Soft Tissue Surgery
Soft Tissue Surgery in the Oral and Maxillofacial Region
Richard A. Smith, DDS; Nestor Karas, DDS, MD; Michael Anthony Pogrel, DDS, MD; Newton C. Gordon, DDS, MS; Kim Goldman, DMD; Rebeka Silva, DMD; and Michael Whalen, DDS, MD
Copyright 2000 Journal of the California Dental Association.
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The practice of dentistry is most often perceived as the treatment of the hard tissues of the oral region, specifically the teeth and jaws. However, there are many disorders and conditions involving surgical treatment of the soft tissues that extend to the adjacent and associated structures of the oral and maxillofacial surgery region.
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Dentistry is defined as the evaluation, diagnosis, prevention, and/or treatment (nonsurgical, surgical, or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his or her education, training and experience, in accordance with the ethics of the profession and applicable law.
Oral and maxillofacial surgery is the specialty of dentistry that deals with the diagnosis, and surgical and adjunctive treatment of diseases, injuries, and defects involving both the functional and esthetic aspects of the hard and soft tissue of the oral and maxillofacial region.
This definition of dentistry reflects the scope of practice of soft tissue surgery in the oral and maxillofacial region and includes a wide and diverse group of surgical procedures, including temporomandibular joint surgery, nerve repair, repair of oral and facial lacerations, closure of oroantral and oronasal defects, excision of soft tissue lesions, pre-prosthetic surgery (split thickness for esthetic implant reconstruction skin graft vestibuloplasty), soft tissue surgery for esthetic implant reconstruction, and sleep apnea surgery (including laser surgery).
These soft tissue procedures in the oral and maxillofacial region are frequently combined with hard tissue (dental and osseous) surgery, which enables the profession to provide comprehensive care to restore function and esthetics. The general practitioner should be familiar with the variety of soft tissue procedures that can be performed so that these services may be considered and appropriate referral made.
Surgery for Snoring and Sleep Apnea
Snoring is usually more of an inconvenience to a snorer’s sleeping partner than to the snorer him- or herself. It is generally caused by an excess floppiness in the uvula or posterior border of the soft palate, which vibrates on breathing and causes the typical noise of snoring. Alone, it is rarely of medical significance.1 Sleep apnea, on the other hand, is a condition in which the sufferers stop breathing for periods while asleep. They may unknowingly wake themselves up because of cessation of breathing and may have several hundred such episodes each night. This restlessness results in excessive daytime tiredness and has been shown to be associated with a higher incidence of motor vehicle and industrial accidents.2 Additionally, it can lead to hypertension and cardiac problems.3,4 Sleep apnea can be in the form of central sleep apnea, in which it is thought that the respiratory center fails to respond to high carbon dioxide levels during sleep so that there is no central drive to breathing, and obstructive sleep apnea, in which excessive narrowing of the upper airway during sleep causes the apnea. The narrowing can be at various levels from the nasopharynx to the base of the tongue and the hypopharynx. Many cases are mixed, with an element of both central apnea and obstructive apnea. Sufferers from sleep apnea are likely to be obese males who often have mandibular retrognathia.5 It is necessary to differentiate between simple snoring and sleep apnea, which may have snoring as one of its components, since the treatment is different; and, in fact, treatment of a sleep apnea patient as merely a snoring patient can potentially be dangerous, converting a snoring sleep apneic to a silent sleep apneic. All patients with snoring and tiredness or other symptom of sleep apnea who require treatment should be monitored in a sleep laboratory to assess their exact problem and identify the appropriate treatment.6
Snoring often responds to simple measures varying from devices that stop the snorer from lying on his or her back while sleeping,7 to a variety of dental devices to reposition the mandible or soft palate.8,9 Some patients prefer a surgical treatment for snoring since it tends to be more permanent and allows one to lead a normal lifestyle afterward. Traditionally, treatment has involved a formal surgical palato-uvuloplasty,10 which has required hospitalization and is normally not covered by medical insurance. More recently, laser-assisted uvulopalatoplasty11 has become popular since it can be performed on an outpatient basis, thus considerably lowering the costs (Figures 1,2, and 3). Under local anesthesia, utilizing the surgical carbon dioxide laser with a special attachment to protect the posterior pharyngeal wall, the uvula is shortened and the posterior margins of the soft palate tightened. Patients complain of a very sore throat for one to two weeks; but the results are good, and most patients report either complete cessation of snoring or great improvement.
