A technique for vestibular sulcus extension

Alfred F. Tortorelli, Major, DC, USA

Walter Rerd Army Medical C~~rtu. Il;aslLngtm. 1). C.‘,

T his article presents a technique that will enable prosthodontists

more stable lower dentures. With stability, patients will be encouraged
to construct
to learn
how to effectively use complete lower dentures. Patients with edentulous ridges
which have undergone much atrophy present a formidable challenge to dentists.‘.

LITERATURE REVIEW
Kazanjian “, 4 found that, under certain conditions, surgery seems to be essential
for the efficient adaptation of dentures, and he outlined a method of vestibular
sulcus extension. Others”-‘” have also de\%ed techniques for obtaining vestibular
sulcus extension and for forming a broad band of attached gingiva.

RATIONALE
In the light of periodontal investigations,l”-” there is evidence that cicatricial
fixation does not occur with any degree of predictability unless bone is denuded
or unless the continuity of the periosteurn is interrupted in some way. Bone de-
nuding alone produces adequate results in deepening the vestibular sulcus.“’
In the procedure described by Corn,’ an attempt is made to create additional
attached gingiva on the labial side of the lower alveolar ridge. The vestibulal
sulcus is deepened without loss of bone around the alveolar process, because the
cortical plate of bone is denuded in only a localized area deep on the facial aspect
of the mandible.
Granulation tissue forms rapidly and covers this small area of denuded bone
within 10 days postoperatively. Patients are more comfortable when treated by this
procedure than wha all of the bone is denuded.

Condensed from a thesis submitted as partial fulfillment of the requirements for the Army
Dental Internship Program, Walter Reed Army Medical Center, Washington, D. C.
This material has been reviewed by the Office of the Surgeon General, Department of the
Army, and there is no objection to its publication. This review does not imply any indorse-
ment of the opinions advanced or any recommendation of such products as may be named.

14
Volume 20 Technique for vestibular sulcus extension 15
Number 1

TECHNIQUE FOR VESTIBULAR SULCUS EXTENSION

The periosteal separation procedure can be adapted for edentulous patients
(Fig. 1). The vestibular sulcus can be extended labial to the anterior segment of
the lower ridge with the use of sutures to bind the labial mucosa and periosteum
and to hold the tissue in place. The natural tendency of the lower lip to drape
over the lower ridge affords protection for the surgical site, and it eliminates the

Fig. 1. The basic steps in the technique described. a, Lower anterior teeth with severe perio-
dontal disease and with loss of alveolar bone. b, The postextraction situation with the labial
sulcus very shallow and the muscular attachments close to the crest of the ridge. C, The
initial incision with sharp dissection close IO the periosteum and to the sulcus depth desired.
d, The periosteal incision and fenestration are established. e, The labial mucosa is sutured to
the inferior edge of separated periosteum.
16 ?‘ortordli

t’ig. 2

Fig. 3

Fig. 4

aeed for stents and surgical dressings. which arc often as traumatic to the patient
as the operation itself.‘. ”
The initial incision is made at tht: mucogingival junction j Fig. 2). it extends
from the first bicuspid region on one side to the first bicuspid region on the other
side. The lateral extent of the incision is kept anterior to the mental foramen and
to the mental nerve and vessels. The rrl~dcs along the length of the incision are
detached from the periostcum by sharp dissection without perforating the perios-
Volume 20
Number 1
Technique for vestibular sulcus extension 17

Fig. 5

Fig. 6

Fig. 7

Fig. 5. Sutures are placed at 5 mm. intervals to maintain the tissues in position so that the
denuded bone remains exposed.
Fig. 6. The labial flange of the denture is removed and the borders are polished so the
patient can wear it during the healing process.
Fig. 7. The denture is in place immediately after surgery. The flange is short enough so that
it cannot touch the tissue involved in the surgery.

teum (Fig. 3). This dissection is carried to the planned depth of the sulcus (Fig.
4). Then aln incision parallel with the mucogingival line is made through the
periosteum. Light pressure is applied to the scalpel so as not to gouge the bone.
The cut edge of the periosteum is gently pushed toward the inferior border of
the mandible (Fig. 5). In doing this, care must be taken to avoid shredding of the
lower cut edge of this tissue because the periosteum is thin and friable. In follow-
ing these procedures, a band of bone about 3 mm. wide along the entire length of the
 18 Tortorelli 1. I’ros. Dent.
July, 1968

horizontal incision should be exposed. Vertical relaxing incisions may be made at

both ends of the horizontal incision to free the labial mucosa for easier reposition-
ing.
Black silk 0000 sutures at 5 mm. intcr\.als arc used ttr connect the lower edge
of separated periosteurn and the alveolar mucosa (Fig. 5). The sutures should hold
the mucosa firmly against the periosteum to resist displacement toward the crest of
the ridge (Fig. 5 I. Thus, the alveolar mucosa lining the inner surface of the lip
is maintained, and the labial plate is covered by periostrum from the sitca of the
previous mucogia+val junction to the superior edge of the exposed bone. ‘l‘he
sutures may be removed in 6 to 7 days.
The entire labial flange of the patient’s lower denture is cut away from bicus-

