Studies in the Alteration of Vestibulär Depth

I
Complete Denudation*
by Harry M. Bohannan,*5 a.b., d.m.d., m.s.d., Lexington, Kentucky

MUCOGINGIVAL
the most recent
surgery isone of
advances in the
surgical phase of periodontal case
management. This aspect of surgery is con-
gical pocket reduction procedures.
emphasized particularly that a shallow
tibule leads
gingival margin
to
He
ves-
food impaction against the
and into the interproximal
cerned with the treatment of aberrations in spaces, which at the same time makes it
form involving the attached gingiva and difficult for the patient to place the tooth-
its relation to the underlying alveolar sup- brush properly and cleanse the area. From
port, the alveolar mucosa, and with the its inception, therefore, the concept of
depth of the vestibulär fornix. Since muco- mucogingival surgery encompassed two
gingival procedures are performed upon a intimately associated aims, namely the al-
complex of tissues of variable nature and teration of vestibulär fornix depth and the
are involved with problems of wound production of a new and wider zone of at-
healing, mucogingival surgery has assumed tached gingiva.
paramount importance in periodontal
methodology. This importance is reflected buleTechniques designed to deepen the vesti-
in the marked increase in study currently in edentulous patients were introduced
associated with this field. These studies as early as 1924 by Kazanjian.2 A number
of additional procedures for the prosthetic
may well result in a complete reappraisal of
periodontal surgical techniques. patient have been reported over the years
and were reviewed recently by Thoma3
Goldman was the first to point out the and Kruger.* One of the first periodontal
limitations of mucogingival topography applications of mucogingival surgery was
upon periodontal surgery. In 195 3,1 he de- reported by Nabers*' in 1954. He intro-
scribed three special problems which, in his duced a technique of apical repositioning
opinion, called for interrelating gingival, of the attached gingiva in order to elimi-
mucosal, and vestibulär surgery: 1) the nate pocket depth extending into the alveo-
extension of pocket depth through the at- lar mucosa. No mention was made, how-
tached gingiva into the alveolar mucosa; 2) ever, of the vestibulär fornix.
the extension of the frenum attachment
into the marginal gingiva, and 3) a shal- Although Hirshfield" first drew atten-
low vestibulär trough resulting from sur- tion the frenum as an etiologic factor in
to
periodontal disease in 1939, it was not
until 19 54 that Stewart7 and Gottsegen*
introduced surgical methods for its elimi-
*This paper is based on a portion of a thesis nation. Additional modifications of frenum
presented in partial fulfillment of the requirements
for the degree of Master of Dental Science, Graduate surgery were described by Robinson9 and
School of Medicine, University of Pennsylvania, Grupe.10 The frenectomy, in a sense, can
Philadelphia, Pennsylvania, 1961. The thesis was be considered part of the origin of muco-
awarded the Bernhard Gottlieb Prize for Research gingival surgery in general, and vestibulär
in Periodontics by the Northeastern Society of Perio-
dontists, New York, 1961.
extension in particular.
''"'^Instructor, Department of Periodontics and The first detailed discussion of the ra-
Endodontics, School of Dentistry, University of tionale and techniques of the emerging
Washington at the time this study was conducted. field of mucogingival surgery was set forth
Presently, Associate Professor and Chairman Depart-
ment of Periodontics and Endodontics, College of in 1956 by Goldman, Schluger and Fox.11
Dentistry, University of Kentucky. The Schluger "pouch" and the Fox "push-
Page 120
 Vestibulär Depth Page 121

back" procedures, previously known only Among the mucogingival techniques in-
through personal communications, were troduced over the past eight years were a
formally introduced into the literature and number specifically designed to increase the
renamed the "local extension of the vestib- depth of the vestibulär fornix. Reports
ulär trough" and the "gingival extension concerning the efficacy of these operations
operation" respectively. Both procedures have been contradictory and confusing in
introduced bone exposure as an aspect of nature. To date, there has been no con-