When obstructive sleep apnea is diagnosed, simple measures such as weight loss, avoidance of alcohol, and the use of dental appliances can be successful.9 In more severe cases, traditional treatment has been to use continuous positive airway pressure to breathe air under pressure while asleep.12 This treatment can be quite successful, but many patients are unable to tolerate trying to sleep while breathing through a mask. In patients who are retrognathic, and where the base of tongue is believed to be the obstructing factor, sleeping with a dental device that protrudes the mandible and provides an airway can be successful although, again, some patients find it difficult to tolerate these devices.9 If the patient is retrognathic, a mandibular advancement procedure that will physiologically reposition the mandible and bring the base of tongue away from the posterior pharyngeal wall may be successful.13 The addition of a genioplasty, which also includes the genial tubercles, may increase the success rate since this will preferentially advance the hyoid bone and further open up the airway14 (Figure 4). A formal hyoid suspension operation utilizing fascial lata or a similar suspensory sling can also be performed.15 In patients who are not retrognathic, the same result can be obtained by carrying out both mandibular and maxillary advancement procedures to keep the jaws in harmony and get the same results.16 The esthetic results may not be as satisfactory in all cases, however. In some cases, if these measures are unsuccessful and sleep apnea is severe and symptomatic, a permanent tracheostomy is necessary for the patient to be able to breathe at night; it is closed off during the day.17
Since in many cases the breathing obstruction occurs at several levels, it has been suggested that only bimaxillary advancement surgery will address obstruction at all levels from the nasopharynx down to the hyoid region. An arbitrary maxillary advancement of 10 mm coupled with appropriate mandibular advancement plus a possible genioplasty has been advocated as the logical next step after continuous positive air pressure has been tried and before permanent tracheostomy, which is the final treatment for this condition.18
Sleep apnea remains a fairly newly diagnosed condition that may be suffered by as many as 9 percent of women and 24 percent of men in the United States;19 and the dental profession can play a considerable role in its management with operations such as a laser-assisted uvulopalatoplasty, mandibular advancement, genioplasty, hyoid suspension, and bimaxillary orthognathic surgery, in addition to the provision of a variety of dental appliances and advice on weight loss and other measures.
A Soft Tissue Flap in TMJ Surgery
Soft tissue transfer from the temporalis muscle to line the glenoid fossa is a technique that has enjoyed success in a variety of temporomandibular joint surgeries and diagnoses.20 It has application as a natural interpositional material to prevent bony or fibrous re-ankylosis following surgical correction of the condition. It has also been used as a replacement for the native disc in the event that it must be excised for disease or perforation. The temporalis muscle flap is also indicated after the removal of a failed alloplastic implant and whenever a resilient soft tissue interposition is needed. Such circumstances include the use of the temporalis flap in combination with complete joint replacement for advanced degenerative joint disease, tumor resection, and congenital defects.
The use of the patient’s own soft tissue for lining the glenoid fossa is desirable because of the lack of antigenicity. The fact that the flap is pedicled to a blood supply (the deep temporal arteries that branch off the internal maxillary artery) promotes an excellent chance of healing. Its accessibility to the surgical site makes this technique a logical choice.
The surgical technique for procuring the temporalis soft tissue flap allows the associated fascia to be harvested along with the muscle just deep to it. This is significant because the nondistensible fascia can add body and shape to the flap. When the flap is then rotated into the glenoid fossa, it has integrity and a stable form.
The temporalis flap, which may be considered a composite flap since it includes the fascia, was first reported by Verneuil in 1860 when he used it as interpositional soft tissue in the treatment of TMJ ankylosis. Clinical research has shown that using the temporalis flap as passive interpositional soft tissue results frequently results in reduction of pain, increased mandibular mobility, improved function, and patient satisfaction. In addition, a biopsy will show that the muscle remains viable within the glenoid fossa, although it may demonstrate evidence of partial denervation. Electromyographic studies demonstrate that the remaining temporalis muscle functions normally postoperatively.
Technique
The TMJ may be accessed through different incisions: usually either a straightforward preauricular incision placed in a crease just anterior to the ear or an endaural incision that dives into the ear canal behind the tragus. The surgeon selects the approach based on his or her experience. There must also be a superior extension to the incision that allows the surgeon to visualize the deep temporalis fascia overlying the temporalis muscle. The incisions are designed to preserve branches of the facial nerve that cross the zygomatic arch 0.8 to 3.5 cm anterior to the anterior margin of the bony external auditory canal.
