Vestibuloplasty

RIDGE EXTENSION
PROCEDURES
- ZEESHAN ARIF
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©M. S. Ramaiah University of Applied Sciences
INTRODUCTION
• The size and shape of the denture bearing area affects the outcome for
the conventional complete denture
• An overlooked prognostic factor is the nature of the denture bearing
surface mucosa
• Following extractions, there is progressive resorption of bone along with
general deterioration of the quality and amount of attached mucosa
that remains.
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• As the alveolar process decreases in size, adjacent muscles are found to
attach at or near the crest of the residual ridges.
• The residual gingiva becomes diminished and the labiobuccal vestibule

and lingual sulcus becomes shallow
• An adequate amount of bone must remain to develop a new vestibule
mandible – 12 to 15 mm
maxilla – reduction of nasal spine

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• Definition– surgical procedure whereby the oral vestibule is deepened
changing the soft tissue attachments and thus increasing the size of the
denture bearing area and height of the residual alveolar ridge
• Deepening of the vestibule without any addition of the bone is termed

as vestibuloplasty or sulcoplasty or sulcus deepening procedure
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class definition
I The alveolar ridge is adequate in height

but shows significant undercut areas and
insufficient width
II The alveolar ridge is deficient in both

height and width and presents as a knife
edge appearance
III The alveolar ridge has been resorbed to
the level of the basal bone
IV The mandible or the maxilla presents with
severe resorption; there is impending
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pathological fracture
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TECHNIQUES
1)MUCOSAL ADVANCEMENT VESTIBULOPLASTY
2)SECONDARY EPITHILIZATION VESTIBULOPLASTY
3)GRAFTING VESTIBULOPLASTY
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MUCOSAL ADVANCEMENT VESTIBULOPLASTY
• When the vestibule is extended, the first choice of procedures should be

the one where-by the neighbouring mucosa can be advanced to line
both sides of the sulcus.
• The prime criterion for this type of procedure is the presence of an

adequate amount of bone and healthy mucosa.
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Clinical test- with the lips in a relaxed
position, a mouth mirror is inserted into
the vestibule to the depth required
prosthetically. If the lip is not displaced
upward or drawn inward, it can be
assumed that there is sufficient mucosa
for advancement procedures
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CLOSED SUBMUCOUS VESTIBULOPLASTY
OBJECTIVES
• To extend the vestibule to provide additional ridge height
• To excise or transfer the submucous connective tissue and adjacent

muscles to a position farther from the crest of the ridge to prevent
relapse of the vestibule to its preoperative condition
• Generally done in the maxilla where better results are obtained
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MAXILLARY VESTIBULOPLASTY
• Obwegeser described this procedure in
1958
• 1)SUBMUCOSAL TUNNEL
• Vertical incision made in the midline of
vestibule from the crest of the ridge
proceeding superiorly approximately
15 mm.
• Metzenbaum scissors introduced
through the incision and blunt
dissection done to separate mucosa
from the submucosa on the right and
left sides to create a submucosal
tunnel
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2) SUPRA-PERIOSTEAL TUNNEL
• Supra-periosteal tunnel made with the

scissors, separating the connective
tissue and muscles from the periosteum
(parallel and below the submucosal
tunnel) till the zygomatic butress
• If anterior nasal spine is prominent, it is

reduced at this point
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3) EXCISION
• The wedge shaped strip of connective
tissue that remains between the two
tunnels is excised
• The freely movable mucosa is adapted

to the deepened sulcus with finger
pressure and the vertical incision is
sutured
• A roll guaze is placed into the vestibule
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to support the mucosa temporarily
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• A compound impression is made of the extended vestibule by using the
patients denture or a splint
• The denture/splint with extended flanges is sutured to the maxilla with

peralveolar wires or pins or circumzygomatic wires for 10-15 days
• A new denture is made in 3-4 weeks
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MANDIBULAR VESTIBULOPLASTY
• Boering 1979
• Not commonly done
• Similar to maxillary
vestibuloplasty
• Extra incision is given in

