|Year : 2022 | Volume
| Issue : 2 | Page : 179-182
Collagen grafting in Godwin's vestibuloplasty
Swaminathan Chidambareswaran, Saroj Kumar Rath
Command Military Dental Centre, Northern Command, Jammu and Kashmir, India
|Date of Submission||09-Sep-2021|
|Date of Acceptance||19-Jul-2022|
|Date of Web Publication||21-Dec-2022|
Command Military Dental Centre, Northern Command, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Preprosthetic surgery is a part of maxillofacial surgery that restores oral function and facial form rendered deficient through loss or the absence of teeth and associated structures because of disease, trauma, or elective surgery for tumors and other conditions. This is concerned with the surgical modification of the alveolar process and its surrounding structure to enable the fabrication of a well-fitting, esthetic dental prosthesis. There are various techniques of vestibuloplasties, but the mostly used techniques are Kazanjian's and Clark's with split skin graft (SSG) or other grafting. With its better properties in all aspects, bovine collagen has become an alternative to SSG in intraoral grafting. Here, we have elaborated a successfully managed case of short lower anterior vestibule treated by Godwin's technique of vestibuloplasty followed by collagen grafting.
Keywords: Collagen grafting, Godwin's Technique, Kazanjian's technique, vestibuloplasty
|How to cite this article:|
Chidambareswaran S, Rath SK. Collagen grafting in Godwin's vestibuloplasty. J Dent Def Sect. 2022;16:179-82
| Introduction|| |
As the average life span of an individual increases, the edentulous population also increase. The edentulous patients pose different problems on prosthetic rehabilitation. One of the problems is residual ridge resorption, the ways to overcome this is vestibuloplasty, if sufficient bone is available and if not, alveolar augmentation followed by vestibuloplasty. Although recent advances in implant prosthodontics aid the prosthodontist to rehabilitate the patient with residual alveolar ridge resorption, the steady census of the complete denture wearers is maintained. Thus, vestibuloplasty is an inevitable procedure in periprosthetic surgery. This article discusses a successfully managed case of lower anterior vestibular deficiency in a completely edentulous patient by Godwin's vestibuloplasty technique with collagen grafting.
| Case Report|| |
A 63-year-old male patient reported to the department of maxillofacial surgery and was referred for vestibuloplasty in the mandibular anterior vestibule. On examination, the patient was completely edentulous for the past 5 years and was not wearing a complete denture. On general examination, the patient was nonanemic, nonicteric, no pedal edema, cyanosis, and clubbing and with no systemic illness. The anterior vestibular depth was 5 mm and thus referred for vestibuloplasty in mandibular anterior region [Figure 1]. Primary impression was recorded, and the cast was poured, and once dried, the depth of the anterior buccal vestibule was increased in the cast by 10 mm, and a stent was fabricated.
Under local anesthesia and aseptic precaution, an incision was made on the labial mucosa about 8-mm buccal to the depth of the vestibule. After incising the submucosa, submucosal dissection was done for the entire length of the flap toward the alveolar bone [Figure 2]. Periosteal incision was placed over the alveolar bone, and the periosteum was reflected [Figure 3]. The mentalis muscle attachment was stripped to create a vestibular depth of 15 mm [Figure 4]. The dissected flap was sutured to the attached periosteum along the alveolar bone to create a deeper vestibule. The defect in the labial mucosa where the flap was raised was reconstructed using collagen graft [Figure 5]. Bovine collagen “surgicol” was adapted over the defect and sutured at the margins. After 7 days, the collagen graft took up, the sutures were removed and the vestibular depth created was 13–15 mm all along the anterior mandibular region [Figure 6]. The patient was asked to wear the stent to prevent relapse. The 6 months post-operative review showed well-maintained vestibular depth in the lower anterior labial vestibule.