The surgeon begins by incising through the scalp and the superficial temporalis fascia, until the white layer that marks the deep temporalis fascia is exposed. From there, one follows the distinctive plane inferiorly as it leads directly to the zygomatic arch. The temporalis muscle dives deep to the arch. The insertion of the muscle is the coronoid process where the temporalis flap is based. Once the zygomatic arch is reached from the superior portion of the incision, the surgery continues by development of the dissection just anterior to the tragal cartilage. While following the cartilage and using it as a guide, the posterior aspect of the condylar head and neck is reached. The upper and lower halves of the dissection can then be united over the root of the zygomatic arch.
The zygomatic arch, which contains the glenoid fossa, is exposed subperiosoteally by creating an incision through the lower aspect of the deep temporalis fascia. The superior joint space of the TMJ is entered into through a T-shaped incision through the capsule. The development of the temporalis flap may then begin whether the TMJ meniscus is to be removed at this juncture or is already absent.
The muscle flap, which is approximately 2 to 3 cm wide and 5 to 6 cm in length, may be of either partial or full thickness. Either way, the deep temporalis fascia overlies the muscle and may be sutured to it. If it is full thickness, the pericranium is included and the muscle is sandwiched between the pericranium and the fascia. The orientation of the flap complex may be aligned posteriorly so that it is roughly parallel to the arch. The flap is then rotated into the glenoid fossa by bringing it over or under the zygomatic arch (Figure 5). Remnants of the disc deep within the fossa or remnants of the retrodiscal tissue may be used to suture the flap so that it drapes well over the condylar head. The result is a vascularized soft tissue bed that serves to cushion the joint.
Finally, as with any TMJ surgery, postoperative physical therapy is of utmost importance for a successful result. Passive mouth-opening exercises are recommended for the first week followed by more vigorous physical therapy. A goal of increasing maximum incisive opening and lateral excursions must be emphasized to the patient.
Nerve Repair Surgery
Involvement of the inferior alveolar nerve, the lingual nerve, or the mental nerve can occur with many forms of dental treatment, including major surgical procedures, dentoalveolar surgery, periodontal surgery, endodontic treatment, implant-related procedures, and, very occasionally, local anesthetic injections.21 Although in most cases nerve involvement is only temporary, it is sometimes permanent. For example, it is estimated that inferior alveolar nerve involvement occurs from 0.5 to 5 percent of the time with wisdom tooth removal22-27and lingual nerve involvement from 0.6 to 2 percent of the time.28-31 Of these cases, 97 percent of inferior alveolar nerve involvement recovers spontaneously, as does 83 percent of lingual nerve involvement.22 Inferior alveolar nerve probably recovers more predictably since it is enclosed in a bony canal that guides regeneration.
It is estimated that if total recovery is going to occur, it will have begun by two months. If there has been no recovery at all by four months, then total recovery is unlikely and even partial recovery becomes less likely.32 Conversely, if surgery is going to be performed to try to repair a damaged nerve, there is general agreement that the sooner it is done, the better the final result will be.33 Herein lies the dilemma because there is no point in operating early on a nerve that will get better on its own; but if surgery if delayed too long, the results are poor. This has led to the development of current protocols that suggest that if the area supplied by the nerve is still totally anesthetic two to three months after the causative incident, then surgical exploration may be indicated. Similarly, if dysesthesia or painful sensation is the main problem, then surgical exploration after two to three months may be indicated. In other cases, surgical exploration is normally delayed for from four to six months to allow any spontaneous recovery to occur. Present protocol suggests surgical exploration only if there is less than about 30 percent of normal sensation remaining at this time and spontaneous recovery has ceased. This is because surgical exploration and repair rarely results in full return of sensation; and, although results do vary,34,35 it is possible that nerve repair surgery only provides return of some sensation in about 50 percent to 60 percent of cases.
Current protocols advise regularly monitoring patients with nerve involvement for the first few months. Testing is carried out by semi-objective techniques such as Von Frey’s hairs for light touch and direction, two-point discrimination for quality of sensation, and Minnesota thermal discs for temperature sensation.36
If the patient’s nerve involvement fulfills the criteria for surgical exploration, it is normally performed under general anesthesia with magnification by surgical loupes or, more often, an operating microscope. Exploration of the lingual nerve is done intraorally and exploration of the inferior alveolar nerve can be done intraorally or extraorally. When done extraorally with decortication of the mandible, a better surgical result can usually be obtained; but this does not always translate into better nerve recovery. Surgical exploration can have three outcomes (Figure 6):
* A finding of nerve compression or impingement such that removal of the cause of the compression or impingement is all that is required for a good result.
* A nerve transection or localized area of nerve damage. This will require the removal of the damaged segment and freshening of the ends with direct anastomosis with 8/0 or 9/0 nylon sutures under magnification (Figure 7). This carries a reasonable prognosis for some recovery in 50 percent to 70 percent of cases.
