Vestibular Depth Research Articles

Modified Inverted Periosteal Flap Versus Buccal Advancement Flap Technique for Oroantral Fistula Repair: A comparison

Oroantral fistula is a pathological and epithelised communication between pseudo stratified columnar ciliated epithelium of maxillary antrum and squamous epithelium of oral mucosa. Various techniques in literature point to the fact that repair of oroantral fistula is one of the most challenging problems in oral and maxillofacial surgery. Buccal advancement flap technique causes vestibular shortening, reduction in keratinized gingiva width with closure under tension thereby increasing the chances of wound dehiscence. On the other hand, Inverted periosteal flap preserves vestibular depth, maintains keratinized gingiva width providing true tension free closure. However, it is technically very challenging with maximum chances of perforation of delicate periosteal flap. A new Modified Inverted Periosteal Flap technique for oroantral fistula repair will eliminate all the potential complications and adverse effects of both the conventional buccal advancement flap and inverted periosteal flap procedures providing a true ideal closure.

A Novel Approach For Reconstruction Of Large Oro-antral Fistulae Defects With Simultaneous Sinus lift. (A Clinical Study)

Background: The Oro-antral fistulae (OAF) compromises the oral mucosa and the alveolar bone integrity, depleting its capacity to receive dental implants.Purpose: This clinical study aims to assess the clinical outcomes and the radiographic vertical bone gain of an innovative technique that combines the (OAF) closure, bone grafting, and sinus lift. Patients and methods: The study represents a case series conducted on thirteen patients with large (OAF), closed by sliding the buccal advancement flap combined with a distant palatal releasing incision after inverting and elevating the fistulous epithelial tract to set, elevate and conceal the floor of the maxillary sinus from the underlying bone graft. Meanwhile, evaluating the clinical outcomes and justifying a radiographic linear bone height comparison between the sinus floor height preoperatively and three months after. Results: The healing went uneventful, with neither shallowing of the vestibular depth nor obliterating the sinus cavity. The bony sinus floor was admirably elevated, and the grafted defects demonstrated appropriate bone width and height. The mean baseline bone height recorded (9.28 ±2.4 mm) versus ( 17.54 ± 1.6 mm ) for the three months postoperative. The vertical bone gain ranged from (4 to 12.5 mm), with a mean of ( 8.26 ± 2.6 mm), computing a statistically significant linear gain increase ( p < 0.00001). Conclusion: The novel approach provided comprehensive coverage of the oral defect, an appropriate primary elevation of the maxillary sinus with consolidated alveolar graft, cutting short the routine treatment time with the conduction of significant linear bone height gain values.

Lip repositioning surgery for gummy smile: 6-month clinical and radiographic lip dimensional changes.

The present case series aimed to examine lip repositioning surgery (LRS) outcomes related to changes in external and internal upper lip (UL) dimensions, utilizing both conventional clinical and novel radiographic approaches. Patients (n = 13) diagnosed with hypermobile UL (>8-mm mobility during smile) and excessive gingival display (≥4-mm) were included and assessed at baseline and 6 months postoperatively. Clinical parameters at rest included total lip and internal lip length (vestibular depth). At maximum smile included total lip, philtrum (ergotrid), and vermilion lengths. Cephalometric parameters included anterior maxillary height; lip length; nasolabial angle; anteroposterior lip thickness; internal lip length (vestibular depth); and vestibular fornix position (using novel approach employing radiopaque marker). Linear mixed-effect models, Pearson's correlation, and linear regression were used for statistical analyses. LRS did not affect total UL length at rest (p = 0.418). It resulted in significant internal UL length decrease (-3.8 ± 2.1 mm, p < 0.001) and significant increases of vermilion length (1.9 ± 1.0 mm, p < 0.001) and anteroposterior lip thickness (0.7 ± 0.7 mm, p = 0.002). The clinical and radiographic measurements of total UL length at rest (r ≥ 0.734) and of internal UL length (r ≥ 0.737), and the two radiographic assessments of vestibular depth (r = 0.842), were strongly correlated. LRS resulted in significant decrease of vestibular depth/internal UL length and in significant increases of UL vertical vermilion length and UL anteroposterior thickness, without affecting total UL length at rest. The documented lip dimensional outcomes should help practitioners when treatment-planning LRS and counseling patients seeking treatment for hypermobile UL.