the premolar region to
prevent damage to the
neurovascular bundle
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MODIFIED MAXILLARY SUBMUCOSAL VESTIBULOPLASTY
George a. Wessberg, stephen a. Schendel and bruce n. Epker- 1980
OBJECTIVES ADVANTAGES
• To create increased exposure • Excellent surgical access and visualization of

of the operative site the operative site.
• To decrease the vertical • Increases anterior labial vestibular depth
midline scar and eliminates a low frenum attachment or
• To more predictably deepen vertical midline scar.
the anterior vestibular sulcus • Permits the extension of the incision beyond
the ANS into the lip mucosa without fear of
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creating a fibrous frenula 15
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SECONDARY EPITILIZATION VESTIBULOPLASTY
• The mucosa of the vestibule is used to line one side of the extended vestibule,
and the other side heals by growing a new epithelial surface
INDICATION
• Sufficient bone is present, but mucosa is either insufficient in quantity or

quality(inflammatory hyperplasia, ulceration or scar tissue)
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Godwins
modification
Kazanjian Lipswitch
Secondary Bipedicled
epithelization
vestibuloplasty
Obwegesers
modification
Clark
Tortorellis periosteal
fenestration
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KAZANJIAN TECHNIQUE
• Incision made in the
mucosa(premolar to premolar) of the
lip and a large flap of labial and
vestibular mucosa is reflected
• Supraperiosteal dissection done to

deepen the vestibule
• Flap of mucosa is turned downward

from the alveolar ridge and sutured
against the periosteum
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• Rubber catheter stent placed into deepened sulcus and fixed through the lip to the
outer surface with percutaneous sutures
• The catheter holds the flap in its new position and maintains the depth of vestibule
during the initial stages of healing.
• Catheter is removed after 7 days
• Labial donor site coated with tincture benzoin and left to granulate by secondary
epithelisation
• Drawback – severe scarring of the lip is seen which will further restrict the
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movements of the lower lip
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GODWINS MODIFICATION
• Similar to kazanjian technique
• Mucosal incision on the inner aspect of the lip is designed longer than the proposed
vestibular depth to be achieved
• Flap of labial mucosa is elevated but the vestibule is deepened by means of sub-
periosteal stripping instead of supraperiosteal dissection
• The periosteum is either excised or pushed downwards
• The labial and vestibular flap is placed directly against the bone and sutured
DISADVANTAGE – Scar contracture with a loss in sulcus depth

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LIPSWITCH TECHNIQUE
• Variation of Kazanjian's technique
• Keithly and gambly (1978) – lipswitch technique to be more successful in mandible
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BIPEDICLED FLAP
mucosal incision
is made
approximately 10 incision down to
to 12 mm in the periosteum is made at the
bi-pedicled mucosal flap is carefully elevated
mucosa junction of the attached
mucosa on the ridge
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Mandibular Anterior Ridge Extension: A Modification of the Kazanjian Vestibuloplasty
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Technique 24
• The flap is advanced and secured to the
depth of the vestibule with a polyethylene
tube fixed through the lip with
percutaneous sutures are placed.
• The labial and alveolar sides of the flap

