ALVEOLOPLASTY WITH RIDGE EXTENSIONS ON THE LINGUAL

SIDE OF THE LOWER JAW TO SOLVE THE PROBLEM OF A

LOWER DENTAL PROSTHESIS

PROF. L)R. R. TRAUSER,+ GRAZ, AUSTRIA

HEN people lose teeth, the problem of constructing a prosthesis without

W the aid of natural teeth, and which rests only on the alveolar ridge, must
be met. In the maxilla where the surface of the hard palate covered with im-
movable mucous membrane is utilized for the adhesion and retention of the
prosthesis, the problem is lessened because of the increased flat surface area. In
the mandible conditions are less favorable as the available surface area for a
prosthesis covering immovable mucous membrane is much smaller.
Parts of the alveolar ridge anteriorly (if teeth were extracted recently)
or posteriorly at. the beginning of the ascending ramus may offer a limited
resting surface for a total prosthesis. In most cases the floor of the mouth
rises between the cuspid and molars. This can be seen by having the patient
lift his tongue, first to the left, then to the right, as far as the alveolar ridge.
Sometimes the floor of the mouth even overlaps the ridge (Fig. 4). If patients
with total lower prostheses chew well, they have learned to stabilize the pros-
thesis by neither moving the tongue too much nor opening the mouth too wide
when eating or speaking. This requires a considerable degree of practice.
Behind the posterior edge of the mylohyoid muscle, lingually from the
angle of the jaw, there is a muscle-free area just as buccally below the lower
edge of the buccinator muscle there is such an area also. Patients do not en-
dure posterior wings of the prosthesis equally well. The main obstacle is the
mylohyoid muscle which in case of atrophy of the alveolar process is inserted
close to the alveolar ridge, hindering the making of really deep-reaching lingual
wings on a lower prosthesis (Fig. 1). This muscle extends lingually at an
angle of about 45 degrees, inward and downward, and tightens like an oblique
plate. The second obstacle is the mucous membrane of the floor of the mouth
which starts from the mandibular ridge and rises with every lifting of the
tongue and floor of the mouth (Figs. 3 and 4). In performing the alveoloplasty
both these obstacles must be removed. The mucous membrane and the muscle
must be separated from the mandibular ridge so that the prosthesis can extend
deeply on the lingual side of the lower jaw in order to rest in a completely
stable position. This can be achieved by a surgical operat.ion, with absolute
security of a successful result in most cases.
The separation of t,he mylohyoid muscle from the mandibular attachment
is of no consequence as far as function is concerned. In none of the cases have
Received for publication Nov. 10, 1951.
*Director of the Dental and Maxillary Clinics of the University of Graz.
340
 ALVEOI,OI’IASTY \VITH RIDC:E ESTESSIOSS 34 I

difficulties in speaking, swallowing, or moving the lower ,jaw result.cd. Tl,c

function of this muscle is supposed to be mainly the listing of thr hyoitl IWI~C
and floor of the mouth during the fimt part of deglutition.

Fig I. Fig. 2.

Fig. 3. Fig. 4.

Fig. l.-Showing attachment of mylohyoid muscle on inner surface of edentulous mandiblr.

Fig. 2.-Introduction of instrument below mylohyoi(i muscle in order to section it at its
attachment to the mandible.
Fig. 3.-In atrophy of the alveolar process the nrylohyoid muscle is attached just belocv
the gingiva, preventing the use of a lingual flange.
Fig. 4.-In atrophy of the alveolar process the raising of the tongue elevates the tloor ,)f
the mouth and displaces the denture.

The so-called alveoloplasty with ridge extension on the outer side of the
jaw was independently developed bp Kazanjian (1924), Pichler (193(l), and
Wassmund (1931) during and after the first World War. It never bec~rt~e
very popular in general practice. The reasons are the following : in the masilia
it has been proved that in most cases the retention of the prosthesis can be O/J-
tained without surgical operation, although there is no doubt that the st,abili I)
may be improved by a ridge extension. However, the dentist as well its the
pat,ient will decide in favor of the operation only if there is no ot,her wily 10
obtain a satisfying result. In the mandible the operation is limited hy the
342 R. TRAUNER

mental nerve which emerges in these cases close to the alveolar ridge. More
important is the impairment of the final result by t,he tightening of the buccal
mucous membrane toward the upper jaw when the mouth is opened. The main
obstacle to the stability of a lower prosthesis, however, lies lingually. An
alveoloplasty with ridge extension here should give a satisfactory result.

Indication for the Operation

The operation is advisable when the mucous membrane of t,he, floor of the
mouth rises upward with a lifting of the tongue extending as high as the al-
veolar ridge, and when the touching finger feels t,hat the firm plate of the
mylohyoid muscle extends directly from the mandibular ridge.

