The combined augmentation/vestibuloplasty procedure preventing

Oral Surgery ISSN 1752-2471
CASE REPORT
The combined augmentation/vestibuloplasty procedure
preventing gingival recession in orthodontically/surgically treated
prognathic patient: a 14 year follow-up
Z. Stajčić, LJ.Stojčev Stajčić, P. Aditya, M. Rodić, B. Mileusnić & A. Aditya
Dental/Medical Clinic of Maxillofacial Surgery, Beograd-Centar, Belgrade, Serbia
Key words:
augmentation, bone loss, gingival recession,
orthognathic surgery, prognathic,
vestibuloplasty
Abstract
A novel technique is presented combining bone augmentation with
vestibuloplasty to prevent gingival recession in prognathic mandible treated
surgically and orthodontically that was followed up for 14 years.
Correspondence to:
Professor Z Stajčić
Beograd-Centar
Kralijice Natalije 35
11000 Belgrade
Serbia
Tel.: +381 113610651
Fax: +381 113610764
email: beogradcentar@sbb.rs
Accepted: 18 January 2015
doi:10.1111/ors.12159
Introduction
Orthodontics is frequently chosen to achieve a correct
correlation and alignment of the teeth in an individual.
A variety of periodontal problems have been seen in
such patients ranging from simple plaque-associated
gingival inflammation to gingival recession, loss of
bone and root resorption1–6.
Orthodontics especially becomes challenging with
Skeletal class III individuals owing to the presence of
narrow and high mandibular symphysis with thin bone
around the incisors7,8. Orthodontic movement of lower
incisors in such cases, particularly pronounced sagittal
incisor movements and de-rotation or de-compensation
during routine fixed appliance therapy, may be critical
and lead to progressive bone loss of lingual and/or labial
cortical plates9–14.
There have been very few reports in the literature
about cases warranting de-compensation of mandibular lower incisors in prognathic mandibles undergoing
preventive treatment for such complications11,15.
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© 2015 The British Association of Oral Surgeons and John Wiley & Sons Ltd
We present, therefore, a case with mandibular
prognathism subjected to orthognathic surgery and
pre- and post-operative orthodontic treatment with a
14 year follow-up in whom a unique treatment
approach was used to prevent the bone loss and gingival recession in the mandibular anteriors.
Case report
A 19 year-old male with mandibular prognathism
subjected to mandibular set-back via the bilateral sagittal split osteotomy; the wire osteosynthesis and the
intermaxillary fixation were referred postoperatively
by his orthodontist for a consultation and possible
treatment for his condition regarding an unfavourable
response to postoperative orthodontic treatment.
During the final orthodontic adjustment, it was noted
that the roots of the lower incisors were seen on the
lingual side pushed through the bone appearing
underneath the gingiva. An attempt was then made to
de-rotate or push the apices of the roots towards the
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Combined augmentation/vestibuloplasty procedure
Stajčić et al.
labial side. However, the same condition appeared then
on the labial side.
Clinical examination revealed visible roots of the
lower incisors and the canines on the labial side as well
as a thin gingival biotype with slightly noticeable gingival recession (Fig. 1).
Surgical technique
The procedure was performed under local anaesthesia
where a copious amount of local anaesthetic solution
was injected into the submucous plane to separate the
mucosa from the underlying muscles. A semi-lunar
incision, using the no 15 blade, was placed in the labial
mucosa terminating near the mucogingival junction at
the level of the lower second premolars (Figs 2 and
3A)16. The mucosa was then, cranially, dissected off the
submucosa and the mentalis muscle reaching the
attached gingiva (Fig. 3B). The periosteum was incised
at this level and was stripped off the bone together with
the muscle down to the projection of the apices of the
roots (Figs. 3C and 4) leaving sufficient muscular
tissues attached to the vestibular periosteum to avoid a
sagging chin. A biocompatible porus bone substitute
(Bio-Oss®, Geistlich Pharma AG, Wolhusen, Switzerland), size small, was placed covering the roots and
particularly filling up the inter-radicular spaces (size
large) (Figs 3D and 5). The collagen membrane (BioGide® Geistlich Pharma AG) was cut to the size and
placed over the graft.
The mucosal flap was advanced and sutured to the
periosteum with a 4-0 resorbable mattress stay sutures
on a round needle at the level of the future bottom of
the sulcus by leaving a 5 mm-wide free mucosal
Figure 1 Preoperative condition with visible roots of the lower incisors
and canines.