Preorthodontic Management of Gingival Recession using Epithelial Embossed Connective Tissue Graft: A Case Report with Two years Follow-up

Gingival recession is an aesthetic and functional problem requiring surgical management in most cases. Adequate gingival health is a prerequisite to maintain plaque control during orthodontic treatment. This case report described management of gingival recession before orthodontic treatment using a novel surgical method. Here, authors presented a case of 27-year-old female patient reported to the Department of Periodontics for management of gingival recession in the lower front tooth region. The patient was diagnosed with Miller’s Class II gingival recession on mandibular right central incisor. Vestibular depth and width of attached gingiva was found to be inadequate at the recession site. The case was managed with epithelial embossed connective graft. The recipient site was prepared using envelope technique and internal vestibular deepening was performed before placing the graft. Complete root coverage, adequate vestibular depth and width of attached gingiva were obtained postoperatively. Due to high aesthetic demand of the patient, orthodontic therapy was instituted six months following root coverage and patient could maintain good oral hygiene during orthodontic treatment. Results of surgical treatment were maintained till two years follow-up. Careful selection of surgical technique could enhance thickness and width of attached gingiva and retain vestibular depth at the recipient site. Successful case management enabled the patient to maintain gingival health during orthodontic treatment.

Comparison of Vestibular Depth Relapse and Wound Healing After Reconstructive Preprosthetic Surgery Using Cryopreserved Amniotic Membrane and Acellular Dermal Matrix - A Comparative Study.

Introduction:The significance of membranes as wound dressing in oral surgeries has been reported by previous studies. The aim of the present split-mouth randomized clinical study was to assess and compare the wound dressing properties of acellular dermal matrix (ADM) and cryopreserved human amniotic membrane (AM) after reconstructive preprosthetic oral surgery.Materials and Methods:Twenty-eight patients with complete mandibular edentulism and resorbed alveolar bone were included. After taking mandibular impression, a clear acrylic splint with increased labial flange height was created. In each participant, labial vestibular depth was elevated using the Clark's technique. Subsequently, half of the exposed periosteum was covered with ADM while the other half was covered with cryopreserved human AM. Vestibule depth and relapse in the two sides were measured immediately after vestibuloplasty and at the end of the 1st week, 2nd week, 1st month, and 3rd months with graduations of 0.1 mm. Furthermore, after 3 and 7 days, samples were collected from graft material, and the macrophage population was analyzed by flow cytometry.Results:There was no significant difference in the relapse of vestibule depth between the two grafts at different time intervals. However, the frequency of wound-infiltrating macrophages (CD68+ cells) was significantly higher in areas covered by ADM after 3 and 7 days.Discussion:ADM is as effective as cryopreserved AM in terms of maintaining the postoperative vestibular depth. On the other hand, our results suggested that the onset of healing phase in ADM-covered areas occurs faster compared to the periosteum covered with cryopreserved human AM. This clinical trial showed significantly faster postoperative healing onset when ADM was used than when cryopreserved human AM was applied on the periosteum.

Evaluation of the Free Gingival Graft Along with Low Level Laser Therapy for to Increase Keratinized Gingiva and Vestibular Depth in Lower Anterior Teeth- Randomized Controlled Clinical Study

Evaluation of the Free Gingival Graft Along with Low Level Laser Therapy for to Increase Keratinized Gingiva and Vestibular Depth in Lower Anterior Teeth- Randomized Controlled Clinical Study

Single-step surgery for treating chronic periodontitis and increasing the width of keratinized gingiva in Mandibular Anterior Region: A case report

Chronic periodontitis is precipitated as periodontal pockets, gingival recession (GR), decreased keratinized gingiva, and vestibular depth (VD). In the mandibular anterior region, it is frequently seen as GR and decreased VD. The development of high frenal attachment due to loss of periodontal support further increases the rate of progression of the disease and compromises the condition of the incisors. As mandibular incisors have short roots, they usually tend to become mobile early during the progression of periodontal disease. In this case report, a single-step surgery was done, which included periodontal flap surgery with bone augmentation in relation to mandibular anterior teeth. Following this, the width of keratinized tissue was increased using Diode laser by deepening the vestibule. This combined procedure can cover the exposed roots and increase the width of keratinized gingiva.

