationale and technique. Pract Proced Aesthet Dent 1992;4:59-64. 22. Rapley JW, Mills MP, Wylam J. Soft tissue management during implant maintenance. Int J Periodontics Restorative Dent 1992;12:373-81. 23. Hughes WG, Howard CW third. Simultaneous split-thickness skin grafting and placement of endosteal implants in the edentulous mandible: a preliminary report. J Oral Maxillofac Surg 1992;50:448-51. 24. Artzi Z, Tal H, Moses O, Kozlovsky A. Mucosal considerations for osseointegrated implants. J Prosthet Dent 1993;70:427-32. 25. Simons AM, Darany DG, Giordano JR. The use of free gingival grafts in the treatment of peri-implant soft tissue complications: clinical report. Implant Dent 1993;2:27-30. 26. Bohannan, H. Studies in alteration of vestibular depth. I. Complete denudation. J Periodontol 1962;33:120-8. 27. Bohannan, H. Studies in alteration of vestibular depth. II. Periosteum retention. J Periodontol 1962;33:354-9. 28. Bohannan, H. Studies in alteration of vestibular depth. III. Vestibular incision. J Periodontol 1963;34:209-15. 29. Corn H. Periosteal separation; its clinical signicance. J Periodontol 1962;33:140-53. 30. Moore JR. A modication of stent design for preprosthetic surgery. J Oral Surg 1970;28:263-6. 31. Sanders B, Starshak TJ. Modied technique for palatal mucosal grafts in mandibular labial vestibuloplasty. J Oral Surg 1975;33:950-2. 32. Firtell DN, Oatis GW, Curtis TA, Sugg WE Jr. A stent for a split-thickness skin graft vestibuloplasty. J Prosthet Dent 1976; 36:204-10. 33. Kahnberg KE, Nystrom E, Bartholdsson L. Combined use of bone grafts and Branemark xtures in the treatment of severely resorbed maxillae. Int J Oral Maxillofac Implants 1989;4: 297-304. 34. Small SA. Surgical stents and major oral maxillofacial surgery. Dent Clin North Am 1989;33:497-509. 35. Brygider RM, Bain CA. Custom stent fabrication for free gingival grafts around osseointegrated abutment xtures. J Prosthet Dent 1989;62:320-2. 36. Ziccardi VB, Misch C, Patterson GT, Nawrocki JS. Use of

We observed that the technique presented here, in combination with palatal mucosal graft and use of a postoperative stent, decreased the pull of mental muscle and provided a peri-implantally stable soft tissue around implants. CONCLUSION This new approach is indicated for the resorbed mandible where the anatomic alterations render specic surgical procedures necessary beyond the classic palatal mucosal graft. These include preservation of the lingual ap attachment, periosteal incision at the bottom of the recipient bed, an osseous exposure of a 4-5 mm, and the use of a surgical stent. The primary goal in this technique was to decrease the pull of the mental muscle in peri-implant areas. The technique provided an increase in keratinized tissue and prevented muscle reinsertion during the observation period.
The authors thank Ariadne Machado G. Letra for translating this article. REFERENCES
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Reprint requests: Luiz Gustavo Nascimento de Melo Av. Waldir Felizola de Moraes, 1560, BL. 01, AP.31 Jardim Umuarama 16011-155, Araatuba, SP Brazil luiznsc@terra.com.br