Received: 1 October 2020 Revised: 11 November 2020 Accepted: 13 November 2020

DOI: 10.1111/scd.12546

ARTICLE

The versatile “lip switch” or transitional flap vestibuloplasty

combined with alveoloplasty and implant placement to
treat atrophic mandibles with inadequate vestibules and
attached tissue: A case series and review of the literature
David R. Adams1 Yuliya Petukhova2 Leslie R. Halpern1

1Department of Oral and Maxillofacial

Surgery, School of DentistryUniversity of
Utah, Salt Lake City, Utah
2Department of Oral and Maxillofacial
Surgery, Mayo Clinic, Rochester,
Minnesota
Correspondence
Leslie R. Halpern, Department of Oral and
Maxillofacial Surgery, School of Dentistry,
University of Utah, Salt Lake City, UT.
Email: Leslie.halpern@hsc.utah.edu
Abstract
Introduction/Aims: The edentulous mandibular ridge and associated shallow
vestibule are often seen as a challenge in the oral rehabilitation of patients. Den-
tal implants can provide an improvement in mastication and patient satisfaction.
The aim of this study is to utilize a preprosthetic mucosal flap combined with a
repositional periosteal flap concomitant with an alveoloplasty and placement of
endosteal implants as a single-stage procedure in the anterior mandible. This
approach provides a valued alternative for dental rehabilitation in patients with
poor masticatory efficiency using a conventional denture.
Methods: Eight patients underwent the preprosthetic surgical plan in the oral
surgery clinic of the dental school during a 1-year period. Age, sex, preoperative,
and postoperative vestibular depth, as well as hard and soft tissue elements were
measured (P < .05) at 4-6 months.
Results: Mean age was 53 years ± 14.62 (N = 8). Anterior mandible height was
19 ± 4.8 mm. A significant difference was measured using a two-tailed Student’s
t-test between pre- and postoperative vestibular depths, respectively (3.9 mm vs
10.5 ± 0.96 mm; P < .01).
Conclusions: A lip switch vestibuloplasty combined with placement of two
implants provide a one-stage procedure that is convenient, provides a shorter
postoperative period, and can be financially affordable. Future research requires
larger sampling to support this treatment as a standard of care.

KEYWORDS
dental implants, edentulous mandible, preprosthetic surgery, ridge augmentation, vestibulo-
plasty

1 INTRODUCTION width (KMW), thickness, and height is often seen as a

challenge in the oral rehabilitation of patients suffer-
The edentulous mandibular ridge with associated shallow ing from loss of dentition.1-3 The shallow mandibular
vestibule and limited peri-implant keratinized mucosal vestibule with high muscle attachments and lack of ker-