are sutured to the lip and periosteum,
respectively, using horizontal mattress
sutures
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EDLAN MEJCHAR MODIFICATION
• Described as a modification of Kazanjian in 1924 for deepening the mandibular
labial vestibule in edentulous patient’s .
• Lipswitch modification done in the mandibular anterior region
ADVANTAGES –
• Healing occurs by first intention and no bone is left exposed, thereby minimizing
the chances of bone resorption and further recession.
• More practical and less technique sensitive
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vertical incision mesial to the
mandibular canines ; distance of 10
to 12 mm extending on to the lower
lip
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CLARKS TECHNIQUE
• Reverse of Kazanjian's technique
• Based on 4 principles
1. Raw surfaces of connective tissue contract whereas the same surfaces undergo
minimal contraction when covered with epithelium
2. Raw surfaces overlying bone cannot contract
3. Epithelial flaps must be undermined sufficiently to permit repositioning and
fixation without tension
4. Soft tissues undergoing plastic revision have a tendency to return to their former
position, so over correction and firm fixation are necessary
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PROCEDURE
• Incision is made on the alveolar ridge and a
supraperiosteal dissection is done to the
desired depth
• Mucosa of the lip is undermined till the
vermillion border
• Non absorbable percutaneous sutures are
placed in the free margin and are carried
through the skin and tied over the cotton roll
• Soft tissue side of the vestibule is covered with
mucosa, whereas on the osseous side the raw
periosteal surface is left to granulate and
epithelise
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OBWEGESER’S MODIFICATION
• Similar to Clark’s method
• The area of the alveolar bone with it‘s periosteal attachment is covered with a split
thickness skin graft and held in position by sutures or stent constructed
preoperatively.
• Instead of skin, mucosal graft has also been tried.
• ADVANTAGES
• Covers the bone and ensures faster healing
• Reduces chances of postoperative infection
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• Less bone loss and scarring
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PERIOSTEAL FENESTRATION
• Periosteum at the base of newly created vestibule is fenestrated/incised
horizontally , parallel with muco-gingival junction
• The inferior periosteal margin is sutured to the free margin of the mucosal flap
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• When the periosteum is fenestrated, healing of the denuded bone is delayed by 2-3
weeks.
• By the time the denuded boned begins to granulate, the periosteum covered bone
will already have grown a new epithelial surface
• This differential rates of healing could account for the reduction of relapse at the
line of fenestration
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GRAFTING VESTIBULOPLASTY
INDICATIONS
• Inadequate amount of bone to compensate for relapse after vestibuloplasty
• When a bone graft has been placed before in the surgical site
• Large surgical defect
DISADVANTAGES
ADVANTAGES
Donor site morbidity
Less relapse Skin grafts may not take up well on exposed
Early covering of surgical defect bone
Rapid healing Hair growth if graft is thick
Reduced secretory capacity, colour and surface
consistency
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PRINCIPLES OF GRAFTING
1. Skin grafts to be removed from a relatively hairless area.(upper thigh, inner surface
of arm)
2. Thin split thickness grafts are less likely to have hair follicles in the dermis
3. Split thickness graft will give better results than full thickness, but a full thickness
graft contracts less
4. Recipient site should be free of infection and have good blood supply
5. Graft should cover the entire raw area
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6. Haemostasis should be obtained in the recipient site before graft placement
7. Graft should be placed over periosteum and not cortical bone
8. Graft should be immobilised until healing has occurred(7 to10 days) by either by
stent or suturing
9. If palatal mucosa used, it should be defatted to make it as thin as possible
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MAXILLARY
Pocket inlay
Macintosh modification
Wallenus modification
SKIN GRAFT
MANDIBULAR
GRAFTING DERMIS GRAFT
VESTIBULOPLASTY
PALATAL MUCOSA
MUCOSAL
BUCCAL MUCOSA
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SKIN GRAFT VESTIBULOPLASTY
STAGE I - DONOR SITE SURGERY
• Patients thigh is prepared with a surgical soap and

Skin lubricated with mineral oil
• Graft width depends on the height of body of

mandible(5 to 6 cms) and thickness being about
0.012 inch(0.3mm)
• Dermatome used to prepare skin graft
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• The skin graft is kept moist and rolled in gauze
• Donor site is covered with fibre mesh gauze and pressure dressing
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STAGE II - RECIPIENT SITE SURGERY
• Mucosa infiltrated with local anaesthesia and crestal incision given from lateral
margin of one retromolar pad to the other
• Mandibular labio-buccal, submucosal and supra-periosteal dissections done,

mucosal flap reflected and sutured to the desired vestibular depth
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STAGE III – GRAFT SECURED
TO THE RECIPIENT SITE
1. STENT – dermatome cement is