Clark’s Technique of Vestibuloplasty - A Case Report

Shallow vestibule can create a barrier in oral hygiene maintenance and can cause gingival recession due to the muscular traction. Inadequate vestibular depth in combination with inadequate attached gingiva is said to cause more food accumulation during mastication. Hence, shallow vestibule impeding with oral hygiene maintenance requires correction. Vestibuloplasty involves surgical procedure for repositioning of mucosa and muscle attachment thereby increasing the vestibular depth. There are various techniques of vestibuloplasty. This case report highlights upon the Clark’s technique of vestibuloplasty for correction of shallow vestibule.

Comparison between two surgical techniques for vestibuloplasty – A retrospective study

Aim and Objective: 1) Comparing the vestibular depth achieved in the mandibular anterior region with the two techniques. i.e Modified Kazanjian and Lipswitch technique 2) Patient satisfaction. Materials and Methods: In the present study a comparison of two techniques of vestibuloplasty, i.e. Modified Kazanjian and Lipswitch techniques was done to evaluate the efficiency in maintaining the vestibular depth in a follow up period of 6 months. 40 patients medically fit patients who required vestibuloplasty procedure were selected; 20 patients underwent Modified Kazanjian technique and 20 patients underwent Lipswitch technique. Vestibular Depth, patient compliance and complications if any were recorded and reviewed on the 1st day, 1 week, 1 month and 6 months postoperatively. Results: The immediate post-operative depth in modified Kazanjian group ranged from 10.3 to 15.3 mm, it was 9.8 to 14.9 mm after 1 week, 9.5 to 14.5 mm after one month and 4.8 to 13.9 mm after 6 months postoperatively. The immediate post-operative depth in Lipswitch group ranged from 11.2 to 15.1 mm. it was 11.6 to 14.9 mm after 1 week, 10.6 to 14.8 mm after 1 month and 10.2 to 14.2 mm after 6 months postoperatively. The percentage of increase in vestibular depth 6 months postoperatively was 166.70% in Modified Kazanjian technique and in that of Lipswitch technique it was 283.88% which showed a highly significant P value of 0.003. Conclusion: Reviewing the results with regard to the maintenance of vestibular depth, patient compliance and complications, we recommend Lipswitch technique over the Modified Kazanjian technique for vestibuloplasty. Keywords: Lipswitch, Mandibular anterior sulcus depth, Kazanjian, Modified Kazanjian, Orthopantamogram, Vestibuloplasty, Denture.

Lateral pedicle graft: A treatment modality for root coverage of localized gingival recession: A case report

Gingival recession has been defined as the apical shift of gingival margin from its physiologic level (1 to 2 mm coronal to cementoenamel junction) causing pathologic exposure of root surfaces. Mucogingival esthetic surgery is all about treatment of mucogingival esthetic alterations. Mucogingival problems may be caused by gingival recession often in association with non-carious cervical lesion or by root caries or by altered passive eruption. Patient with gingival recession frequently report to dental clinics which could lead to pain or hypersensitivity, esthetic problem, retention of plaque hence inflamed gingiva, root caries, abrasion and fear of tooth loss. Gingival recession can be treated by surgical or non-surgical means. Nonsurgical means include - restorations, crowns, veneers and gingival masks whereas surgical approaches includes various methods of increasing the width of keratinized tissue such as frenectomy in case of high frenal attachment & root coverage procedures. The lateral displaced pedicle flap was first described by Grupe and Warren in 1956. It was used to cover the isolated, denuded root surfaces that have adequate amount of donor tissue adjacent to the recipient site. The vestibular depth must be adequate to laterally slide the pedicle. A case of gingival recession is presented that was managed using LPG technique. This technique was selected because of certain advantages – single surgical area, preservation of blood supply of flap, the postoperative color being in harmony with surrounding tissue. Keywords: Lateral pedicle, Graft, Gingival recession.

Innovative use of increasing the width of attached gingiva using chorion membrane along with platelet rich fibrin membrane.