© 2020 Special Care Dentistry Association and Wiley Periodicals LLC

Spec Care Dentist. 2020;1–7. wileyonlinelibrary.com/journal/scd 1

2 ADAMS et al.

atinized oral mucosa often interfere with the fabrication

of the ideal removable overdenture prosthesis.3 Their
mandibular ridges are often knife-edged or irregular and
not suitable for denture fabrication without concomitant
preprosthetic hard and soft tissue preparation. Performing
conventional alveoloplasty (especially when significant
bone is removed) often will result in a significant decrease
in vestibular depth and compromise the hard and soft
tissue peri-implant phenotype needed for dental implant
placement.1-3 As such, in cases where implant-supported
FIGURE 1 Panoramic X-ray of edentulous mandible
overdentures are treatment planned, often these hard
and soft tissue foundations require “anatomic correction”
prior to placing implant fixtures.2-4
Modern implant dentistry has significantly improved
the treatment options for functional restoration of the
edentulous mandible.2,4-7 Considering the removable
prosthetic choices available, implant-retained dentures
offer a substantial improvement in function, patient
satisfaction, and bite force compared to conventional
dentures.1,2,4-8 This requires a peri-implant phenotype
consisting of adequate soft tissue KMW, depth, as well as
a thickened bony ridge that will satisfy the placement of
dental implants.3-5
This report presents a case series utilizing an inno-
F I G U R E 2 Sagittal cone beam computed tomography (CBCT)
vative preprosthetic surgical approach consisting of a depicting the height of the mandible in relation to the vestibular
mucosal flap combined with a repositional periosteal depth
flap concomitant with an alveoloplasty and placement of
endosteal implants as a single-stage procedure in the ante-
rior mandible. A review of the literature is also provided to
suggest the advantages of traditional hard and soft tissue
preprosthetic enhancement in the deficient mandibular All patients had medical and surgical histories that
vestibule, followed by oral rehabilitation with an implant- posed no contraindication for dental and preprosthetic
supported overdenture. This approach may provide a val- surgical interventions. Written and informed consent
ued alternative for dental rehabilitation in patients pre- were obtained, and risks and benefits were discussed.
senting to the dental center who are limited by both access Each patient’s mandible was imaged with a panoramic
to care and limited financial resources. radiograph and in three dimensions using a cone beam
computed tomography (CBCT) (Plan Meca, Chicago, IL)
approach in order to measure the height and width of
2 MATERIALS AND METHODS their anterior mandibular ridge between the bilateral
mental foramina (Figures 1 and 2). Each mandible was
The Institutional Review Board (IRB) of the University of classified as a Kent Class 4; characterizing the inability
Utah approved this study (IRB # 00134553). A case series to have proper retention and stability of the mandibular
of eight patients (N = 8; three females and five males), denture.4 A minimum of 10-15 mm of anterior mandibular
age range 30-82 years old presented to the University of height was measured from a CBCT in each patient prior to
Utah School of Dentistry, oral and maxillofacial surgery surgical intervention (Table 1). Vestibule depth was mea-
clinic with a need of restoring their edentulous mandible. sured with a periodontal probe. There was no soft or hard
All the patients complained about the loss of retention tissue pathology noted. The same surgical team performed
and stability of their lower dentures, which impeded their the procedure in all patient cases, and all the cases were
ability to chew and speak properly, as well as their every- designed as a single-stage approach with concomitant
day functioning in the workforce. They also stated that placement of two anterior mandibular implants. Age
they were limited by financial means for a fixed dental distribution was calculated with Student’s t-test. Other
implant prostheses, but were able to afford an implant- demographic variables measured were gender, as well as
assisted mandibular overdenture. postoperative follow-up time over 4-6 months.
ADAMS et al. 3

TA B L E 1 Patients’ characteristics undergoing vestibuloplasty and placement of implants

Keratinized
mucosal
width Preoperative Postoperative Diameter/depth
(facial, Mandible vestibule vestibule of Follow up
Age (years) Sex lingual) height(mm) depth(mm) depth(mm) implants(mm/mm)
(months)
41 Male 2-3 mm B/L 15 4 10 3.7/10 (2) 6
49 Male 2 mm B/L 20 4 9 3.7/10 (2) 6
57 Female 3 mm B/L 15 3 9 3.7/11.5 (2) 6, 12
82 Female 4 mm B/L 16 4 14 3.7/11.5 (2) 6
30 Male 4 mm B/L 30 5 11 3.7/11.5 (2) 4
51 Male 3 mm B/L 18 4 10 3.7/11.5 (2) Lost to F/U
65 Male 4 mm B/L 22 4 11 3.7/10 (2) 6
49 Female 3 mm B/L 16 3 10 3.7/10 (2) 6.5

T A B L E 2 Comparison of preoperative (pre-op) and

postoperative (post-op) vestibule depth
Pre-op Post-op
vestibule vestibule
depth depth
Mean 3.88 10.50
Standard deviation (SD) 0.64 1.60
Standard error of the mean 0.23 0.57
(SEM)
N (sample size) 8 8
F I G U R E 3 Preoperative intraoral photograph of the edentulous
Two-tailed P-value <.0001 mandibular ridge. Note the shallow vestibule
Confidence interval 95%

