P re p ros t h e t i c

Dentoalveolar Su r g er y
Wallace S. McLaurin, DMD, Deepak Krishnan, DDS*

KEYWORDS

Pre prosthetic
Edentulous
Vestibuloplasty
Tori
Exostoses

KEY POINTS

Preprosthetic dentoalveolar surgery continues to be an important factor in successful rehabilitation
of the oral cavity.

Anatomic considerations in preprosthetic surgery.

Hard-tissue preprosthetic surgical techniques.

Soft-tissue preprosthetic techniques.

Skin substitutes in preprosthetic surgery.

INTRODUCTION health of the patient. During the physical examina-

tion, the patient should undergo a standard head
Rehabilitation of the dentition has been an ongoing and neck evaluation with a focus on the unique
process as far back as 700 BC, which often anatomic consideration of the edentulous condi-
referred to removal of disease and replacement tion, including asymmetries of the maxilla or
of the lost structures to restore function. Prepros- mandible, gingival type and mucosal quality, pres-
thetic surgery is a vital component to achieving the ence of maxillomandibular tori and exostoses,
goals of restored dentition. Regardless of whether high frenum attachments, interarch space, vestib-
it was the prehistoric times or the era of osseointe- ular depth, and vertical dimension of occlusion.
grating implants, most patients require some The use of standardized classification systems
aspect of preprosthetic surgery when an attempt such as the one introduced by Cawood and
is made for oral rehabilitation. This rehabilitation Howell can help standardize the evaluation of the
of the edentulous patient can pose significant edentulous ridge anatomy.2 Traditionally, the
challenges to the restorative dentist and surgeon. data collection process required standard stone
The intent of this article is to discuss preoperative models for surgical planning and prosthetic fabri-
patient planning, preprosthetic surgical options, cation. However, current technological advance-
and other relevant considerations. ments, such as with cone beam computed
tomography scan and intraoral scanner, have
modernized data collection processing to an
PREOPERATIVE EVALUATION
incredibly accurate level, bypassing the need for
Complete or partial edentulism is known to be alginate impressions and stone models.3,4
more common in the aging population. The surgi-
cal management of the condition demands a thor- ANATOMIC CHANGES WITH EDENTULISM
ough preoperative assessment to ensure both
medical risk stratification and optimization before Understanding the unique maxillomandibular
oralmaxsurgery.theclinics.com

rendering safe surgical treatment.1 Thus, the initial edentulous anatomy and its differences from its
evaluation entails the investigation of any medical dentate counterpart is vital to the success of sur-
comorbidities and a deep dive into the overall gery. Edentulous ridges resorb significantly with

Oral and Maxillofacial Surgery, University of Cincinnati Medical Center, 200 Albert Sabin Way ML 0461, Cincin-
nati, OH 45219, USA
* Corresponding author.
E-mail address: gopaladk@ucmail.uc.edu

Oral Maxillofacial Surg Clin N Am 32 (2020) 583–591

https://doi.org/10.1016/j.coms.2020.07.001
1042-3699/20/Ó 2020 Elsevier Inc. All rights reserved.
584 McLaurin & Krishnan

time, and with time there is a significant reduction SURGICAL PROCEDURES

in both bulk and quality of available bone stock,
and with resorption, the inferior alveolar canal Once the decision has been made to proceed with
and foramen are positioned more superiorly in preprosthetic surgery, the goal is to establish ideal
the mandible.5 The foramen can have variable pre- hard and soft tissue contours. The bony ridge
sentations of its anatomic location.6 The genial tu- should be U-shaped with adequate height and
bercle can become more superiorly positioned. width without undercuts, protuberances, or sharp
With edentulous, aging, and bony atrophy, the edges. The oral mucosa should have adequate
vascular support to the mandible shifts from a cen- thickness with appropriate buccal and lingual
trifugal to a centripetal arrangement.7 depth.9,10
In the maxilla, there may be little bone between
Mandibular Tori
the crest of the ridge and the nasal floor. Similarly,
the posterior maxilla in the region of the maxillary A common procedure before denture fabrication is
sinuses may have minimal bone between the crest mandibular tori removal (Fig. 1). The procedure
of ridge and the sinus cavity. The entire ridge may may be completed in the ambulatory setting under
seem flat and confluent with the palatal shelf in se- general anesthesia or local anesthesia. Excessive
vere and chronic edentulism. tori may pose more of a surgical challenge and
be better addressed in the operating theater.
Regardless of the setting, establishing profound
INDICATIONS FOR SURGERY local anesthesia is imperative. In general, the initial
incision involves making a crestal incision and
The edentulous ridge of the maxilla and mandible
reflecting a full-thickness mucoperiosteal flap. In
resorb differently among individuals but generally
the case of bilateral mandibular tori, the crestal
follows a similar pattern. The maxilla resorbs on
incision is carried from the posterior right alveolar
the facial surface and the inferior surface of the
ridge to the posterior left alveolar ridge. If needed,
alveolar ridge. The mandible resorbs in an inferior
a buccal hockey-stick releasing incision may be
and anterior pattern.8 These resorptive patterns
completed to the posterior extent. A full-
can yield a ridge that is unable to accommodate
thickness mucoperiosteal flap is elevated on the
a denture.
lingual surface of the mandible, exposing the tori.
The following circumstances can necessitate a
Delicate soft tissue management is imperative,
surgical procedure to ensure smooth ridges with
as trauma to the lingual mucosa complicates the
adequate width and height for denture retention:
postoperative recovery. After the tori are exposed