periodontics and became basic to subsequent trolled study to measure objectively the
developments in mucogingival surgery. alteration in depth. All reports have re-
sulted from a subjective evaluation of
Many of the procedures described since post-operative clinical appearance. Since no
1956 have been refinements of previous
avoid the postop-
precise measurements from fixed points
techniques, designed to have been offered, this subjective evalua-
erative pain which results when extensive tion has been the source of much contro-
areas of exposed bone are covered only with
versy. Therefore, a series of studies was
a periodontal dressing. These refinements
undertaken to determine what operative
endeavored to retain or create a protective
cover of mucosa or periosteum for bone
techniques, if any, would produce increased
vestibulär depth; to what extent depth
which had been exposed for recontouring. could be increased; and the relative per-
One such modification by Ariaudo and manence of such alteration. This report
Tyrrell12 combined Naber's repositioned concerns the first method tested, a variation
flap5,13 with a minimal post-operative ex- of Schluger's "pouch" procedure.
posure of bone. Chaiken14 and Fox15'18
introduced the "stripping" procedure, method and materials
which accomplishes the necessary osseous
contouring by means of rotary abrasives Twenty-seven patients with indications
through the previously undisturbed peri- for vestibulär extension in the mandibular
osteum after the overlying mucosa has anterior area were selected from the dental
been removed. The most recent innovation clinic of the University of Washington. A
by Ochsenbein,17 the "double flap" proce- complete evaluation, including case his-
dure, retains partial periosteal coverage while tory, clinical examination and charting,
allowing for visibility and access for osteo- and pre-operative photographic and roent-
plasty, and reportedly places attached gin- genographic records was carried out.
giva extension on a predictable basis while Method of Registration. A cephalometric
extending the vestibulär fornix. This pro- method of registration, utilizing the Broad-
cedure retains the advantages of the Schlu-
bent-Bolton cephalometer, as described by
ger "pouch" procedure while eliminating
the disadvantages of excessive osseous ex- Broadbent,27 was employed. A #7l/z lead
shot was placed at the depth of the vestib-
posure.
ulär fornix labial to the mandibular right
Within the past few years, the emphasis lateral incisor and, with the mandible at
in mucogingival study has shifted from rest position, a cephalometric film exposed
one of technical development to the in- (Figure 1). This film provided a perma-
vestigation of basic biological phenomena. nent record of the pre-operative fornix

Histologie studies by Grant18,19 concern- depth with reference to the mandibular in-
ing the type of replacement tissues created cisor and the bony topography of the man-
following mucogingival procedures ushered dibular Symphysis. The operative procedure
in a new era of investigation. Since then, was then carried out. Immediately following

many additional wound healing studies in the operation and prior to the placement of
this area20"*" have been undertaken, focus- the surgical dressing, the patient was pho-
ing increased attention on this phase of tographed and returned to the cephalom-
periodontics. eter. A post-operative record was obtained
Page 122 BOHANNAN

Fig. 1. A. Pre-operative cephalometric roent-

genograph. Radiopaque lead shot demonstrates
the depth of the vestibulär fornix in relation to
incisor point and the osseous topography of the
mandibular symphisis. This is an example of
the type of roentgenography taken to record
position of vestibulär fornix.
Fig. 2. 1 illustrates pre-operative depth of ves-
tibulär fornix. 2 indicates immediate post-
operative depth. 3 shows position of fornix at
with an identical lead shot placed at six months post-operatively. Distance between
1 and 2 (A) records the amount of surgical ex-
the deepest apical extent of the surgical tension while distance between 1 and 3 (B)
demonstrates the increased vestibulär depth
wound in the right lateral incisor region. achieved.
Photographic and cephalometric records
were taken in a similar manner at 1-2-3- experimental method was tested and modi-
4-6-8-12-16 and 26 weeks post-operatively. fied to eliminate or control the possible
By this means it was possible to follow sources of error.
clinical changes during healing and to
record roentgenographically the soft tissue Roentgenographic cephalometry has been
level with respect to the underlying bony
accepted as a valid approach to anatomical
measurement. There is, however, some error
landmarks (Figure 2). inherent in its use. The divergence of the
roentgen rays from tube to target result in
Method of Evaluation.The pre-operative
enlargement and distortion of the image.
film served the base line for all evalua-
as
With a five foot tube-target distance and
tions. Changes in vestibulär depth were a constant target-film distance this error
measured to the nearest one half millimeter has been shown to be approximately
directly from superimposed films. Actual 7%.28-31
linear change was recorded and the per-
centage of retained operative extension One of the accepted methods for con-
calculated. This percentage was determined trolling enlargement error is to make it
from the difference between the immediate constant on all films. This standardization

post-operative depth and the position of the can be accomplished for each individual
healed fornix at the twenty-sixth post- film series by constant tube-target and
operative week. Since it was impossible to target-film distances. This method of con-
terminate the incision at the identical api- trol was adopted for this study for two
cal depth in each case, this percentage pro- reasons. First, all effective linear measure-
vided a basis for comparison of results ments were relatively short, none of them
from patient to patient as well as being the exceeding 15mm. (a 7% error, therefore,
most reliable method for comparison with would be reflected at most as only a 1 mm.

the results of other investigations which increase in length). Second, and more im-
followed. portant, as healing occurred, all measure-
ments became progressively shorter. The
Determination of Experimental Error. final measurements were recorded as the
Prior to the initiation of this study the difference between two points on two
 Vestibulär Depth Page 123

posed. Exposure time was one-half second.