Width of attached gingiva plays an important role in maintaining periodontal health, provides stabilization of the gingival margin against frictional forces and aids in dissipating physiological forces exerted by the muscular fibers of the alveolar mucosa on the gingival tissues. Inadequate width of attached gingiva leads to attachment loss, soft tissue recession, and impedes oral hygiene measures. Hence, procedures using autografts and allografts have been proposed to augment the attached gingiva. Allografts like chorionic membrane (CM) are known to enhance release of growth factors, promote neovascularization, healing and enhance biotype. To assess the efficacy of CM in increasing the width of attached gingiva, vestibular depth and gingival thickness. Fifteen patients with inadequate attached gingival width were included in the study. Patients were randomly allocated to each group: Control group, CM group and CM + platelet rich fibrin (PRF) group. Attached gingiva width, vestibular depth, and gingival thickness were measured at baseline and 4weeks post procedure. The control, CM and CM + PRF groups showed an increase in all parameters from baseline to 4weeks. The increase in the attached gingiva (p = 0.042) width, vestibular depth (p = 0.043) and gingival thickness (p = 0.034) were statistically significant at 4weeks for CM group and CM + PRF grouprespectively. The CM + PRF group showed better results compared to other groups. CM and PRF can be effectively incorporated to increase the width of attached gingiva and depth of vestibule.

A Modified Technique of Tacking Acellular Dermal Matrix to Increase Keratinized Mucosa Around Dental Implants as an Alternative to a Free Gingival Graft: A Case Report

Free autogenous graft was the gold standard to increase the keratinized mucosa (KM) and vestibular depth. The major downfall of this technique is the postoperative morbidity at the donor site. The purpose of this case report is to demonstrate a modified technique using acellular dermal matrix (ADM) to increase the KM around implants to achieve faster healing with less postoperative morbidity. Patient presented with inadequate keratinized tissue band and shallow vestibule at submerged implant sites bilaterally. Initially, surgical procedure of vestibuloplasty in conjunction with free gingival graft (FGG) was performed at one side. However, patient opted for the allograft as a substitute for the other side due to the postoperative discomfort from palatal donor site. On the left side, the FGG procedure was performed in a conventional way stabilizing with sutures. On the right side, the ADM was stabilized with tacks only at recipient site and left exposed. The new vestibule was established and stabilized with tacks. A significant gain of KM and vestibule depth was observed at the site of using ADM when compared with baseline. For the site of using FGG, KM was increased. However, the vestibule was rebounded compared with the site of using ADM with tacks. The use of ADM stabilized with tacks is a predictable procedure that can increase KM and establish stable vestibule around dental implants. It can lead to less chair time, faster healing, and reduced postoperative morbidity compared with autogenous soft tissue graft.

Submucosal Fibrotic Bands in Oral Lichen Planus: A Clinico-Pathological Investigation of a Newly Described Phenomenon.

Fibrosis is a recognized complication of chronic inflammatory conditions, which has not yet been described in oral lichen planus. To describe characteristics of submucosal fibrotic bands in oral lichen planus. Prospective study. Patients with biopsy confirmed lichen planus were included. Clinical examination recorded fibrotic bands, mouth opening, vestibular depth loss, gingival recessions adjacent to band, lichen subtypes, areas of affected mucosa, extra-oral manifestations. Patients completed the Chronic Oral Mucosal Disease Questionnaire, with additional questions regarding stiffness, restricted opening, symptom frequency, time from diagnosis of lichen, co-existing medical conditions. 73 patients were included, 14M, 59 F, age 28-84 (mean 61) years. Buccal fibrous bands were palpated in 22 (30.1%), 13 (59%) were bilateral. Self-reported restricted opening/stiffness were significantly associated with fibrous bands (36% Vs. 11% in controls, p = 0.02). Mouth opening less than 40mm was recorded in only 2 (9%) with bands, none in controls. Reduced vestibular depth was significantly associated with bands (11 (50%) Vs 3 (6%) in controls, p = 0.0001).Gingival recessions adjacent to bands were recorded in 3 (13.6%). No association was demonstrated between fibrous bands and erosive lesions, extra oral involvement, smoking, age, visual analogue scale, quality of life questionaire and disease duration. Histological evaluation of one case each with and without band and control showed increased mean width of connective tissue. Submucous fibrous band is first described in the present study. It is common in oral lichen planus, may lead to feeling restricted mouth opening, stiffness, loss of vestibular depth and adjacent gingival recession.