Mandibular tori and adequately visualized, a Seldin retractor is

Maxillary palatal torus placed between the exposed lingual surface of

Mandibular or maxillary exostoses the mandible and the lingual mucosal flap in order

Overhanging maxillary tuberosities to protect the lingual tissue.10

Severe bony undercuts There are several methods to remove the bony

Knife edge ridges protuberances. A rongeur can be used to snip
the exostoses. A drill using a pineapple-shaped
Alveoloplasty can be completed in order to bur under copious irrigation may be used instead.
flatten the bone and allow for a larger “shelf” of Most surgeons prefer to score the superior aspect
bone for the denture. Soft tissue may also require of the protruding bone with surgical drill and a
augmentation before restoration fabrication. With fissure bur with irrigation. A chisel with mallet is
conventional dentures, vestibular sulcus depth is then used to removal the tori. After the initial ostec-
of utmost importance. Shallow sulcus depth will tomy, a bone file or handpiece with bur may be
require a vestibuloplasty. used to level any remaining undercut (Fig. 2). Dig-
Other instances of soft tissue indications may ital palpation of the lingual surface of the mandible
include is performed to assess the smoothness of the

Hyperplastic maxillary tuberosities, remaining structure and the presence of residual

Epulis fissurata, or undercuts or projections. After bone removal is

Unfavorable frenum attachments. completed, the area is thoroughly irrigated to
remove unwanted debris. The area is checked
In the patient with dental implants adequate tis- for hemostasis. The mucosal flaps are then closed
sue height and thickness is a necessity. Soft tissue in running fashion with resorbable sutures. This
augmentation in the form of vestibuloplasty, kera- technique, largely reliant on diligent soft tissue
tinized tissue augmentation, or lowering of the management, can be used for any bony protuber-
floor of the mouth may be required. ance in the maxilla or mandible.
 Preprosthetic Dentoalveolar Surgery 585

well-fitting denture in the presence of the tori.

The technique for removal of a palatal torus is pre-
dominantly based on clinical presentation (Fig. 3).
As with mandibular tori, these cases can be
addressed in the ambulatory or operating room
setting under general or local anesthesia depend-
ing on the extent of surgery required. Given that
this procedure can be highly stimulating and may
result in excess bleeding, additional precautions
should be undertaken with surgery in the ambula-
tory setting, especially in the presence of an open-
“guarded” airway and the potential respiratory
sequelae. A protected airway with endotracheal
tube may be necessary when the removal of the
torus is suspected to be more demanding than
Fig. 1. Mandibular tori: large bilateral mandibular routine.
tori. Following administration of local anesthesia, a
#15 blade is used to make a complete incision
through the palatal mucosa to bone. The incision
Maxillary Palatal Torus is performed along the long axis of the tori in the
A thorough discussion with the restorative dentist center of the protuberance. With a larger palatal
is necessary before proceeding with surgical torus, a “Y” type incision is added to the anterior
removal. At times, surgery can be avoided with a and posterior extent of the incision for adequate

Fig. 2. Mandibular tori removal. (A)

Scalloped sulcular incision as noted.
(B) Reflection of the mucosal tissue.
(C) Rotary instrument use to score
bone and create groove at the tori/
alveolar bone junction. (D) Chisel
and mallet use to separate tori. (E)
Bone file or rotary instrument used
to smooth any remaining edges.
(From Ness GM. Palatal and lingual
torus removal. In: Kademani D, Ti-
wana PS, editors. Atlas of oral and
maxillofacial surgery. St. Louis: Elsev-
ier; 2016. p. 124–5; with permission.)
586 McLaurin & Krishnan