During the period following the lead shot
placement and time of film exposure, the
patient wasclosely observed for any move-
ment or muscular activity. If this was
seen, the film was discarded and another
exposed. Following each film exposure the
position of the lead shot was visually
checked for movement. Regardless of ob-
served activity, in almost all cases addi-
tional exposures were repeated and the re-
Fig. 3. Cephalometric roentgenograph with
sulting images compared. In the greatest
three (3) lead shot in place. Difference in vestib- number of instances these films were proved
ulär depth at the rigid central incisor (shallow-
to be duplicates by exact superimposition
est), right lateral incisor, and right canine
(deepestI, illustrated. of images. In instances where difference in
the level of the lead shot did occur, that
superimposed films for which the enlarge- film showing most apical position of the
ment error was considered relatively con- shot was chosen.
stant. Since this final measurement in no
case exceeded 6 mm., a possible Measurement of Displacement Error. In
7% error
fell well within the ±.5mm. range of ac- an attempt to accurately determine the
amount of distortion that could conceiv-
curacy recognized for roentgenographic
cephalometry and was therefore accepted ably result from lateral misplacement or
for this study. displacement of the lead shot, a series of
experimental films was exposed. In these,
Image distortion and consequent error the lead shot was positioned in the vestibu-
also results from differences in the amount lär fornix opposite the mandibular right
of enlargement of various parts of the central incisor, lateral incisor, and canine
same film. This distortion stems from the and an individual film exposed with the
fact that structures on the right side of shot in each of these positions. Compara-
the head are further from the film than tive tracings and measurements were made
their counterparts on the left side. Since from these films. Roentgenograms also
this study concerned the relationship of the were exposed with the three pellets in place
lead shot to the mandibular lateral incisor simultaneously, resulting in the image
and the mandibular Symphysis, the use of seen in figure 3. Obviously some error will
a nearmidsagittal plane resulted, making result from misplacement of the lead shot
this of error insignificant.
source in a lateral direction because of the gradual
The greatest single potential source of slope of the base of the vestibulär fornix,
error was considered to be inherent in the generally from the central incisor area
downward toward the canine area. The de-
repeated positioning of the lead shot over
the right mandibular lateral incisor. Al- gree of error possible is a direct reflection
of the relative increase in vestibulär depth
though extreme caution was exercised in
this positioning, the possibility of unde- medio-laterally and will vary with each
tected error was present and warranted ad- individual case. However, it should be
ditional precaution. In all cases with the noted that the variation shown here reflects
patient positioned in the cephalometer, the the result of misplacement of the shot, the
lead shot was carefully placed in the vesti- width of one entire tooth either mesially
bule. The patient was taught to relax the or distally. Since extreme caution was ex-

mandibular musculature in order to ap- ercised in the placement of the shot during
proximate rest position and cautioned to the experiment and its position checked
remain motionless until the film was ex- following exposure of the film, it is highly
Page 124 BOHANNAN

Fig. 4. Clinical appearance immediately follow- Fig. 5. Seventh post-operative day. Minimal
ing the complete denudation operation. Note
depth to which tissue was removed resulting in healing progress indicated. Labial plate remains
exposure of the labial plate. largely exposed. Little activity apparent at the
base of the surgical wound.

unlikely that an error of such magnitude twelve millimeters) which permitted de-
could have occurred.
tachment of the mentalis muscles from
Operative Procedure. The term "com- their origin. The resulting soft tissue flap
was removed by excision. Osseous reshap-
plete denudation" is introduced as most de-
scriptive of the first operative method ing with rotary abrasives and chisels was
tested. According to the Friedman Classi- then performed marginally, as dictated by
fication32 it would be considered a combi- the defects of the individual case, and a
nation of gingival replacement and deep- periodontal dressing of the rapid-setting
ening of the vestibule. zinc oxide-eugenol type placed directly
over theexposed osseous tissue. The dress-
Adescription of the operative procedure, ing was changed at seven-day intervals for
as utilized in this study, follows: After in- a
period of four weeks in all cases.
terpapillary and vestibulär infiltration an-
esthesia, a routine gingivectomy was per- This procedure was carried out for six
formed, extending laterally to the first of the twenty-seven patients selected for
premolars and apically to the mucogingival the series of investigations.
junction. All soft tissue coronal to this line RESULTS
was removed (Figure 4). By blunt dissec-
tion the periosteum and adherent fibrous All six patients of this group reported
tissue detached apically and the labial
was intense post-operative pain and routine
alveolar plate thus exposed. This exposure prescription of narcotic analgesics was
was extended to a depth (approximately necessary. By the end of the second post-