2.1 Surgical approach

Preoperatively, the patients were given either 1 g of

amoxicillin, or 600 mg clindamycin if allergic to
penicillin, followed by 0.12% chlorhexidine rinse for
30 seconds. Local anesthesia was performed using
2% lidocaine (1:100 000 epinephrine) via nerve block
injections and local administration of 0.25% marcaine
(1:200 000 epinephrine) postoperatively. The depth of
the vestibule anteriorly was measured with a caliper
at the midline with passive pushback of the lip. These
measurements were taken both pre- and postoperatively
(Table 2).
2.2 Vestibuloplasty technique
A marking pen outlined the intraoral area of the lip that
would serve as the donor site for the lip switch, and pro-
vide mucosal covering over the exposed mandible to the
depth of the newly created vestibule. A No. 15 blade was
then used to make an incision through the labial mucosa
12-15 mm from the alveolar ridge. Releasing mucosal inci-
F I G U R E 4 Intraoral view of the boundaries of submucosal dis-
section that will lead to a mucosal flap
sions were made to the crest of the ridge anterior to the
mental foramens (Figures 3 and 4). A submucosal dissec-
tion was performed toward the crest of the ridge to just
inferior to junction of the keratinized and nonkeratinized
gingival tissues. The mucosal flap was folded over the crest.
A horizontal incision through the periosteum to bone was
made just inferior to the mucosal flap reflection extend-
ing between the releasing incisions in the premolar areas.
A subperiosteal dissection was made to near the inferior
boarder of the mandible reflecting the periosteal flap out
onto the lip. The mental nerves were identified and pro-
4 ADAMS et al.
F I G U R E 5 Intraoral view of the prepared flap at the level of the
ridge and suturing of the periosteal to the inner aspect of the lip
F I G U R E 6 Sagittal drawing of the surgical submucosal dissec-
tion of the labial mucosa flap (A) and periosteal layer (B) that will be
sewn to the inner aspect of the lip
tected. The edge of the periosteal flap was sutured to the
edge of the lip mucosal incision with 4-0 Vicryl suture
(Figures 5-7).
2.3 Alveoloplasty and dental implant
placement
Once the vestibuloplasty dissection was completed, atten-
tion was turned to the crest of the ridge where a subpe-
riosteal dissection was carried up over the ridge and on to
the lingual side of the mandible. The reflected keratinized
and nonkeratinized mucosal flap now lingual allowed for
exposure of the alveolar bone. The knife-edge/irregular
alveolar bone was contoured as needed with rotary instru-
F I G U R E 7 Intraoral view of the periosteal layer sutured to the
inner aspect of the lip
ments to provide the peri-implant bone thickness required
for implant placement. Two Zimmer dental implants,
diameter of 3.75 mm and height of either 10 or 11.5 mm,
were placed anterior to the mental foramina in the usual
manner (see Figures 8 and 9). Cover screws were placed,
and the mucosal flap was advanced to cover the exposed
bone and sutured to the reflection of the periosteum at the
depth of the newly deepened vestibule with interrupted 4-0
Vicryl mattress yielding a vestibule with a depth of approx-
imately 15 mm (Figure 10). A postoperative panoramic X-
ray was recorded. After surgery, the patients were pre-
scribed amoxicillin 500 mg or clindamycin 300 mg, ID, for
7 days, and a 0.12% chlorhexidine gluconate solution BID
for 10 days. All the patients were placed on a soft mechan-
ical diet for 3 weeks.
The patients returned for the placement of two healing
abutments 3 months postsurgery. Overdentures were deliv-
ered 1 month later (Figures 11 and 12).
3 RESULTS
Table 1 depicts a descriptive overview of the patients
(N = 8) in this study. The mean age of the examined sam-
ple was 53 years ± 14.62 (age range of 30-82). The aver-
age height of the anterior mandible postoperatively was
19 ± 4.8 mm (P < .05), and average KMW at 3.13 ± 0.7 mm.
Table 2 depicts the depth of the vestibule measured at mid-
F I G U R E 8 Intraoral view of the preparatory sites for the
implants. Note the contour of the alveolar ridge
F I G U R E 9 Sagittal drawing depicting the implant placement
after the alveoloplasty (A), the mucosal flap sutured to the depth of
the deepened vestibule (B), and the periosteal flap sutured to the ini-
tial lip incision (C)
ADAMS et al.
F I G U R E 1 0 Intraoral view of the postoperative mucosal layer
sutured to the depth of the new vestibule
F I G U R E 1 1 Intraoral view of the vestibular depth and mucosal
layer at 3 months after surgery
line of the mandible preoperatively and postoperatively,
respectively, at an average of 4-6 months. A significant
difference was measured using a two-tailed Student’s test
when the preoperative and postoperative vestibular depths
were compared (3.9 vs 10.5 ± 0.96; P < .01) during the
follow-up period.
Postoperatively, there were minimal complications with