Fig. 5. Palatal torus: exposure of torus with instru-

ments placed to safe-guard the maxillary mucosa.
Fig. 3. Palatal torus: large irregular shaped midline Torus removal may be completed with scoring of the
palatal torus. bone and a chisel or rotary instrument.

tissue reflect10 (Fig. 4). After adequate exposure

and visualization, the torus is scored into smaller excess tissue, the surgeon can then choose a sur-
sections (Fig. 5). A chisel and mallet are then gical technique.
used to remove each section and thus the bulk An elliptical incision along the most bulbous
of the torus. A 4.0-mm oval carbide bur is used un- portion of the overhanging crest is preferred by
der copious irrigation to relieve any irregularities. most to address excess fibrous tissue. The area
The mucosal tissues are protected by placing a is widely undermined, and the fibrous tissue is
Seldin retractor or a periosteal elevator in between then removed10 (Fig. 7). At this point, there is usu-
the bone and the flap. The area is thoroughly irri- ally excess mucosal tissue, which should be
gated and then closed with resorbable sutures. A trimmed and primarily closed. Care must be taken
variety of alternative techniques exist but are not to identify and preserve anatomic landmarks,
discussed here. especially the maxillary sinus floor when removing
bone.
Maxillary Tuberosity Reduction In the case of excess bone contributing to the
hyperplastic tuberosity, a similar crestal incision
Excess tissue in the maxillary tuberosity region or elliptical incision can be made to expose this
can restrict the interarch distance and compro- bone. As previously described, the soft tissue is
mise denture fit and fabrication (Fig. 6). When widely undermined with the periosteum
evaluating this area, imaging or soft tissue probing adequately reflected to expose the overhanging
can help distinguish between soft or hard tissue bone. At this point rongeur or handpiece with bur
abnormalities. After determining the nature of this under irrigation may be used to reduce the bony
excess. Primary closure is then achieved via stan-
dard suture technique (Fig. 8).

Fig. 6. Tuberosity reduction. (Left) Poor dentition

with excessive tuberosities bilaterally. (Right) Postex-
traction of teeth and bilateral bony tuberosity reduc-
tion with crestal incisions. Note the increased
Fig. 4. Palatal torus: "double-Y00 type incision for interarch space. (Courtesy of Gordon Huntress, DDS,
exposure of palatal torus. Cincinnati, OH.)
 Preprosthetic Dentoalveolar Surgery 587

Fig. 7. Maxillary soft tissue tuberosity

reduction. (A) Elliptical incision
around soft tissue to be excised in
the tuberosity area. (B) Soft tissue
area excised with the initial incision.
(C) Undermining of buccal and
palatal flaps to provide adequate
soft tissue contour and tension-free
closure. (D) View of final tissue
removal. (E, F) Soft tissue closure.
(From Tucker MR, Bauer RE. Prepros-
thetic surgery. In: Hupp JR, Ellis E III,
Tucker MR, editors. Contemporary
oral and maxillofacial surgery. 7th
edition. Philadelphia: Elsevier; 2019.
p. 234; with permission.)

FRENECTOMY However, when the tissue is hyperplastic and

short, Z-plasty is a better-suited technique. In the
Although a frenectomy is often not thought to bicuspid region, a local vestibuloplasty may be
be a preprosthetic procedure, it can be helpful often necessary to relieve the hyperplastic tissue.
in prepping the oral cavity for a prosthetic reha- In this situation, an incision is made in the area of
bilitation. Maxillary and mandibular vestibular or the mucogingival junction, and a supraperiosteal
labial frenum can cause the denture bases to flap is generated. The resultant flap edges are
become unseated.9 When evaluating a patient, then sutured in an apical position to the perios-
frenum attachments should be assessed for teum and thus reestablishing a more appropriate
high attachments on the alveolar ridge, which frenum height.
can distort denture seating. Frenuloplasty or fre-
nectomy should be performed in such sce-
Soft Tissue Vestibuloplasty
narios. Many techniques have been described
to relieve freni. Diamond excision has been Inadequate depth of the vestibule can occur due to
frequently used for maxillary midline and many reasons. Most notably, the edentulous bony
mandibular lingual frenum release. This excision atrophy causes the muscle attachments of the
is best used in the presence of ample soft mandible to become superiorly positioned over
tissue. time. This reduced vestibular height compromises
588 McLaurin & Krishnan