* Where there is a larger area of nerve damage or a segment of nerve missing, once the ends are identified and freshened up, it may not be possible to obtain enough mobilization for an end-to-end anastomosis. In this case, some kind of graft or conduit must be used. Initially, a donor nerve was used, such as the great auricular nerve in the neck37,38or the sural nerve on the lateral side of the foot.39,40 These are reasonably effective (30 percent to 40 percent recovery of some sensation) but do result in a sensory deficit in the donor area and the second surgical site. The authors have done a number of grafts utilizing Gore-Tex tubes41 as a conduit for nerve repair, but the results were poor and the authors no longer use this technique.36 Autogenous veins have been shown to form a physiological conduit for nerve recovery since the vein wall contains nerve growth factors.43-45 Interposed muscle has also been suggested as an autogenous donor repair.46-48 The authors have now performed a series of cases using autogenous veins (Figure 8), utilizing either a branch of the facial vein or the external jugular vein if an external incision has been made in the neck, or the long saphenous vein in the leg if an intraoral approach is being used. The provisional results are comparable to autogenous nerve grafting. The success rate is lower than for a direct anastomosis since there are two anastomoses for the regenerating nerve to negotiate.
Most active research in this area is in the areas of prevention of nerve involvement, early detection and monitoring, and the use of nerve growth factors to encourage spontaneous regeneration of nerves.
Maxillofacial Soft Tissue Injuries
Soft tissue injuries in the face require particular attention for esthetic reasons and because of the proximity to vital structures. Cranial nerves, eyes, ears, and drainage ducts can be injured with serious functional and cosmetic consequences.
Lacerations are often simple to repair.(Figures 9a through c). However, they can sometimes be complex injuries involving important structures such as the eyelids, tear ducts, bone, and nerves.
The principle steps of laceration repair include a thorough exam to identify the extent of the injury followed by adequate anesthesia, debridement of nonviable or irreversibly injured tissue, and irrigation with large amounts of normal saline. Finally, repair is performed to reapproximate tissues anatomically. If the skeleton is fractured, it should be repaired first. This is followed by repair of critical anatomic structures such as tendons, muscle, ducts, and nerves. Finally, the skin is repaired with fine suture. Exact reapproximation of the dermal layer will prevent contour abnormalities that make scars noticeable. The epidermis can then heal with minimal scar formation. Sutures are removed in three to five days to prevent suture tract marks.
If tissue has been lost, it must be replaced with like tissue to restore form and function. This may involve undermining, local flaps, or even composite grafts or free tissue transfer.
Closure of Oral Antral and Oral Nasal Defects
Oroantral communication after the removal of maxillary molars occurs in approximately 0.3 percent of cases.49 However, implant placement and maxillary antroplasty (sinus lift) can also cause oronasoantral defects. Fortunately, most surgically created communications are small and tend to close spontaneously. However, larger defects or communications, usually associated with infection, may cause persistent opening and fistulization requiring soft tissue surgery for closure.
Various techniques are currently available for closure including a sliding advancement buccal flap, a rotational pedicled palatal flap,50 a buccal fat pad flap, a tongue flap, and the Fickling inkwell technique.51
Case Report
A 53-year-old male patient presented with complaints of communications between his mouth and sinus and nasal cavities subsequent to endosseous implant failure, maxillary antroplasty, and autogenous onlay bone grafting (iliac crest and tibial) (Figure 10a). Oral fluids would exit through the nose during meals. The patient had the procedures performed simultaneously as well as excision of a nasopalatine cyst. All six of the maxillary implants were subsequently lost, leaving the patient with a 1 cm oroantral fistula in the left maxillary premolar region and a 0.5cm oronasal fistula in the maxillary midline. There was no evidence of acute infection, drainage, or nasal obstruction. A CT scan was ordered to identify the magnitude of the defects (Figure 10b). The patient elected to have the fistulae closed surgically rather than treated with a prosthetic obturator.
Under general anesthesia, the fistulae were closed in a double-layer fashion using the Fickling inkwell technique. Brilliant green dye was used to outline the incision, which extended circumferentially around the fistula with two arms of the incision extending broadly into the buccal vestibule, anteriorly and posteriorly. A No. 15 scalpel blade and a No. 66 beaver tip blade were used to incise around the fistula. A split-thickness mucoperiosteal flap was reflected approximately 1.5cm anteriorly and posteriorly. After the fistulous tract was incised from its bony margins but left deeply attached, resorbable sutures were inserted with the knots on the antral side of the fistula, which, when tied, caused the fistula to evert in the form of an unspillable inkwell. This created the antral closure and allowed the ultimate suture line of the buccal advancement flap to be placed over supporting bone, rather than over the original defect. The buccal flap was trimmed for maximum adaptation and advanced for a tension-free closure of the oral side of the defect. A similar procedure was used to close the oronasal fistula (Figure 10c). The patient healed without complication with the oral and nasal communications remaining closed. The patient subsequently had a complete maxillary denture constructed.