Vestibuloplasty following denture hyperplasia resection with diode laser

Denture hyperplasia is a common clinical finding in patients wearing dentures. In this case report, a patient who was treated for denture hyperplasia presented with a post operative complication which led to inadequate vestibular depth. Inadequate vestibule is a common challenge dental surgeons encounter while considering fixed or removable prosthesis and implants. Objective is to achieve acceptable retention and aesthetics for the prosthesis by increasing the vestibular depth and also to manage the complication encountered during the resection procedure. Several techniques have been employed to increase the vestibular depth and the width of attached gingiva in the literature. In this case the denture hypereplasia was resected using diode laser which resulted in bone necrosis and opening of the wound post surgically. This was managed with curettage and PRF application. Following this the patient presented with inadequate vestibular depth. Vestibuloplasty was performed with Diode laser to deepen the vestibular depth and augment keratinized tissue to facilitate prosthetic rehabilitation. Three months following vestibuloplasy, patient presented with adequate vestibule. At six months follow up there was sufficient keratinized tissue to facilitate prosthetic rehabilitation. This case presents a unique way of managing a complication encountered after denture hyperplasia resection followed by vestibuloplasty with diode laser. The results obtained were clinically acceptable. PRF provides excellent results when used for the management of surgical complications like wound exposure. Laser technique is optimal for the treatment of soft tissue defects and is proven to be ideal for vestibuloplasty.

An alternative approach for vestibular extension using temporary coverage of epithelialized palatal grafts

An alternative approach was used to increase the buccal vestibular depth of two edentulous patients, using free epithelialized palatal grafts. Two edentulous patients presented with shallow vestibules and inadequate keratinized tissue width in the mandibular anterior region. These sites were treated with vestibuloplasty followed by placement of an epithelialized palatal graft. In order to minimize graft movement and possible mechanical trauma to the area, the graft was covered with the buccal flap during the initial stages of healing. The patients maintained an increase in the vestibular depth as well as the keratinized tissue width at 14 months and 5 years postoperatively. Successful outcomes in terms of increase in vestibular depth can be achieved with the use of epithelialized palatal graft that is covered during the initial stage of healing. The dental practitioner fabricating the complete denture should be aware of the advantages offered by this alternative surgical technique.

Prosthetic Rehabilitation of Patient with Anterior Segmental Mandibulectomy Using Cast Partial Removable Denture: A Clinical Report

Marginal mandibulectomy involves resection of mandibular body with overlying soft tissues while maintaining inferior cortex of mandible and its continuity. It may lead to numerous problems associated with mastication, speech and deglutition and esthetics. Problems associated with such defect depend upon location and extent of surgical resection. Prosthodontic rehabilitation of such patient poses challenges because of obliterated vestibular depth, inadequate denture bearing areas for support, lesser number of remaining teeth. This article describes rehabilitation of patient who underwent anterior segmental mandibulectomy with cast partial removable denture to replace the missing teeth and maintain esthetics.

LARGE NASOPALATINE DUCT CYST IN A YOUNG MALE

A 25-year-old black male patient presented with a chief complaint of asymptomatic swelling in the anterior maxilla and nasal deformation of 2 years’ duration. Intraoral examination showed a large increased volume in the hard palate extending to the right vestibular region of the maxilla, causing displacement of the nose wing and shortening of vestibular depth. Panoramic radiography revealed a radiolucent area in the maxilla causing displacement of tooth 11 and tooth 21. Needle aspiration revealed a darkened fluid. An incisional biopsy was done, and a cannula inserted into the cavity to enable cystic decompression. Pathologic examination revealed fragments of cystic cavity coated by either simple cuboidal or nonkeratinized squamous stratified epithelium. A capsule of fibrous connective tissue completes the picture with a diagnosis of nasopalatine duct cyst. After an 8-month period, a cystic enucleation was done. No evidence of recurrence was noted after 1-year of follow-up. Support: FAPEMIG.

Evaluation of Color and Width of Attached Gingiva Gain in Two Surgical Techniques: Free Gingival Graft and Connective Tissue Graft Covered By Thin Mucosal Flap, a Clinical Trial.