used to attach the graft to the
stent such that the raw side is in
contact with the periosteum
2. SUTURES
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DERMAL GRAFTING
• Introduced by smiler et al
Advantages
• Readily available in sufficient quantity
• Easily re-vascularised
• Viable and immuno-compatible transplants
• Inhibit wound margin contracture
• Ability to take on the characteristics of surrounding mucosa
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SURGICAL PROCEDURE
• Thin split thickness graft (0.012 – 0.014 inch),

is raised with a dermatome, but the skin is not
removed and left pedicled at one end.
• Dermatome is again used to get a slightly

narrower strip of only dermis (0.015 – 0.022
inch) thick (below the skin pedicle)
• The pedicled skin flap is returned to its bed

and sutured in place
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MUCOSAL GRAFT VESTIBULOPLASTY
• BUCCAL MUCOSA GRAFT
Supraperiosteal dissection done to

Incion given from 1st premolar to 1st reflect a labial flap, which is
premolar, at the alveolar crest sutured till the desired vestibular
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Buccal mucosal graft
harvested using arhenm
retractors; 5mm longer than
the recipient size required
Primary sutured and

stent placed
Post stent removal (7 to 10 days)

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PALATAL MUCOSAL GRAFT (sanders and starshak 1975)
• Supraperiosteal dissection done in
vestibule and desired height is
achieved
• 2 spilt thickness strips of mucosa

taken from right and left side of
palate
• The 2 grafts are then placed on the

recipient site and sutured, followed
by stent placement.
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LINGUAL VESTIBULOPLASTY
• Also called floor-of-the-mouth-plasty
• Extension of the lingual sulci or lowering of the floor of the mouth
• It extends the denture bearing surface and improve stability and retention of the
mandibular denture
• Eliminates the muscle attachments that dislodge the prosthesis.
• Used in the mandible, when the mylohyoid and genioglossus attachments are close
to the alveolar ridge.
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anterior Caldwell
Lingual
sulcoplasty
posterior Trauner
obwegeser
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ANTERIOR LINGUAL SULCOPLASTY
• Cooley 1952
• Often combined with reduction of genial

tubercles
• Crestal incision given to expose the upper genial

tubercle and to detach the genioglossus muscle
(only lateral and superior fibres to prevent post
operative complaints of swallowing and speech)
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• Genial tubercles removed if too large
• Heavy nylon sutures attached to the muscles and pulled thru the skin under the chin
and repositioned inferiorly using buttons
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POSTERIOR LINGUAL SULCOPLASTY
CALDWELL PROCEDURE
• It is a subperiosteal procedure
• Suggested method when mylohyoid ridge reduction is recommended along with the
sulcoplasty
COMPLICATIONS
• Haematoma and edema of the sublingual tissues
• Difficulty in swallowing and speech for few days

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• Crestal incision given(molar to molar) and subperiosteal dissection done to reflect a full thickness
periosteal flap
• Mylohyoid muscle stripped away to expose the prominent ridge which is reduced with a chisel or
rounger
• Flap is sutured back to the ridge
• Denture or splint with an elongated flange is used to hold the lingual tissues down to the required depth
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TRAUNERS PROCEDURE
• Trauner in 1952
• Supra-periosteal procedure
INDICATIONS
• If mucosa of floor of mouth rises as high as the mandibular ridge
• When the tongue is elevated
• Mylohyoid muscle is attached at the level of the residual alveolar ridge
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• Long crestal incision given , supraperiosteal dissection done using gloved finger or
haemostat as close to the mandible to detach the muscle
• Heavy nylon sutures placed and mylohyoid muscle pulled down to desired depth
• Held in place with buttons
• Stent placed with split thickness graft to enhance healing
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OBWEGESERS PROCEDURE
• Macintosh and obwegeser in 1967
• Method of combining skin graft vestibuloplasty along with lowering of the floor of
the mouth
• Lingual sulcus deepening followed by buccal/labial vestibuloplasty
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REFRENCES
• Preprosthetic oral and maxillofacial surgery-Thomas j. Starshak, bruce sanders