mostly minimal bleeding, as well as a transient paresthesia
that resolved over 1 month in one patient. All patients were
followed postoperatively for a time period of 4-6 months.
At 4 months postoperatively, the implant sites healed well
with 3-4 mm of KMW surrounding the implants, and a
probing depth range of 1-3 mm. The mucosa against the
F I G U R E 1 2 Intraoral view of the new vestibule with healing
abutments and measured depth at 3 months after surgery
5
mandible was not movable from the crest all the way to the
depth of the vestibule (Figure 12). The periosteal flap that
had been sutured to the lip incision transitioned to normal
appearing lip mucosa within 2 weeks postoperation.
In one patient, healing at the site of the vestibulo-
plasty was delayed with exposed bone at 3 weeks post-
surgery. These findings were attributed to the patient’s
lack of smoking cessation. At 1-month follow-up appoint-
ment, granulation tissue was present overlying the bone
in the mandibular vestibule in this patient. The vestibule
was healed at the 2-month follow-up visit. All mandibu-
lar overdentures were delivered 3-4 months after surgery.
The time of follow up after prostheses delivery varied
over 1-2 months. No dental implants have been lost
to date.
4 DISCUSSION
The case series presented provides an innovative approach
for the restoration of an edentulous mandible using a
supraperiosteal (lip switch) transitional flap vestibulo-
plasty, combined with alveoloplasty and implant place-
ment in the edentulous mandible. Vestibuloplasty is an
often overlooked traditional “work horse” procedure that
provides a preprosthetic rescue using the physiologic
foundation already present. This surgical modification
enhances a recipient site that will not only provide a bet-
ter retention and stability for a denture, but also potenti-
ate the placement of dental implants that can survive for
years to come.1,4–9 This is a versatile surgical technique
that can be used in the mandible or maxilla. It can be
done in segmental areas where the vestibule may have
been obliterated from past surgical procedures or from
localized alveolar atrophy. It can be performed in con-
junction with implant placement, or implant placement
can be done in the area of the vestibuloplasty at a later
time. The rationale for performing a pre-prosthetic soft
tissue augmentation with implant placement in existing
literature includes: inflammation prevention of the peri-
implant keratinized and nonkeratinized mucosa due to
muscle attachment proximity, an increase in stability of
the peri-implant phenotype, the attainment of lip sup-
port via increased space for a sufficient buccal flange, and
the avoidance of movement restriction on the mentalis
muscle.3–5
Research suggests that a shallow vestibule is associ-
ated with increased mucosal recession and bone loss
surrounding implants.2 These findings can impair a
patient’s ability to maintain oral hygiene due to lack of
space available for appropriate placement of a toothbrush
or other hygiene device. Kwakman et al reported on
successful attainment of peri-implant tissue with an
6 ADAMS et al.
adequately deepened vestibule 5 years after a combined
vestibuloplasty and implant placement procedure.5 Kao
et al evaluated the use of a supra-periosteal (lip switch)
vestibuloplasty with simultaneous implant placement
on 17 patients with severely atrophic edentulous ridges.6
The retention, stability, function, and esthetics of the
dentures were reported to be excellent. The authors noted
the advantage of increased visualization during implant
placement and improved vestibular morphology. Motlagh
et al conducted a study to compare results of a combined
vestibuloplasty and implant placement procedure with the
results of a two-step procedure, where implant placement
occured 6 weeks post-vestibuloplasty.7 The results of both
techniques were similar; implantation combined with the
preprosthetic surgery had no effects on crestal bone loss,
and resulted in a comparable gain in vestibular depth.
The combined procedure decreased treatment time and
cost, caused less pain, and shortened the rehabilitation
time.6,7
The vestibuloplasty technique may also be of benefit
after implant placement. Cortell-Ballester et al reported on
the successful use of vestibuloplasty after implant place-
ment to expose the prosthetic abutments and improve soft
tissue adaptation.8 Hakim et al employed a novel approach
to the implant-uncovering procedure utilizing a transpo-
sition multiple-flap vestubuloplasty.9 This technique was
able to refine the soft tissue environment after implant
insertion. For patients with insufficient keratinized
mucosa, a vestibuloplasty with an accompanying soft tis-
sue gingival grafting has been recommended.10 Complica-
tions for grafts, however, generally include donor site mor-
bidity, increased cost and surgical time, as well as a longer
healing period. Cillo and Finn evaluated the long-term
