Abstract
Nowadays, upper denture instability secondary to severe maxillary atrophy is treated, in most cases, with dental implants. However, a significant number of patients cannot afford this procedure. Palatal bone deepening through a U-shaped osteotomy has been described previously. The procedure increases retention by improving the suction effect of the palate and prevents anteroposterior and lateral movement of the denture. By combining this procedure with a secondary epithelialization vestibuloplasty, the labial aspect of the ridge is also extended and it does not require a skin graft. This article describes a modification of the palatal vault osteotomy through the presentation of a case.
Severe maxillary atrophy affecting denture stability causes masticatory, aesthetic, and psychosocial problems. Implant placement to treat this condition is today’s standard of care, however, a significant number of patients cannot undergo this procedure for pecuniary reasons or have medical co-morbidities contraindicating complex bone grafting interventions. Soft tissue procedures, such as submucous vestibuloplasty, mostly prevent lateral movement of the denture. Bone grafting operations (onlay, inlay, or interpositional) carry morbidity, and without implant placement, they resorb quickly.
In 1976, the team reported a technique to increase palatal depth based on the original description by Wassmund. This simple technique involves a deepening of the palatal vault by elevation of a bone segment towards the nasal cavity. The procedure allows a significant improvement in denture stability by reducing anteroposterior movement of the prosthesis and by increasing the suction effect of the palate. This operation has been performed on over a hundred patients through the years, with good results, no relapse, and few complications.
More recently, the authors have modified the original technique to improve denture retention by combining the palatal osteotomy with a secondary epithelialization vestibuloplasty (sometimes called a lipswitch or Kazanjian vestibuloplasty). This modification has the advantage of indirectly increasing the alveolar crest height on the palatal and the labial aspect of the ridge and it does not require a skin graft. It also facilitates soft tissue closure. The purpose of this article is to describe a modified palatal vault osteotomy technique through the presentation of a case.
Case presentation
A 62-year-old female patient was referred to the department of oral and maxillofacial surgery of hospital with a chief complaint of upper denture instability. The patient was unable to chew or speak with the denture in place and did not wear the prosthesis most of the time. Her past medical history was significant for schizophrenia and depression, for which she was taking quetiapine, olanzapine, clonazepam, and paroxetine. On physical exam, it was noticed that her upper prosthesis was unstable and was dislodged every time the patient made an effort to speak. Vestibular and palatal vault depths were significantly reduced ( Fig. 1 ). The ridge was flat and most of the alveolar process was resorbed. The patient was diagnosed with a class V Cawood and Howell maxillary resorption. Reconstruction with a bone graft with subsequent implant placement was proposed to the patient, but she refused this therapeutic option for pecuniary reasons. The decision was made to perform a palatal osteotomy with a secondary epithelialization vestibuloplasty under general anaesthesia.
The patient was brought to the operating theatre, placed under general anaesthesia, and intubated nasally. She was given 2 mg of cephazolin intravenous (IV) and 80 mg of methylprednisolone IV 30 min before the start of the operation.
Methylprednisolone was repeated every 4 h postoperatively for a total of four doses. The buccal vestibule was infiltrated with 10 ml of mepivacaine with epinephrine 1:200,000. A vestibular incision approximately 1 cm superior to the mucogingival junction was performed. In the middle, the incision was kept almost at the mucogingival junction because it was impossible to gain vertical height due to the presence of the anterior nasal spine. A supraperiosteal dissection was carried out superiorly to the level of the infraorbital nerves anteriorly and to the zygomatic buttresses posteriorly. Inferiorly, the flap was also dissected supraperiosteally to the summit of the remaining alveolar process and then the periosteum was incised. The palatal mucosa was carefully elevated so as to preserve both greater palatine arteries ( Fig. 2 ). The nasopalatine neurovascular bundle was sectioned.
A U-shaped osteotomy along the palatal side of the alveolar ridge from the nasopalatine canal to the posterior part of the hard palate was done with a carbide-cutting bur under copious saline irrigation ( Fig. 2 ). The osteotomy was maintained medially to the greater palatine canals posteriorly to preserve the vascular supply to the mucosa. Once the osteotomy was completed, the palatal bone segment was moved inferiorly and the nasal septum sectioned, freeing it completely. A septoplasty and bilateral inferior turbinectomies were done to position the palatal bone superiorly without interfering with nasal structures.
The free palatal bone was elevated until it was in contact with the nasal mucosa and the depth of the palate judged adequate ( Fig. 2 ). Two transalveolar wires were inserted in the premolar area. These wires serve the dual purpose of maintaining the palatal bone and denture in position during healing ( Fig. 3 ). The palatal mucosa was sutured to the periosteum with 4–0 Vicryl sutures on top of the alveolar process. The palatal portion of the patient’s own prosthesis was augmented with a thick layer of rigid impression compound (Kerr Corporation, Romulus, MI, USA). The peripheral margin of the prosthesis was also augmented with orthodontic resin (Dentsply Caulk, Milford, DE, USA) to allow an increased vestibular depth by secondary healing of this area. The modified denture was put back in place and secured with the two previously inserted stainless-steel wires ( Fig. 3 ). Six weeks postoperatively, the denture was removed and relined with resilient acrylic material (Bosworth Trusoft, Skokie, IL, USA) and the final prosthesis delivered 3 months later. The depth of the vestibule and palate were significantly increased and excellent denture stability was achieved ( Fig. 4 ). No postoperative complications were noted.