Fig. 8. Bony tuberosity reduction. (A)

Incision extended along the crest of
the alveolar ridge distally to the supe-
rior extent of the tuberosity area. (B)
Elevated mucoperiosteal flap pro-
vides adequate exposure to all areas
of bony excess. (C) Rongeur used to
eliminate bony excess. (D) Tissue reap-
proximated with a continuous suture
technique. (E) Cross-sectional view of
the posterior tuberosity area,
showing vertical reduction of bone
and reapposition of the mucoperios-
teal flap. (In some cases removal of
large amounts of bone produces
excessive soft tissue, which can be
excised before closure to prevent
overlapping.) (From Tucker MR, Bauer
RE. Preprosthetic surgery. In: Hupp JR,
Ellis E III, Tucker MR, editors. Contem-
porary oral and maxillofacial surgery.
7th edition. Philadelphia: Elsevier;
2019. p. 226; with permission.)

denture fit and function for the patient. One of the available, skin grafting or adjunctive grafts may
several vestibuloplasty techniques can be per- be necessary. The split-thickness skin graft has
formed in order to increase vestibular depth been shown to provide a stable vestibular depth
depending on the remaining bone height. The without significant loss of the gained depth or
selected method pursued depends chiefly on the adverse bone resorption.11,12 Adjunctive tech-
remaining bone height. niques use commercially available dermal or
collagen matrices instead of the skin grafts that
Transpositional flap vestibuloplasty are now available. Porcine collagen matrices
Patients with 15 mm or more between the mental have shown promising results when compared
foramina are good candidates for transpositional with autogenous grafts.13–15 One must consider
flap vestibuloplasty.9 The primary intent of this adnexal structures and esthetics when deciding
procedure is to increase the vestibular depth along on the best material to use. Given that high suc-
the anterior mandible to assist with denture stabil- cess has been demonstrated and that a donor
ity. A horizontal incision is made on the inner sur- site is spared, a mucosal substitute is a sound op-
face of the lower lip, and a supraperiosteal tion for these procedures. The skin substitutes are
dissection is executed superiorly. Once the alve- gaining in popularity as their function and success
olar ridge is encountered, the superior extent of has become established over time. In addition to
the dissection is complete. A #15 blade is used avoiding the second surgical site, it also often re-
to make an incision in the periosteum at the level duces the chances of hair growth in the mouth.
of the alveolar ridge. The resultant periosteal flap The inner thigh or the lateral thigh is considered
is dissected away from the bone inferiorly; a skin an ideal location for harvesting split-thickness skin
graft is applied and secured to the denuded lip. grafts due to the absence of adnexal structures in
The raised mucosal bed is then sutured at the this region. The graft is usually obtained with a
depth of the vestibule. thickness of 0.012 to 0.016 mm3. The dermatome
Vestibuloplasty with split-thickness skin graft is set to these dimensions and used to harvest a 5
or collagen or dermal matrix substitutes to 6 cm width graft. The surgical incision is made
When the operator is facing a situation where min- along the mucogingival junction, and a supraper-
imal vestibular depth and mucosal tissue are iosteal plane is dissected to the desired depth of
 Preprosthetic Dentoalveolar Surgery 589

the vestibule. The incisional margin is then sutured point, the extent of the mylohyoid muscle can be
to the depth of the vestibule. The graft is trimmed determined, and the posterior attachment is
to the desired size and fixed in place either with a incised freeing the muscle for inferior reposition-
surgical stent, circummandibular wiring, or by su- ing. Close attention should be given to the genio-
turing the graft to the host bed.16 If using a stent, glossus attachment to the genial tubercle. In
it is typically left in place for 7 to 10 days.9 The graft general, half of the genioglossus muscle can be
can also be immobilized by anchoring it either to a removed at the tubercle in order to gain depth infe-
preexisting implant or to the surgical bed during riorly.16 At this point, if a skin graft is planned, your
implant placement.17 skin graft may be inset and sutured (suturing may
In similar fashion, a mucosal substitute such as require passing transdermal via an awl) (Fig. 11).
a dermal matrix or a collagen matrix can be An acellular skin substitute such as a dermal or
applied instead of a harvested autogenous graft. collagen matrix may also be used and placed
When using such a substitute the procedure is over the denuded periosteum in lieu of using a
essentially the same. A standard supraperiosteal skin graft.18 Occasionally, the wound is left to
dissection is created, and once appropriate allow healing by secondary granulation, and in
vestibular depth is achieved, the graft is placed those instances, 2 weeks should be allowed for
and secured as discussed previously15 (Figs. 9 such secondary mucosalization.
and 10).

