Removal of exostoses and tori

Tissue atrophy and bone augmentation

With significant loss of bone volume in the upper and lower jaws, the topography of the adjacent soft structures changes critically. The oral vestibule becomes excessively shallow, and the mobile mucosa of the mucobuccal fold begins to attach directly at the level of the alveolar ridge or even overlap it. The high mobility of these tissues makes reliable fixation of a removable laminar denture impossible.

Surgical improvement of the prosthetic bed quality can be performed either as a standalone procedure or in combination with alveolar bone augmentation. In cases where hydroxyapatite is used for plasty, obtaining a stable bone ridge shape presents a technical challenge. In the mandible, this problem is solved using an interim immediate denture, which is fixed with circumferential sutures for a period of one week. An alternative and highly effective approach is placing hydroxyapatite granules enclosed in a special Vicryl mesh directly under the mucosa. This ensures the preservation of both the specified volume and the required shape.

It is important to note that modern oral surgery has completely abandoned outdated vestibuloplasty techniques that involve open wound management (including healing under iodoform gauze). An open wound surface inevitably leads to the formation of coarse scars, which hinder prosthetic treatment just as much as the initial shallow vestibule.

Submucosal vestibuloplasty according to Obwegeser

This outpatient technique is indicated for patients with a shallow vestibule against the background of moderate alveolar process atrophy. The intervention is performed under local anesthesia. The main anatomical limitation is lip shortening — if this factor is present, the operation must be categorically abandoned (to assess risks, a special test with an instrument pressing on the mucosa is performed beforehand).

Execution Technique:

• A neat midline vertical incision is made.
• The surgeon creates multidirectional submucosal subperiosteal tunnels, dissecting the muscle fibers and submucosal base.
• If excess submucosal tissue is detected, its partial excision is permitted.
• The mobilized mucosa is firmly pressed against the alveolar bone.

For successful healing, strict tissue immobilization is required for one week. For this purpose, a relined or immediate denture is used. In the maxilla, it is rigidly attached to the palate using microscrews, while in the mandible, it is fixed with circumferential sutures. The main disadvantage of the Obwegeser operation is the high risk of gradual relapse with the return of tissues to their original position.

Mucosal flap advancement (Kazanjian operation)

The Kazanjian technique (Lip Switch) is designed to deepen the oral vestibule exclusively in the anterior region. A mandatory anatomical condition for its implementation is the preserved height of the alveolar part or process of the jaw — at least 15 mm.

During the outpatient surgery, a specific flap consisting solely of mucosa is outlined on the lip. It is detached from the deep soft tissues and, in the lower part, from the periosteum. Having formed a new, deeper vestibule, the mucosal flap is adapted to the bone and sutured at the deepest point of the wound. The resulting defect on the lip heals by secondary intention.

Disadvantages of the method include the formation of a narrow vestibule and a high risk of scarring, which complicates the patient's subsequent adaptation to a laminar denture. Modifications of this technique exist. For instance, in Edlan vestibuloplasty, periosteum rather than mucosa is used to cover the labial wound. However, such interventions, associated with periosteal stripping, can significantly enhance alveolar bone resorption processes.

Use of grafts and elimination of scar contractures

Free grafts are used for reliable closure of postoperative wounds in the vestibule. A mucosal autograft is considered optimal in terms of characteristics. However, tissue harvesting from the palate is limited in volume, while the buccal mucosa possesses excessive mobility and a risk of donor site scarring. Alternatives include skin autografts (they retain color, epidermal structure, and hair growth capacity if hair follicles are preserved), as well as allogeneic materials that eliminate trauma to the patient's donor sites.

A special surgical approach is required for the treatment of scar contractures of the vestibular vaults and cheeks. Such deformations occur as a consequence of secondary wound healing after burns, severe trauma, or prolonged inflammation. Scars can completely flatten the vestibule, causing functional disorders and making prosthetics impossible. Classic vestibuloplasty methods are ineffective in such situations.

Stages of inpatient surgical treatment of scars:

1. Under block and infiltration anesthesia, scar-altered tissues are radically excised. When working in the projection of the mental foramen, extreme caution is required to preserve the neurovascular bundle.
2. A special Stent's compound blank is softened in a hot isotonic solution, modeled to the shape of the formed defect, and cooled.
3. The cooled Stent's stent is wrapped with a pre-prepared split-thickness skin autograft. The graft is positioned with the epidermis facing the Stent's material.
4. The structure is placed into the wound and fixed with interrupted sutures in the upper part.

Choosing a split-thickness graft specifically is critically important: compared to a thin graft, it is much more viable and yields minimal shrinkage during the healing process, reliably preserving the specified vestibular depth.

Class and exam questions

What else to study on this topic

• Topographic anatomy of the neurovascular bundle in the projection of the mental foramen
• Algorithm for performing the preoperative test in Obwegeser vestibuloplasty
• Features of bone tissue augmentation using Vicryl meshes
• Pathogenesis of alveolar process atrophy after partial or complete tooth loss
• Immunological aspects of mucosal allograft application

Other topics in "Chapter 16. Surgical Preparation of the Oral Cavity for Prosthetic Treatment (A.V. Shchipsky)"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.