Statement of the Problem:The periodontal health and marginal stability of gingiva can be negatively affected by a number of dental conditions in association with deficiency of attached gingiva. Purpose:This study aimed to compare the color and width of tissue grafted by two surgical techniques of keratinized gingival augmentation, namely free gingival graft(FGG) and connective tissue graft (CTG) covered by thin mucosal flap . Materials and Method: This clinical trial was performed on 15 adult individuals. The patients showed less than 2mm keratinized gingiva on two different recipient sides. One side was to be treated with CTG as the test group and the other side to be treated with FGG as the control group. The amount of keratinized gingiva before the surgery, size of grafted tissue during the surgery and 6 month after the surgery was documented. Six months after healing, the test and control sides were compared in terms of the width of generated gingiva on both sides, and the color match of the grafted areas with the surrounding gingiva or mucosa. The color of the grafted areas was determined and compared by using both professional evaluation and digital evaluation. Results: In digital evaluation, ∆E (which shows color mismatch) was higher in FGG. In professional evaluation, visual analogue scale (VAS) was used by two blinded periodontists. The mean VAS in FGG was less than CTG. The mean increase of gingival width was higher in CTG. The increased width in CTG technique was more than that in FGG technique. This difference was statistically, but not clinically, significant. Conclusion:Higher ∆E in control side and higher mean VAS CTG both showed better color adaptation of CTG side. FGG can be used in case of increasing keratinized gingiva, vestibular depth, and in patients with low smile line without esthetic concerns. However, using connective tissue in the underlying thin mucosal layer is preferred for gingival augmentation if there are adequate vestibule depth and esthetic concerns, like in maxillary canine.

A minimal invasive periodontal surgery around implant

Background Various soft tissue manipulations during bone augmentation surgeries, in particular in order to obtain primary and watertight closure of the flaps, weaken the soft tissues. This modification is accompanied by a severe loss of keratinized tissue (KT) and vestibular depth and thereby with displacement of the mucogingival line. The aesthetic and biological integration of implant-prosthesis is directly related to the presence of favorable mucosal conditions. Aim/Hypothesis This case series study was performed to evaluate the quantity and quality of keratinized tissue in 13 sites following the combination of the strip gingival graft technique described by Urban with the use of a xenogeneic collagen matrix over a period of 36 months. Material and Methods 13 sites where selected on healthy and non-smoker 11 patients with a mean age of 59.13 years (range- 22 to 78.5 years, 1 male, 10 females). A combination technique using a free strip gingival graft sutured to the apical end of the recipient bed and a xenogeneic collagen matrix sutured on the coronal bed was done. The strip was harvested from the palate and had only 3 mm wide. The primary outcome measurement was the increase in the width of KT between baseline (T0 at 10 days after surgery) and 36 months post-surgery (T36). The augmented tissue was assessed with a calibrated periodontal probe from the apical extension of the strip graft to the established reference point at T0 and T36. The secondary outcome was the degree of graft shrinkage, expressed in percentage and calculated by measuring the graft contours with the probe in place at T0 and T36. The patient's pain was recorded through a visual analog scale. Postoperative complications, such as infection and bleeding was recorded. Results After 36 months, significant gain in KTW, with an average width at 36 months of 6.15 mm was observed (range between 4 and 9). The percentage of shrinkage was 48.70%. The regenerated soft tissue demonstrated a good healing and homogeneity with the neighboring tissues in 6 sites whereas in 7 sites there where a significant difference of color and texture. Coral pink color was the main color of the gum. Some pale pink white color was observed at the contour. Bridles were observed in 7 sites specially at the contour and the apical end of the strip graft. No postoperative complications, such as intense pain, infection, or bleeding where noticed. No patient complained of pain on the donor site which rapidly epithelialize. All patient required continuous pain medication during the first post-operative 3 days. The score from VAS varies from 1 to 7 (mean 2.61). Paracetamol codeine was the main prescribed molecule. Only one patient needed tramadol. No problem on chewing was noticed. Conclusion and Clinical Implications The strip gingival graft is minimal invasive and seems effective muco-gingival surgery to restore severe loss of keratinized tissue with a minimum of post-operative complications. This gingival graft technique is promising to better the comfort for the patient and reduce morbidity. However, due to unpredictable aesthetic result, it is better to limit this muco-gingival graft on posterior sites. Larger group of patients and long term assessment must be conducted in order to confirm these results.

Evaluation of Oral Hygiene Status in Patients with Shallow Vestibular Depth in A Hospital Setting - A Retrospective Analysis

Evaluation of Oral Hygiene Status in Patients with Shallow Vestibular Depth in A Hospital Setting - A Retrospective Analysis