Floor of Mouth Lowering SOFT TISSUE AUGMENTATION

The practice of most vestibuloplasties have Keratinized tissue is vital to periimplant tissue
become unnecessary in the era of osseointegrat- health.11 In today’s practice, dental implants are
ing implants but they continue to be a necessary at the forefront of every treatment plan. Although
tool in the armamentarium of a preprosthetic sur- dental implants have lessened the need for pre
geon. Once a very popular and commonly per- prosthetic surgery, bone grafting techniques may
formed procedure, floor of mouth lowering has cause vestibular violation and require additional
become a lost art among preprosthetic proced- keratinized tissue or surgical vestibuloplasty. Ker-
ures. As noted previously, when inadequate depth atinized tissue may be obtained by completing an
of sulcus prevents prosthesis placement, it may autogenous graft from the palate or by using com-
become necessary to alter the depth of the floor mercial products. Several other skin substitutes
of mouth. are available in the marketplace, and any
When planning for floor of mouth lowering, an
incision is carried out in the retromolar region
crossing midline anteriorly to the contralateral ret-
romolar region. Care is taken in the area of the ret-
romolar region to avoid incising deeply, as the
lingual nerve may be present in the region. Blunt
mucosal and supraperiosteal dissection is then
completed on the lingual surface. Once the mylo-
hyoid muscle is identified, it must be incised ante-
riorly from its attachment to the mandible. At this

Fig. 10. Tissue alternative: incorporated skin substi-

tute in the mandibular vestibule. Increased kerati-
Fig. 9. Tissue alternative: mucosal substitute in place nized tissue and increased vestibular depth by using
to help aid in vestibular depth and keratinized tissue. mucosal substitute.
590 McLaurin & Krishnan

have sound and delicate technique to preserve

the inferior alveolar nerve, lingual nerve, and the
mental nerves. Postprocedure, one might expect
to have hypoesthesia of the lip and chin. The pa-
tient should be monitored for neural recovery on
a monthly basis. The standard window of neural
intervention is at 3 to 6 months.19
Most patients who undergo floor of mouth
lowering will have some dysphagia or odynopha-
gia.20 The patient should be placed on a liquid
diet to adequately maintain nutrition and hydra-
tion. These symptoms typically resolve after surgi-
cal edema subsides. In addition, postoperative
hematoma or arterial bleed may elevate the floor
of the mouth, thereby compromising the airway.
Emergency evacuation in the operating room
setting may be necessary in the event of the hema-
toma including emergency intubation with moni-
Fig. 11. Floor of mouth lowering: crestal incision
completed from retromolar region. Supraperiosteal toring. Emergency tracheostomy can be
dissection and hemostat placed under the mylohyoid considered if unable to perform a standard
to help identify the structure and dissect from the intubation.20
lingual surface of the mandible. The posterior dissec- A major concern for all vestibuloplasties is loss
tion occurs slightly medial to help protect the lingual of vestibular depth. Although variable depending
nerve. Dissection of the anterior occurs hugging the on the type of graft, skin graft shrinkage can be
lingual cortex of the mandible to protect the lingual as high as 40%.20 If regression of the depth is
nerve C. Suture passed through mucosa and mylo- noted, a second procedure may be necessary to
hyoid and is passed through the awl allowing for
regain depth.
the lingual tissue to be lowered and sutured to the
buccal mucosal flap. (From Perciaccante VJ, Farish SE.
Vestibuloplasty. In: Kademani D, Tiwana PS, editors. SUMMARY
Atlas of oral and maxillofacial surgery. St. Louis: Elsev-
Preprosthetic surgery begins with the final goal of
ier; 2016. p. 156–9; with permission.)
ideal prosthetic dental rehabilitation. While evalu-
ating an edentulous patient, preprosthetic surgery
discussion of such available products are beyond should always be considered in order to establish
the scope of this article. future restorative success.21 The surgeon must
collaborate with the restoring dentist to set forth
BONE GRAFTING the best treatment plan possible. Surgery should
establish ideal contour, quantity, and quality of
Bone substitutes to increase bone height and the denture bearing field.10
width have become commonplace in oral rehabil-
itation. Bone grafting is a vital component of pre- DISCLOSURE
prosthetic surgery. Given the complexity of bone
grafting and the products available for ridge The authors have nothing to disclose.
augmentation, the surgical procedures or prod-
ucts that are available for usage are not discussed REFERENCES
in this section. Alveolar ridge augmentation and
1. Steele JG, et al. How do age and tooth loss affect
“preprosthetic” bone grafting are discussed in
oral health impacts and quality of life? a study
separate chapter.
comparing two national samples. Community Dent
Oral Epidemiol 2004;32(2):107–14.
COMPLICATIONS
2. Cawood JI, Howell RA. A classification of the eden-
Generalized complications such as significant tulous jaws. Int J Oral Maxillofac Surg 1988;17(4):
edema, infection, pain, and others are not dis- 232–6.
cussed here. However, there are specific compli- 3. Al-Rimawi A, et al. Trueness of cone beam
cations associated with the procedures computed tomography versus intra-oral scanner
described earlier. derived three-dimensional digital models: an
Neurosensory disturbances can be life chang- ex vivo study. Clin Oral Implants Res 2019. https://
ing. When performing these surgeries, one must doi.org/10.1111/clr.13434.
 Preprosthetic Dentoalveolar Surgery 591