Awareness of the following principles will improve successful closure of oral antral and oral nasal fistulae:
* There should be careful treatment planning of flap design with measurements taken of the donor and recipient sites.
* The flap should be designed to maximize the blood supply and augment the vascularity.
* Treat infection prior to closure.
* Appropriate imaging of the maxillary sinus and region of the defect should be obtained.
* Fistulae may close spontaneously or diminish in size.
* The bony defect is usually larger than the soft tissue opening.
* A tension-free two-layer closure (nasal and oral) provides adequate coverage, added strength, and improved vascularity.
* The labial vestibule may become compromised subsequent to flap mobilization, and a secondary vestibuloplasty may be required if prosthetically necessary.
* Nasal antrostomy or Caldwell Luc operations are usually not required but should be considered if chronic sinus disease persists or there is associated poor nasal drainage
* If an acrylic splint is used postoperatively, compression of the blood supply must be avoided.
Benign and Malignant Lesions
The dentist has the opportunity and the obligation to identify both benign and malignant lesions of the oral and maxillofacial regions. Observation, examination, and investigation of lesions of the face are crucial to the well-being of the patient, particularly when the pathology identified is malignant. Basal cell carcinoma is one of the most common lesions that the dentist may help diagnose, with approximately 500,000 new cases diagnosed every year in the United States. This figure represents 80 percent of all skin cancers, with the number of new cases increasing by 3 percent to 7 percent each year.52
Basal cell carcinoma is characterized as a locally invasive primary epithelial malignancy that grows slowly and arises from the basal cell layer of the skin and its appendages and results from chronic exposure to ultraviolet radiation, especially in fair-skinned individuals. A typical presentation of this lesion is one of a slowly growing lesion that begins as a painless, firm papule that, if untreated, grows into a lesion with a central depression with telangiectatic blood vessels coursing over the rolled border. For relatively small lesions, less than 1 cm, surgical incision with adequate margins usually suffices, with cure rates of 95 percent to 98 percent. When larger lesions are identified, Mohs micrographic surgery can be utilized in which frozen-section assessment of mapped and marked surgical specimens are made to determine if the lesion has been removed in its entirety. Metastasis is extremely rare, but there is a 30 percent chance of the patient developing a second lesion within three years of initial treatment.
Case Report
A 59-year-old patient presented with a 6 to 7 mm by 4 mm dark pigmented lesion inferior to the nasolabial fold. (Figure 11a) and had a slight central ulceration. Under local anesthesia, a wide excision of the lesions was done (Figure 11b). The wound margins were undermined and a tension-free primary closure obtained (Figure 11c).
Microscopic description revealed a lobular proliferation of basal cells in the reticular dermis. The neoplasm was pigmented, had mucoid changes, and exhibited squamoid differentiation. All margins were free of neoplasm. The surgical site healed without complication, and the scar was barely visible three months postoperatively (Figure 11d).
Vestibuloplasty With Split-Thickness Skin Grafting
Loss of the natural dentition leads to physiologic and anatomic changes that complicate the restoration of normal function. These changes include loss of alveolar bone followed by resorption and remodeling. Changes in bony anatomy in turn lead to changes in soft tissue contours, in some cases eventually limiting or prohibiting the successful use of dental prostheses. In selected cases, vestibuloplasty and split-thickness skin grafting may provide a restorable platform by addressing the following three pre-prosthetic surgical goals: provision of a broad and convex ridge form, provision of fixed tissues over the primary denture support area, and provision of facial and lingual vestibules for denture flange extension. Although it is possible to perform a vestibuloplasty alone, allowing the soft tissues to heal by secondary epithelialization, the combination of split-thickness skin grafting with the vestibuloplasty procedure provides greater patient comfort and better stability.53
The history of skin grafting begins in 1869 with the use of "pinch grafts" to cover open wounds. Investigation and trial and error led slowly but steadily to the current knowledge of the biology of skin grafting.