Figure 2 Semi-lunar incision placed in the alveolar mucosa terminating
near muco-gingival junction.
Figure 3 Cross section, diagrammatic representation of the surgical technique; (A) Place of the incision (arrow). (B) The mucosa is lifted of the Mentalis
muscle. (C) The periosteum is incised at the border of the attached gingival and stripped off the bone down to the projection of the apices of the teeth. (D)
The grafted material applied with the barrier membrane, the mucosal flap is sutured to the periosteum at bottom of the sulcus with mattress suture. (E) The
free end of the mucosal flap was stretched and sutured to the incision line in the lip.
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Stajčić et al.
Combined augmentation/vestibuloplasty procedure.
Figure 4 Intra-operative finding with bone dehiscence visible on the root
surfaces.
Figure 6 Wound closed with multiple horizontal mattress sutures forming
the vestibular depth and interrupted single sutures re-approximating the
mucosal edges.
Figure 5 Biocompatible bone substitute placed over the roots and interradicular spaces.
Figure 7 Postoperative condition after 14 years of follow-up with stable
marginal gingiva and band of attached gingivae.
margin (Fig. 3D). This mucosal strip was stretched and
its periphery sutured to the free edge of the labial incision with very little tension (Figs 3E and 6).
The patient was followed up for 14 years in terms
of the skeletal and occlusal stability, condition of the
gingivae, occurrence of recession and inflammation. At
the last recall, the marginal gingivae was stable, and
no progression of gingival recession was noted (Fig. 7).
However, the occlusion deteriorated over time,
whereas the skeletal stability was maintained.
tively stable especially when the lower teeth that
were subjected to the treatment were concerned. The
stability of the gingival margins in turn indicates
stable bone levels which was the aim of our guided
tissue regeneration15.
It can be speculated that that the periodontal status
of the teeth in the symphyseal region would have been
unchanged even if the described procedure had not
been applied17–19. We are of the opinion that it is
unlikely and that our treatment concept has prevented
gingival recession particularly when the data from the
literature are taken into consideration11,15.
The uniqueness of such cases is a twofold problem
starting with the anatomic variation and later on
the amount and direction of teeth movement needed.
Anatomically, prognathic mandibles have been found
to be elongated, narrow and especially thin with thin
bone in the lower incisors region7,8. In such patients,
a pronounced sagittal or antero-posterior incisor
Discussion
A reasonably long follow-up period of 14 years of
our patient has disclosed interesting findings over
time. The combined orthodontic/orthognathic treatment has rendered a skeletal stability that was associated with dental relapse. The periodontal status in
terms of gingival margin levels has remained relaOral Surgery 9 (2016) 47--51.
© 2015 The British Association of Oral Surgeons and John Wiley & Sons Ltd
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Combined augmentation/vestibuloplasty procedure
movements during routine orthodontic treatment
might lead to progressive bone loss of the lingual and
labial cortical plates, resulting in alveolar bone fenestration or gingival recession that compromises periodontal health and aesthetics3,10,20,21.
The vestibuloplasty per se has created a band of the
fixed mucosa (Fig. 7), thus preventing the muscle pull
and the loss of the keratinised gingivae. The particulate
bone has apparently integrated and prevented further
bone dehiscence over the roots. This has created a
support to the soft tissues and its stability in addition to
the effects of the vestibuloplasty. We think that our
incision design is superior to the marginal incision
because the papillae are left undisturbed and the crestal
bone loss is less likely to occur7.
We have been using the described surgical technique
of vestibuloplasty for over 18 years for various indications such as vestibuloplasty in edentulous jaws or
localised vestibuloplasty associated with submucous
free grafts in the treatment of peri-implant loss of the
attached gingiva as well as peri-implantitis. It has proven
its versatility and the predictability in terms of the
maintenance of the created width of the fixed mucosa.
Based on the results achieved in our patient, the
described technique appears to be a promising procedure for the prevention of further bone loss and the
gingival recession in patients with the thin symphysis
such as patients with mandibular prognathism undergoing orthodontic treatment. Further applications of
this technique and clinical studies may reinforce
our statements and reveal possible limitations and
drawbacks.
Conflict of interest
The authors confirm that they have no conflict of
interest.
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