4. Papaspyridakos P, et al. Digital versus conventional 14. Preidl RHM, et al. Collagen matrix vascularization in
implant impressions for edentulous patients: accu- a peri-implant vestibuloplasty situation proceeds
racy outcomes. Clin Oral Implants Res 2015;27(4): within the first postoperative week. J Oral Maxillofac
465–72. Surg 2019;77(9):1797–806.
5. Polland KE, et al. The mandibular canal of the eden- 15. Schmitt CM, et al. Long-term outcomes after vesti-
tulous Jaw. Clin Anat 2001;14(6):445–52. buloplasty with a porcine collagen matrix
6. Matveeva N, et al. Morphological alterations in the (mucograftÒ) versus the free gingival graft: a
position of the mandibular foramen in dentate and comparative prospective clinical trial. Clin Oral Im-
edentate mandibles. Anat Sci Int 2017;93(3): plants Res 2015;27(11):e125–33.
340–50.
16. Kademani D, Paul ST. Atlas of oral andMaxillofacial
7. Forman G. Presenile mandibular atrophy: its aeti-
surgery. St. Louis: Elsevier; 2016.
ology, clinical evaluation and treatment by jaw
augmentation. Br J Oral Surg 1976;14(1):47–56. 17. Heberer S, Katja N. Clinical evaluation of a modified
8. Devaki V, et al. Pre-prosthetic surgery: mandible. method of vestibuloplasty using an implant-retained
J Pharm Bioallied Sci 2012;4(6):414. splint. J Oral Maxillofac Surg 2009;67(3):624–9.
9. Costello BJ, et al. Preprosthetic surgery for the 18. Girod DA, et al. Acellular dermis compared to skin
edentulous patient. Dent Clin North Am 1996;40(1): grafts in oral cavity reconstruction. Laryngoscope
19–38. 2009;119(11):2141–9.
10. Ephros H, et al. Preprosthetic surgery. Oral Maxillo-
19. Kushnerev E, Yates JM. Evidence-based outcomes
fac Surg Clin North Am 2015;27(3):459–72.
following inferior alveolar and lingual nerve injury
11. Ladwein C, et al. Is the presence of keratinized mu-
and repair: a systematic review. J Oral Rehabil
cosa associated with periimplant tissue health? a
2015;42(10):786–802.
clinical cross-sectional analysis. Int J Implant Dent
2015;1(1). https://doi.org/10.1186/s40729-015- 20. Samit A, Kenneth K. Complications associated with
0009-z. skin graft vestibuloplasty. Oral Surg Oral Med Oral
12. Landesman HM, et al. Resorption of the edentulous Pathol 1983;56(6):586–92.
mandible after a vestibuloplasty with skin grafting. 21. Cillo JE, Richard F. Reconstruction of the shallow
J Prosthet Dent 1983;49(5):619–22. vestibule edentulous mandible with simultaneous
13. Maiorana C, et al. The efficacy of a porcine collagen split thickness skin graft vestibuloplasty and
matrix in keratinized tissue augmentation: a 5-year mandibular endosseous implants for implant-
follow-up study. Int J Implant Dent 2018;4(1). supported overdentures. J Oral Maxillofac Surg
https://doi.org/10.1186/s40729-017-0113-3. 2009;67(2):381–6.