Vascularization and healing of skin grafts occurs in a two-phase process. The first phase is plasmatic imbibition. During the initial 48 hours, capillary action draws a plasma-like fluid from the underlying recipient bed. A fibrin network forms between the graft and the recipient bed, which helps to secure the graft in place. After this period, blood flow begins in the graft and excess fluid is carried away to the systemic circulation. The second phase is termed inosculation of blood vessels. Vascular buds that proliferated during the first 48 hours provide a mechanism for entry of blood to the graft. By day four to seven, true circulation is established. At the same time, lymphatic channels are re-established.
Thus, survival of the graft depends upon the presence of a vascular recipient bed and fixed contact of the graft with the tissues of the recipient bed. Poor adaptation of the graft to the bed, fluid collections (such as hematoma) underneath the graft, movement, pressure or infection will prevent proper contact and jeopardize the survivability of the graft.
Split-thickness skin grafts consist of epidermis and a variable thickness of dermis. Full-thickness skin grafts include the entire dermis and adnexal structures such as hair follicles, sweat and sebaceous glands. Partial-thickness grafts are further classified into thin, intermediate and thick grafts depending upon the amount of dermis that is included. The choice of which type of skin graft to use depends upon the clinical situation. For intraoral split-thickness skin grafting with vestibuloplasty, a thin split-thickness skin graft (0.015 inches) is found to be most usable. For reference, the #15 scalpel blade is approximately 0.015 inches in thickness. When contrasting and comparing thick and thin grafts, the following observations may be made.
* The thinner the skin graft, the more the graft will contract in the first few months after transplantation. Conversely, thicker grafts contract more immediately upon harvest but less over time.
* The thinner the skin graft, the more likely it is to survive because it does well during the plasmatic imbibition phase of healing and because it is more rapidly vascularized.
* The thinner the skin graft, the less likely it is that adnexal structures will be transplanted with the graft.
* The thinner the skin graft, the more rapidly the donor site is likely to heal.
Thus, a thin skin graft that has been atraumatically removed and placed in a well-prepared donor site and which is well-stabilized during the initial healing phases is best-suited to the purpose of attempting to reconstruct the denture-bearing platform.
Case Report
A 60-year-old patient presented with a chronically infected and mobile subperiosteal implant (Figure 12a), which had initially been placed because of poor mandibular denture stability and retention. Removal of such a device was complicated by inflamed tissue at the level of the transmucosal posts and scarring and tissue intertwining in the metal grid of the subperiosteal implant substructure. Subsequent to the removal of the implant, the patient was left in a clinical situation worse than prior to placement of the subperiosteal implant due to obliteration of the labial and buccal vestibules and crestal attachment of the Mentalis and Buccinator musculature.
A split-thickness skin graft vestibuloplasty was performed. It significantly enhanced the prosthodontist’s ability to construct a well-extended lower complete denture to maximize support, stability, and retention. Under general anesthesia, a standard mandibular vestibuloplasty was performed to lower the depth of the vestibule and provide a keratinized, nonmobile tissue base. The skin graft was harvested from the lateral aspect of the patient’s thigh (Figure 12b). The donor site was covered with an adhesive dressing for patient comfort and infection prophylaxis. The skin graft was then placed and secured with a dermal glue (Figure 12c and Figure 12d), in a relined, previously constructed acrylic splint. The splint was secured with circummandibular ligatures and removed after 10 days. The skin graft healed uneventfully and provided the prosthodontist with an increased anterior labial vestibular depth composed of immobile, keratinized tissue. Since elements of the dermis were included in the graft, some hair follicles were transplanted (Figure 12e). The complete dentures were constructed approximately 10 weeks postoperatively (Figure 12f and Figure 12g). The patient was satisfied with the function and esthetics of the prostheses. Although placement of endosseous implants could further stabilize the lower denture, no further treatment was required.
Esthetic Implant Reconstruction
Soft tissue surgery around endosseous implants is indicated in certain clinical situations and can significantly enhance esthetics.54,55 Procedures utilizing pedicle flaps, onlay and interpositional connective tissue grafts, and sculpting techniques can reconstruct deficient soft tissue components creating a natural peri-implant appearance. When these procedures are combined with tissue-preservation techniques and properly designed restorations, the normal appearing regional morphology is more likely to be simulated.
Case Report
A 19-year-old female patient presented with a congenitally missing maxillary left lateral incisor and retained deciduous maxillary left lateral incisor that had been recently extracted (Figure 13a). The patient had a high smile line and high esthetic requirements. The treatment plan called for combining tissue preservation techniques, gingival sculpting, and prosthetically guided tissue regeneration. Two slightly beveled and curvilinear vertical incisions were placed in the interdental grooves avoiding the gingival sulci of the adjacent teeth and avoiding interdental reflection (Figure 13b). This approach camouflages the incisions and preserves the interdental papilla while providing adequate surgical access to place the implant.