Fig. 6. Fourteenth post-operative day. "Collar- Fig. 7. Twenty-first post-operative day. Labial
ing" by young proliferating connective tissue coverage virtually complete. Labial tissue flap
(granulation). Healing activity at base of approximating the new tissue covering the alve-
wounds resulting in partial loss of surgical ex- olar plate.
tension.
 Vestibulär Depth Page 125

Fig. 8. Twenty-eighth post-operative day. Com- Fig. 9. Thirty-fifth post-operative day. Healing
plete labial coverage. Obvious change in color pattern of lateral area markedly advanced over
and texture in new tissue interpreted as indica- that shown marginally.
tions of maturing process.

operative week, however, the patients were be primarily the result of the "outward
relatively comfortable. rolling" of the tissues at the depth of the
wound, and not the result of typical granu-
The healing of wounds in the denuda- lation tissue production.
tion series, as observed clinically, fell into
a consistent pattern. At the end of the first The third week showed progressive
post-operative week the bone was invari- granulation tissue coverage of the labial
ably exposed with little indication that plate with some remaining osseous exposure
healing was in progress. There was a mini- at the depth of the surgical area (Figure
mal amount of granulation tissue at the 7). The granulation tissue also began to
crest of the marginal bone adjacent to the show an alteration in color from fiery red
necks of the teeth of the area (Figure 5). to a deeper pink. This was interpreted as
In some cases there were also a few small,
isolated buds of granulation tissue scattered
over the labial plate. The deepest area of
the surgical wound exhibited little activity
and it was impossible to determine any
clinical change in the new surgically cre-
ated vestibulär depth at this time.

By the end of the second post-operative

week marked change was evident. Granu-
lation tissue encircling ("collaring") the
necks of the teeth at the crestal area was
quite evident resulting in variable degrees
of coverage of the labial plate (Figure 6).
Although in no instance was granulation
tissue coverage complete, at this time, in
two cases the amount of bone exposed
was minimal. Granulation tissue in the

depth of the surgical wound was not seen

to the extent observed marginally, yet
definite proliferative activity was observed
there. While the appearance at the end of
the first week had been one of yellowish
necrotic tissue covered with a fibrinous
Fig. 10. A. Pre-operative appearance of case
exudate, the second week showed far less shown in figures 5, 7, and 8. B. Appearance at
the twenty-sixth post-operative week. Note ex-
necrosis. This change at the base seemed to tension of the attached gingiva.
Page 126 BOHANNAN

Table I was virtually complete and a relatively nor-

Increase in Vestibulär Fornix Depth mal contour prevailed in the marginal and
Complete Denudation Series interproximal areas. Nonetheless, the glossy,
Total Operative Operative smooth tissue surface devoid of strippling
Operative Extension Extension seemed to indicate lack of complete tissue
Patient Extension Retained Retained
(mm) (mm) (%) maturity. A linear scar demarcated the zone
of attached gingiva from the alveolar mu-
A-l 12.5 55 44.0 cosa. Two factors seemingly influenced the
A-2 11.5 5.5 47.8 position of this scar. The first, and appar-
A-3 13.0 5.5 43.1 ently the most important, was the position
A-4 11.0 3.5 31.8 of union between the edge of the labial,
A-5 11.5 5.5 47.8 mature soft tissue flap and the new tissue
A-6 10.0 5.5 55.0 covering the outer cortical plate. The sec-
Mean 11.6 5.1 44.9 ond factor was the level of the periosteum.
In areas of irregular periosteum removal,
Table II The operative incision varied in depth
from 10.0 mm. to 13-0 mm. with an ultimate increase the attachment of the labial flap seemed to
in vestibulär depth varying from 3-5 mm. to 5-5 mm. coincide with the marginal position of the
Forty-five per cent of the depth of the operative periosteum.
incision was retained at the end of the twenty-sixth
post-operative week. From the eighth to twenty-sixth post-
operative week the tissue in five of the six
evidence of maturation and, perhaps, early the clinical characteristics
cases developed
epithelialization. The vestibulär area, at of full maturity, namely; pink, firm, stip-
this time, also showed further change. The
outward rolling of the tissues at the base
pled gingiva devoid of apparent inflamma-
tory changes. This would seem to correlate
of the wound continued, resulting in an with the histologic findings of previous in-
approximation of the edge of the labial vestigation.
on • oi