A D

B E

c F

Fig. 8. The history of the healing. A, The tissue three days postoperative. B, After one week,
granulation tissue was forming. C, After two weeks; epithelialization is well under way. D,
After three weeks, the healing was complete, but changes in form were occurring. E, After
four weeks, impressions for new dentures were made. F, After 6 months, a wide band of
attached mucosa is apparent.
EEL:O Technique for vestibular sulcus extension 19

pid to bicuspid and up to the crest of the labial alveolar ridge (Fig. 6). All rough
edges must be smoothed and polished. No part of the denture should touch or cover
any part of the wound site, and the denture may be worn as usual while the wound
is healing (Fig. 7).
The patient is given an ample supply of a mixture of 3.5 parts of 5 per cent
lidocailne ointment to 1 part petroleum jelly, and is instructed to apply it liberally
to the wound area before meals and at bedtime. He is cautioned to keep move-
ment of the lower lip to a minimum. Codeine may be prescribed for the first two
days postoperatively for the relief of severe pain, while a weaker analgesic, such as
APC, is suggested for milder discomfort (Fig. 8).

DISCUSSION
Severe atrophy of the mandible in the anterior region is a contraindication for
the use of this procedure. There must be enough vertical height of bone to prevent
the complete detachment of the muscles of facial expression from the bone.
Scar tissue invariably contracts following healing. This and the proliferation of
submucous connective tissue will tend to make the mandibular sulcus become more
shallow. To counteract this, the depth of the sulcus should be extended slightly
beyond the desired postoperative depth.
It is most important that the denture flange be kept entirely away from the
operative site. If a dressing supported by the labial flange of the denture is used to
cover the area, it would act as an irritant, retard the healing, and prolong the
pain because it is impossible to completely immobilize the denture.

SUMMARY
A technique is described for deepening the mandibular labial sulcus in edentu-
lous patients. It eliminates the need for dressings and stents.
This technique provides for a predictable increase in vestibular depth, and
separation atnd repositioning of the muscles of facial expression from the region near
the crest of the ridge to a position lower on the body of the mandible. These mus-
cles still maintain their ability to function but exert little effect in displacing the
lower complete denture.

References
1. Smedley, V. C.: Alveolar Bone in Relation to Denture Prosthesis, J. A. D. A. 24: 23-27,
1937.
2. Weinman, J. P., and Sicher, H.: Bone and Bones, St. Louis, 1955, The C. V. Mosby
Company.
3. Kazanjian, V. H.: Surgical Operations as Related to Satisfactory Dentures, D. Cosmos
66: 387, 1924.
4. Kazanjian, V. H.: Surgery as an Aid to More Efficient Service With Prosthetic Dentures,
J. A. D. A. 22: 566-581, 1935.
5. Goodsell, J. 0.: Surgical Aids to Intraoral Prosthesis, J. Oral Surg. 13: 8-34, 1955.
6. Robinson, R. E.: Mucogingival Junction Surgery, J. California D. A. & Nevada D. Sot.
33: 379-385, 1957.
7. Corn, H.: Periosteal Separation-Its Clinical Significance, J. Periodont. 33: 140-153,
1962.
8. Robinson, R. E.: Periosteal Fenestration in Mucogingival Surgery, J. California D. A.
38: 199-202; 238, 1962.
20 Tortorelli

9. Wallenius. K.: Ridge Extension: i\ Modified Operative Technique, J. Oral Sura. 21:
54-59, 1963.
10. Bohannan, H. M.: Studies in the Alteratiorl of \‘estibular lkpth, 1. Cornpletc Denud,l-
tion, J. Periodont. 33: 120-128, 1962.
Il. Bohannan, H. M.: Studies in the .Iltmrtion of Vrstibular Drl)rh. II. Periosteal Krtcntiou.
J. Periodont. 33: 354-359: 1962.
12. Bohannan, IH. M.: Studies in the Alteration of \‘cstibular Depth. III. ‘IYestibular Incision.
J. Periodont. 34: 209-215. 196:3.
13. Carranza, F. A.? and Carraro. J. J.: EfTect of Kernoval of Periostcum on Postopcratikc
Result of Murogingival Surgery, J. Periodont. 34: 223-226. 1963.
l+. Koslin. .4. J.: Fixation Technique for Sulrus Drepening, J. Oral Surg. 21: 60-62, 196J.
1.5. Thoma. K. H.: Oral Surgery. cd. -1. St. Louis, 1963. The (:. V. Mosby Clompany, pp.
:!18-116.1,