At Stage I surgery, a fixture level impression was made (Figure 13c), and a custom provisional crown fabricated to be placed at Stage II surgery in order to obtain guided tissue regeneration. At Stage II surgery, the gingival tissue was sculpted around the provisional restoration. After approximately 10 weeks, the final restoration was constructed (Figure 13d).
To create an esthetic and inconspicuous implant restoration, it is imperative to establish an adequate and closely adherent zone of attached soft tissue to the transmucosal portion of the implant. This creates a healthy soft tissue interface, barrier and biological seal.
Case Report
On Oct. 2, 1998, an essentially healthy 21-year-old Caucasian female presented for consultation regarding placing an implant in the tooth No. 9 position. In 1992, she sustained injury to tooth No. 9 during a bicycle accident but eventually had the tooth removed several years prior subsequent to endodontic failure.
Clinically, there was a severely resorbed residual alveolar ridge with only an estimated 2 to 3 mm of buccal-lingual width at the ridgecrest in the tooth No. 9 region with a very significant labial concavity (Figures 14a and b). The patient had a relatively short midface and according to the dental history had orthodontic maxillary expansion as a child.
There was some retroinclination to the mandibular lower incisors, probably compensatory in nature, which created a significant amount of incisal contact, a factor considered of importance relative to implant loading. There was also evidence of nocturnal tooth grinding, and use of a nightguard was recommended. Dynamic lip function was assessed, which revealed that on a broad smile, the entire crown of the maxillary incisor teeth could be seen.
The patient brought with her a CT scan ordered by another consulting surgeon. Axial sections had been obtained through the maxilla at 1 mm intervals using 1.5 mm collimation (Figure 15). Radial reconstructions were then obtained using the data. Panoramic and periapical radiographs were then taken to supplement the CT scan.
Limiting factors were identified and discussed with the patient and her parents. They included extensive bony defects (horizontal and vertical) in the missing central incisor region, a high smile line that would reveal the interface of the implant and gingiva, short vertical height of bone between the ridgecrest of the anterior maxilla and the floor of the nose (limiting the length of the implant that could be placed), compromised bony support of the adjacent central and lateral incisors, potential for gingival recession after grafting and implant placement, the potential for a vertical soft tissue defect requiring a connective tissue graft, loss of the interdental papilla, a prominent maxillary midline frenum, and a short mandibular height below the apices of the mandibular anterior teeth (limiting bone harvesting and predisposing the patient to neurosensory alteration in the lower incisors).
A proposed treatment sequence and timetable was developed that included options and contingencies. In January 1999, under intravenous sedation, an 8 mm by 13 mm autogenous corticocancellous graft was harvested from the mandibular symphysis (Figure 16a), contoured, mortised, and fixated in place with a 1.2 mm by 12 mm titanium screw (Figure 16b). The graft was positioned so that there would be coronal repositioning of the labial mucoperiosteal soft tissue complex, restoring some of the vertical architecture of the resorbed alveolar ridge.
On June 2, 1999, the graft site was re-entered using a slightly palatal soft tissue incision, and a titanium 13 mm by 3.25 mm implant was placed in the reconstructed alveolar ridge. On Jan. 19, 2000, under local anesthesia, the implant was uncovered using a papillary sparing incision and a 4 mm in height abutment was placed. The soft tissue horizontal incision in the edentulous area was placed slightly palatally to allow transposition of a bulk of tissue to the labial position to fill out the soft tissue contours. After a five-month period to allow for osseointegration, the implant was uncovered using minimal soft tissue reflection, and a temporary abutment was placed. A screw-retained direct-to-fixture restoration was constructed (Figure 17a, b).
Discussion
The above case illustrates some of the principles of hard and soft tissue reconstructive surgery to restore deficient dentoalveolar segments. Ridge preservation is also an essential element for successful implant reconstruction. This includes atraumatic tooth removal with immediate grafting of compromised extraction sites with deproteinized cancellous bone mineral (Bio-Oss) or other suitable grafting materials, and an overlying absorbable collagen membrane. Thus, prolapse of the overlying soft tissue into the alveolar defect is prevented, allowing for guided bone regeneration. This approach allowed bony and partial soft tissue reconstruction of the site and subsequent implant placement.
Conclusion
Soft tissue procedures in the oral and maxillofacial regions can enhance total facial esthetics and balance, while creating a functional, and frequently rejuvenating improvements. These procedures also help correct functional impairments, traumatic injuries, and defects and should be considered by the general practitioner during treatment planning.