outcome of a traditional split thickness skin graft vestibulo-
plasty with concurrent implant placement in patients with
limited mandibular vestibules.10 A keratinized and stable
denture-bearing area was achieved, with no complications
noted in the graft donor nor recipient sites. The authors
concluded that a split thickness skin graft vestibuloplasty
with implant placement was a dependable method for
patients with shallow vestibules. Traditional split thick-
ness skin grafts, however, require a donor site and are
often a hospital procedure that involves financial and
postoperative concerns. The application of soft tissue aug-
mentation has now shifted to the use of gingival grafting in
areas that lack a keratinized mucosa site for dental implant
healing.3
The successful outcomes suggested by the above tech-
nique lends to better dental rehabilitation in patients
who are “dental cripples” due to poor retention and
stability of their prostheses. The patient population
that can benefit most from this treatment therapy often
appears to be individuals in areas of compromised socioe-
conomic conditions (ie, increased need for access to
care and significant financial burdens).12 Studies have
shown that informed decisions shared with patients
and their practitioners make financial sense due to
the long-term psycho-social benefits of an implant-
supported mandibular overdenture.12 A systematic review
by Mishra and Chowdhary scrutinized patients’ oral
health-related quality of life (OHRQoL)11 . Their results
suggested that retention, stability, chewing, speech, com-
fort, and psycho-social variables played a vital role in
patients’ OHRQoL with implant-supported mandibular
overdentures.
Our results, although quite encouraging, do have limita-
tions in data interpretation. Case series are observational
and represent level IV evidence in the hierarchy of evi-
dence pyramid.12,13 This level characterizes a lack of study
control participants and the risk of selection bias. Other
limitations include unknown future outcomes, and case
series models may not allow for generalizability in future
treatment practice. Advantages of case series reports, how-
ever, can include creating a platform for developing clin-
ical skills, as well as refining new techniques/treatment
protocols.13,14 In addition, a well-designed case series can
provide a foundation to develop hypotheses for large
prospective cohort studies, as well as the identification of
rare manifestations of a disease being investigated. Our
results are supported by other studies that strengthen this
approach for dental rehabilitation, especially with respect
to the use of level III and IV evidence stated above. The
latter can help strengthen the value of a case series study
design.13,14
5 CONCLUSIONS
This case series describes the use of a supraperiosteal (lip
switch) vestibuloplasty combined, with the placement of
two dental implants in patients with severely resorbed
edentulous mandibles. This treatment has the advantage
of increasing surgical access for implant placement, as well
as providing an improved hard and soft tissue peri-implant
phenotype for the implant-assisted mandibular overden-
ture. This procedure is convenient, eliminates the need for
a second surgery, does not require a second surgical site to
harvest a skin graft, can be done with the use of local anes-
thesia, provides a shorter postoperative time prior to the
fabrication of a mandibular overdenture, and most impor-
tantly can be more economical for the patient. The lat-
ter contributes to better masticatory function, speech, and
OHRQoL. Future research must include larger sampling,
as well as long-term follow up in order to consider this
treatment modality as a standard of care in the oral health
of our patient population.
ADAMS et al.
CONFLICT OF INTEREST
This research did not receive any specific grant from fund-
ing agencies in the public, commercial, or not-for-profit
sectors, patent or stock ownership, membership of a com-
pany board of directors, membership of an advisory board
or committee for a company, and consultancy for or receipt
of speaker’s fees from a company.
AC K N OW L E D G M E N T S
The authors thank Diane Jones, RDH, MPH, for her assis-
tance in manuscript preparation and Russell Wilson, BS,
D4 dental student from the University of Utah, School of
Dentistry for the artwork. We also thank November Bailey,
BA, for her drawings of Tables 1 and 2.
ORCID
Leslie R. Halpern https://orcid.org/0000-0003-1201-
7240
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How to cite this article: Adams DR, Petukhova
Y, Halpern LR. The versatile “lip switch” or
transitional flap vestibuloplasty combined with
alveoloplasty and implant placement to treat
atrophic mandibles with inadequate vestibules and
attached tissue: A case series and review of the
literature. Spec Care Dentist. 2020;1–7.
https://doi.org/10.1111/scd.12546