|Figure 2: Incision placed and submucosal dissection done till the alveolus|
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|Figure 4: Labial flap over the alveolar bone and collagen grafted upon the defect in labial mucosa|
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|Figure 5: Acrylic stent placed over the mandibular arch to prevent the loss of vestibular depth gained in the procedure|
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| Discussion|| |
Vestibuloplasty is the procedure in which the vestibule is deepened by changing the soft-tissue attachments. Vestibuloplasty aims in repositioning of the muscle and redraping of the mucosa over the bone to increase the vestibular area and improving the stability and support for the prosthesis. They are broadly classified into advancement vestibuloplasty, secondary epithelialization vestibuloplasty, and grafting vestibuloplasty. The advancement vestibulolasty is the submucosal vestibuloplasty and requires adequate healthy attached gingiva and adequate bone support. The various secondary epithelialization techniques of vestibuloplasty are Kazanjian's technique and Clark's technique. The grafting vestibuloplasties are Obwegeser technique and modified Kazanjian's technique.
Kazanjian's technique is a labial vestibuloplasty procedure in the mandible where the incision is placed on the lip and the submucosal dissection is carried out till the alveolar bone. Moreover, once the periosteum is reached, the supraperiosteal dissection is done till the desired depth and the elevated submucosal labial tissue is placed over the periosteal layer of the bone and ends are sutures to the attached periosteum and connective tissue layers. Disadvantage of this technique is that it leaves a raw area over the labial mucosa which leads to the contracture.
Moreover, the Godwins's technique is the modification of the Kazanjian technique where the incision site and all procedures remain the same except the dissection done over the alveolar bone is subperiosteal instead of supraperiosteal.
The lipswitch technique is the one, in which the two flaps are raised, one based on the submucosal supply of the labial mucosa and another periosteal flap based periosteal supply of alveolar bone. The positions of these two flaps are switched and sutured to eliminate the raw area in labial mucosa which is formed in Kazanjian's technique.
Clark's technique is the procedure, in which the incision is placed over the alveolar bone and supraperiosteal dissection is done to the desired depth over the alveolar bone and the dissected tissue is sutured to the depth of the vestibule. The raw area in this technique is over the alveolar bone which does not undergo contracture.
Obwegesser modification of Clark's technique is to graft split skin graft (SSG) over the raw area in the alveolar bone thus improving patient compliance.
Godwin's vestibuloplasty can be combined with grafting the raw area which is formed in the lip. The options for grafting are SSG and its substitutes. Bovine collagen has the following advantages:
- Excellent biocompatability
- Weak antigenicity
- Mechanical strength
- Act as a thermal, chemical. and biological barrier
- Recruits additional fibroblast
- Fastens epithelization.
Collagen can be used as an effective alternate for the SSG as the collagen is the most common denominator in almost all stages of wound healing. According to Pal et al., it not only guides reepithelization but also it improves wound strength, decreases scar contracture, and resists masticatory forces.
In the ultrastructural study, interactions of platelets with microfibrillar collagen were studied which showed that a sequence of morphological changes started to occur in the platelet adherent collagen and collagen acts as chemotactic factor for platelets, influencing their adhesion and aggregation.
The collagen covering the raw areas provides a shield for the exposed sensitive nerve endings, thereby diminishing the degree of pain. As collagen is a natural substrate of extracellular matrix, it reduces the inflammatory process which contributes to reduced pain and burning sensation.
Controlling infection and fastening reepithelialization are the most important methods for controlling scarring. Collagen fulfills these goals, thereby prevents scar contracture.
Collagen membrane gets adapted to the wound of any contour. It was observed that the collagen membrane had good adherence to the mucosa and wound bed. The primary adherence of collagen membrane is due to fibrin collagen interaction and later it is the fibrovascular ingrowth into the collagen.
According to Raghavendra Reddy et al., collagen appears to be biocompatible with no significant immune rejection with biodegradable characteristics.
Fate of the intraoral collagen after it aids in wound healing is to undergo collagenolysis. Preparation of stents becomes necessary to hold the collagen membrane in position when the defect is large.
| Conclusion|| |
Wound healing is the sequence of events which consist of cellular and biological activities aiming to establish a near normal functioning of the wounded tissues. Thus, the above case report shows that the bovine collagen with its advantages of no donor site deformity, anesthetic effect, ease of availability, better esthetics, better mechanical strength, better adherence, and good wound healing property is the most successful intraoral substitute for SSG.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]