Authors
Richard A. Smith, DDS, is a clinical professor in the Department of Oral and Maxillofacial Surgery at the University of California, San Francisco, School of Dentistry.
Nestor Karas, DDS, MD, is an assistant professor in the Department of Oral and Maxillofacial Surgery at UCSF.
Michael Anthony Pogrel, DDS, MD, is a professor in the Department of Oral and Maxillofacial Surgery at UCSF.
Newton C. Gordon, DDS, MS, is a clinical professor in the Department of Oral and Maxillofacial Surgery at UCSF.
Kim Goldman, DMD, is an assistant clinical professor in the Department of Oral and Maxillofacial Surgery at UCSF.
Rebeka Silva, DMD, is an assistant clinical professor in the Department of Oral and Maxillofacial Surgery at the Veterans Administration Medical Center in San Francisco.
Michael F. Whelan, DDS, MD, is a fellow in craniofacial surgery in the Department of Plastic and Reconstructive Surgery at the University of Washington in Seattle.
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Figure 1. A long floppy soft palate and long uvula causing snoring. Figure 2. Soft palate and uvula immediately after laser-assisted palatouvoloplasty. Figure 3. Final result in same case, six weeks postoperatively. |
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Figure 4. A modified genioplasty to include the genial muscles in order to advance the hyoid bone and open the hypopharyngeal airway. Figure 5. The finger-like flap is outlined and the inferiorly based flap is turned outward and downward over the zygomatic arch and placed in the temporomandibular joint. Figure 6. The microneurosurgical procedures currently available: Top -- decompression of fibrosis or scar tissue around nerve allowing normal neuroanatomy. Middle -- excision of an area of localized nerve damage followed by direct anastomosis. Bottom -- excision of a larger area of nerve damage followed by either a nerve graft or the use of an alloplastic conduit placed over the ends of the nerve to allow spontaneous nerve growth and repair. |
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Figure 8. A vein graft (arrowed) from the posterior facial vein used to reconstruct the inferior alveolar nerve from an extraoral approach. |
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Figure 9a. A young woman struck her forehead on a steering wheel with laceration of the upper eyelid and eyebrow. Figure 9b. Exact realignment of the brow helps to hide the scar. Figure 9c. Final result three months postoperative. The eyebrow and contiguous tissues have been aligned. There is some residual erythema in the area of repair which will fade over the next six months to one year. |
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Figure 10a. Ovoid oroantral fistula in the left premolar region and a smaller oronasal fistula in the nasopalatine region. Figure 10b. CT scan showing the oral antral defect. There is evidence of a previous nasal antrostomy not related to the current treatment. Figure 10c. Immediate postoperative view of the soft tissue closures of the oroantral and oronasal defects. |
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Figure 11a. Basal cell carcinoma inferior to nasolabial fold. Figure 11b. Wide excision basal cell carcinoma. |
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Figure 11c. Tension free primary closure of skin. Figure 11d. Healed surgical site six months after excision with barely visible scar. |
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Figure 12a. Chronically infected subperiosteal implant. Figure 12b. Dermatome harvesting split thickness skin graft from lateral aspect of the thigh. Figure 12c. Application of dermal glue to secure skin graft in stent. |
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Figure 12d. Festooned skin graft placed in relined mandibular stent. Figure 12e. Healed skin graft extending the anterior mandibular vestibular depth, providing non-mobile and keratinized tissue; hair is present in the skin due to inclusion of hair follicles during skin graft harvesting. Figure 12f. View of complete dentures with enhanced mandibular extensions of the denture flanges. |
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Figure 12g. Clinical view of complete dentures in place. |
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Figure 13a. Edentulous site after extraction of over-retained carious deciduous left maxillary lateral incisor. Figure 13b. Tissue-preserving, aesthetically placed incision. |
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Figure 13c. Acrylic splint for fixture level, Stage I impression using a light-cured material. Figure 13d. Final single-tooth restoration in maxillary left lateral incisor position. |
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Figure 14a. Severely resorbed partially edentulous alveolar ridge. Figure 14b. Another view. |
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Figure 15. Axial CT scan demonstrating severe alveolar resorption in edentulous site. Figure 16a. Donor site from mandibular symphysis. Figure 16b. Corticocancellous autogenous bone graft fixated to atrophic site. |
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Figure 17a. Restoration placed on implant in tooth #9 position. Figure 17b. Periapical radiograph of implant and restoration. |
To request a printed copy of this article, please contact/Richard A. Smith, DDS, Department of Oral and Maxillofacial Surgery, UCSF School of Dentistry, 521 Parnassus Ave., C-522, San Francisco, CA 94143-0440 or at ras144@aol.com.