• Reconstructive preprosthetic oral and maxillofacial surgery-Fonseca and davis, 2nd
edition
• Reconstructive preprosthetic surgery – john f helfrick and Daniel e waite
• Edlan Mejchar An Underestimated Tool For Vestibuloplasty - A Case Report , Indian
Journal of Dental Sciences, September 2015, Issue:3, Vol.:7
• Vestibular Extension By Edlan-Mejchar Technique Followed By Permanent Fibre
Splinting - A Case Report-Dr. Harinder Gupta, Dr. Pulkit Kinra, Vol .2, Issue 2 March
2010
• Modified maxillary submucosal vestibuloplasty George a. Wessberg, stephen a.
Schendel and bruce n. Epker, Int. J. Oral Surg. 1980: 9: 74-78
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RIDGE EXTENSION

• The residual gingiva becomes diminished and the labiobuccal vestibule

• An adequate amount of bone must remain to develop a new vestibule

maxilla – reduction of nasal spine

• Deepening of the vestibule without any addition of the bone is termed

I The alveolar ridge is adequate in height

II The alveolar ridge is deficient in both

2)SECONDARY EPITHILIZATION VESTIBULOPLASTY

• When the vestibule is extended, the first choice of procedures should be

• The prime criterion for this type of procedure is the presence of an

• To extend the vestibule to provide additional ridge height

• To excise or transfer the submucous connective tissue and adjacent

• Generally done in the maxilla where better results are obtained

• Supra-periosteal tunnel made with the

• If anterior nasal spine is prominent, it is

• The freely movable mucosa is adapted

• A roll guaze is placed into the vestibule

• The denture/splint with extended flanges is sutured to the maxilla with

• A new denture is made in 3-4 weeks

• Not commonly done

• Extra incision is given in

• To create increased exposure • Excellent surgical access and visualization of

• Sufficient bone is present, but mucosa is either insufficient in quantity or

• Supraperiosteal dissection done to

• Flap of mucosa is turned downward

• Catheter is removed after 7 days

• The periosteum is either excised or pushed downwards

DISADVANTAGE – Scar contracture with a loss in sulcus depth

• Keithly and gambly (1978) – lipswitch technique to be more successful in mandible

• The labial and alveolar sides of the flap

University Edlan Mejchar An Underestimated Tool For Vestibuloplasty - A Case Report

• Instead of skin, mucosal graft has also been tried.

• Covers the bone and ensures faster healing

• Reduces chances of postoperative infection

5. Graft should cover the entire raw area

7. Graft should be placed over periosteum and not cortical bone

9. If palatal mucosa used, it should be defatted to make it as thin as possible

STAGE I - DONOR SITE SURGERY

• Patients thigh is prepared with a surgical soap and

• Graft width depends on the height of body of

• Dermatome used to prepare skin graft

• Mandibular labio-buccal, submucosal and supra-periosteal dissections done,

1. STENT – dermatome cement is

• Readily available in sufficient quantity

• Viable and immuno-compatible transplants

• Inhibit wound margin contracture

• Ability to take on the characteristics of surrounding mucosa

• Thin split thickness graft (0.012 – 0.014 inch),

• Dermatome is again used to get a slightly

• The pedicled skin flap is returned to its bed

Supraperiosteal dissection done to

Primary sutured and

Post stent removal (7 to 10 days)

• 2 spilt thickness strips of mucosa

• The 2 grafts are then placed on the

• Also called floor-of-the-mouth-plasty

• Extension of the lingual sulci or lowering of the floor of the mouth

• Eliminates the muscle attachments that dislodge the prosthesis.

• Often combined with reduction of genial

• Crestal incision given to expose the upper genial

• Haematoma and edema of the sublingual tissues

• Difficulty in swallowing and speech for few days

• Macintosh and obwegeser in 1967