Operative Technique
The alveoloplasty with ridge extension in the mandible may be performed
with conduction anesthesia and sedation. The mandibular nerve is blocked,
after which the floor of t,he mouth down to the skin is infiltrated. An incision
is made in the mucous membrane close to t,he alveolar ridge as shown in Fig. 5.
It may extend from third molar to third molar, or may be interrupted in the
middle, depending on the height of the central alveolar ridge. Then the mucous
membrane is retracted downward with the subcutaneous tissue toward the
tongue until the attachment and the upper surface of the mylohyoid muscle are
laid bare, as shown in Fig. 2. This is done very quickly and easily. One must
be careful not to cut the periosteum of the lower jaw when dissecting the
mucous membrane, nor push it off with it,. The periosteum must remain on
the jaw even during the next stage of the operation, the separation of the
mylohyoid muscle from its attachment to the bone. For this purpose its fore-
most bundles, which draw from the region of the canine toward the lingual
area, are laid bare first. Since the muscle is not attached to the lower part of
the mandible but extends inward and downward, one can pass with an instru-
ment under it from the anterior edge (Fig. 2), in order to cut the muscle close
to its attachment. When doing this one should not cut into the muscle too far
from the bone, since doing so might cause moderate bleeding. Sometimes it
is necessary to tie a small vein. In addition the excretory duct of the sub-
maxillary salivary gland may be injured if one bisects the mucous membrane
too far lingually. Subsequently one must remove by means of scissors or a
knife the muscle rests attached to the mandible. One must, however, not make
the serious mistake of bisecting the periosteum when cutt,ing the muscle because
if it is pushed off with the muscle the lingual bone surface becomes bared so
that no cuticular graft can adhere to it. It takes a long time for granulation
tissue to form out of the compact bone of the lower jaw, and still longer for this
to become epithelized. There is also the possibility that small superficial bone
sequestra may form, but the final result just the same will be satisfactory.
It is advisable to separate the muscle in its entire length as far back as its
posterior edge, but one must not injure the lingual nerve which runs close
behind the most posterior bundles of the muscle from the tongue to the angle
of the jaw (Fig. 2). When bisecting the muscle one must be very careful and
 ALVEOLOPLASTY \VITR RIDGE EXTENSIOiXS 343

operate with good vision. The white color of the nerve helps in Its identifica-
tion. Under the muscle, between it and the lingual wall of the lower jaw, the18cB
is only loose connective tissue. It is pushed oft’ with the finger or a tampoil,
not with the periosteal elevator, the use of which might injure the periosteum.
Aft,er the detachment the lingual edge of tbc llluco~ls membrane sinks auto-
matically down and tends to remain there. It dues not adhere to the locvcbl
edge of the mandible but remains slightly lingually with the detached musclt:.
After this part of the operation is finished one can insert a prosthesis l~repard
bei’orehantl with a lingual wing lined with stents or half-hardened q,nthet ic
resin.
It is better, however, to fix the lingual edge of the mucous membrane at
the inferior border of the mandible by means of two or three sutures on eilc~h
side (Fig. 5). These attach it to t,he lingual periosteum. Technically it is
easier and more exact to fix it below the mandibular edge to the outer skill.
A mattress suture is taken with a curved needle to which a suture is aIti.l.ch~(l.
It is inserted 1 cm. below the edge of the lower border t,hrougb the skin n11t1
edge of the mucous membrane and then back below the edge of the lower jaw
to the skin. Silk or strong nylon may be used. The latter is preferred bccausc
it, does not, as the silk does, absorb saliva leading it into the wound, callsing. in
intlividual cases. a slight purulent discha rptx at the nc‘cAc
I Ie punctures ( F’ip. (; 1.

Fig. 5. Fig. ti.

Fig. B.-Lingual ridge extension requires the transplantation of the attachment of the
mylohyoid muscle. A mattress suture taken through the skin under the mandible lowers the
floor of the mouth and leaves the lingual surface of the mandible free for denture construction.
Fig. fi-The exposed lingual surface may be covered by a Thiersch graft.

Penicillin, however, will prevent any serious complications. When taking the
sutures one must not catch the lingual nerve for this would cause pain when
moving the tongue and require that the suture be removed. Also one must
take care that, the submaxillary duct is not caught, with t,he suture. .A post-
operat,ive salivary congestion and swelling of the glands would be the consc-
quences.
Experiments made by my assistant, 1)r. Obwegeser, to cover the lingual
surface of bone with the mucous membrane of the floor of the mouth after
separating it from the muscle, have not turned out favorably. The operakm
was more difficult, and the result obtained did not compare favorably. If’ I he
344 R. TRAUNER

skin sutures which are visible on the outside, as seen in Fig. 7, produce an
unfavorable psychic impression with the patient they may be tied lingually.
The result of the operation, however, is impaired because the lingual edge of the
mucous membrane is not drawn sufficiently down. Exposing the loose tissue
of the submaxillary space from the mouth causes moderate swelling of the floor

Fig. ‘I.--Illustration showing the three mattress sutures on each side which hold the tissue
until it is attached in its new position.

Fig. 8. Fig. 9.
Fig. 8.-Postoperative swelling.
Fig. 9.-Swelling reduced after one week.

of the mouth which becomes visible on the outside, as shown in Fig. 8. This
causes swallowing difficulties in the first two to three days after the operation,
The swelling decreases considerably in a week, as shown in Fig. 9.
 ALVEOLOPLASTY WITH RIDGE EXTENSIO?*‘S 2-I-r,

The lingual periosteum-covered side of the mandible slants outward ~OL’P

or less which is favorable for denture ret.ention. The lingual bone will hr
covered in a few weeks with granulation tissuta and finally, in aboltt. two monf hs.
cpithelium (Fig. 12 ).

Fig. 10. Fig. Ii.

Fig. IO.-Intraoral view of extension of lingual sulcus.
Fig. 11 .--Denture with lingual wings extending into newly created .sulcus.

Fig. I Z.-Plaster model showing extension of sulcus and outline of wing on lin!w:ll fl;rIlg+:
of denture.

The disadvantages of the nonepithelized bone wound are sensitivity to

touch and the existence for some time of the granulation tissue, the surface
becoming smooth only after the cpithelization has been completed. Therefore,
one can cover the bare lingual surface with a Thiersch graft, as shown in E’jg.
6. The transplantation is a minor operation which is worth while for t,hc I’+
lief of pain and shortening of the period ol’ aftertreatment, and has or11.vt IIC
disadvantage that the average oral surgeon is not accxustomcd to it. II this is
the case he may safely refrain from performing it; it is not, at all IIC~~~~SII tyy
346 R. TRAUNER

for the final success. According to Esser, the cuticular graft preferably taken
from the upper arm is fixed in the mouth by sticking its epithelial side with
Mastisol to a stent. This is pressed, in a plastic state, on the surface of the
wound, then cooled, clipped, and dried. Thus the surface of the wound of the
cuticular graft is pressed well against the periosteum of the lower jaw. To
that end one can prepare before the operation on a plaster cast a small plate
of shellac or ‘synthetic resin. Except for penicillin therapy no other postopera-
tive treatment is necessary.

Postoperative Treatment
The patient takes liquid and soft food. Light pains and difficulties in
swallowing always exist for two to three days. They are the greater the farther
backward the incision extends, and the bigger the postoperative swelling is.
Because of possible complications we prefer to hospitalize some of the patients,
especially older ones, for a couple of days. .This is certainly not absolutely
necessary as no very serious complications have to be feared.
Prosthesis
The prosthesis can be made in various ways. It may be prepared before-
hand from a plast.er cast. Long wings are constructed to reach down on the
lingual side (Fig. 11). These wings are lined at the end of the operation and
can be lengthened if necessary. If the prosthesis is made later one must reckon,
unless one has used the Thiersch method, that the lingual bone surface changes
its form. Either one waits for its final epithelization for about two months,
or if he does not want to wait, he must reline the prosthesis later on. We
generally place the prosthesis three weeks after the operation. Its retention
has heen good without exception. The long lingual wings did not have to be
changed and it did not rise any more when moving the tongue or opening the
mouth, or when mastdcating. As the lingual wings tilt in a little the prosthesis
must be inserted from behind, first on one, then on the other side; the patient
must learn to do this in the proper way. In the beginning, it may pain a little.
But the pain does not persist on pressure. If there are high spots which cause
pressure they must be relieved, but not too much. It was not found necessary
to extend the prosthesis far back into the muscle-free triangle, and buccally it
needs only be extended to the margin of the immovable mucous membrane.
If the alveolar ridge is very low anteriorly, it should be improved by ridge
extension.
References
Pichler, H., and Trauner, R.: Ztschr. f. Stomatol. 8: 675, 1930.
Pichler, H., and Trauner, R.: Mund- u. Kieferchirurgie, ed. 3, Wien, Urban & Schwarzen-
berg, vol. 1, p. 397.
Kazanjian, V. H.: Dental Cosmos 66: 387, 1924; J. Am. Dent. A. 22,: 566, 1935.
Wassmund, M. : Deutsche. zahnkztl. Wchnschr. 16: 888, 1931; Vrtljschr. Zahnh. 3: 305,
1931.
Thoma, K. H.: Oral Surgery, St. Louis, 1948, The C. V. Mosby Company, vol. 1, p. 207.
Schuchardt, K.: Verhandl. d. deutsch. Gesellsch. f. Zahnh., Wiesbaden and Miinchen,
1949, Hanser.
Langer, H. : Ztschr. f. Stomatol. 47: 82, 1950.
Mathis, H. : Deutsche. zahnarztl. Ztschr. 6: 644, 1951.