tissue and the new tissue now covering the

osseous alveolar plate. This relationship of Increase in Vestibulär Depth. A post-
the labial cut edge to the tissue of the operative increase in vestibulär depth was
alveolar side seemed to have a marked ef- recorded at twenty-six weeks in all cases
fect on the ultimate vestibulär depth of this series (Table I). This increase was
achieved. seen to vary between 3.5 and 5.5 milli-
meters with a mean gain of 5.1 mm. There
By the fourth post-operative week cov-
was no apparent correlation between the
erage of the labial platealmost invari-
was
increased depth of the vestibule and the
ably complete (Figure 8). The changes in vertical extent of the initial operative in-
surface texture and color of the granula-
cision. This incision varied in depth from
tion tissue were interpreted as further
10.0 mm. to 13.0 mm. with a mean of
maturation in this tissue. These changes
were prominent laterally and in the vestibu-
11.6 mm. Following complete healing an

lär area as contrasted to the marginal re- average extension of 45 percent of the
depth of the operative incision was re-
gion (Figure 9). The vestibulär fundus was tained.
now at an obviously more coronal level
than at the last recording. Tissue had
By the end of the fourth post-operative
completely filled the base of the wound so week ninety percent of the loss, due to
that the edge of the original excised flap
healing, in the surgically created depth had
joined the new tissue covering the labial occurred (Table II). In only one case did an
plate. At this time a definite demarcation, alteration of depth occur after the twelfth
at the point of junction between the labial
and alveolar tissues, was recognized. post-operative week. An example of the
pre-operative and post-operative condi-
By the sixth post-operative week healing tions typical of the patients of this series
 Vestibulär Depth Page 127

Table II
Healing Pattern
Amount of Operative Extension Lost During Healing Period
Complete Denudation Series
Total
Total Extension
Patient Operative Lost in Loss of Operative Extension in Weekly Periods (mm and %)
Extension Healing 0-2 wks 2-4 wks 4-6 wks 6-8 wks 8-12 wks 12-26 wks
(mm) (mm)
A-l 12.5 7.0 3.0 (43%) 4.0(57%)
A-2 11.5 6.0 3.0 (50%) 3.0(50%)
A-3 13.0 7.5 3.0 (40%) 2.5(33%) 1.0(13%) .5(7%) .5(7%)
A-4 11.0 7.5 4.5 (60%) 2.5(33%) .5(7%)
A-5 11.5 6.0 2.5 (42%) 2.5(42%) 1.0(16%)
A-6 10.0 4.5 3.0 (66%) 1.5(34%)
Mean 11.6 6.4 3.2 (50%) 2.6(40%)
Table III The healing pattern illustrates the percentage of total operative extension lost during the
observation period. In only one case (A-3) was there any alteration in depth after the twelfth post-operative
week. Ninety per cent of the loss occurred within the first four weeks.

may be in figure 10. The weekly heal-

seen lar depth can be increased and second, that
ing pattern is illustrated diagrammatically this increase, once achieved, is relatively
in figure 11. stable following the active healing period.
Whether this position will remain constant
DISCUSSION
over a protracted period has not been de-

The current status of vestibulär exten- termined and will be the basis for a subse-
sion procedures is both contradictory and quent portion of this study.
confusing. The controversy surrounding Clinically, it was not possible to ascer-
this phase of periodontal surgery has been tain alteration in vestibulär depth from
an
a
product of subjective evaluation of clini- the fourth to the twenty-sixth post-opera-
cal results without objective substantia- tive week. Although it seemed apparent
tion. that an overall increase in depth had been
The results of this investigation, the first achieved at the end of the observation pe-
of a series, seem to offer basic and objective t riod, it was impossible to determine, by
information concerning vestibulär fornix clinical observation alone, the magnitude
extension. First, it is apparent that vestibu- of this change. In all cases the altered physi-
cal appearance of the operated area was
CASE A-3: COMPLETE DENUDATION interpreted as indicating a substantial in-
crease in depth. Measurements obtained
from the cephalometric roentgenograms
provided an objective, accurate, graphic
representation of the change in depth and,
in all cases, revealed the increase to be less
than anticipated. Because of this it would
seem that reports regarding vestibulär ex-
tension based on clinical appearance should
be regarded with skepticism.
Fig. Diagrammatic representation
11. of the
healing pattern obtained from the position of SUMMARY
the lead shot as recorded roentgenologieally.
5.5 mm. gain in vestibulär depth. 43.1% opera-
tive extension retained. A series of investigations was initiated
Page 128 BOHANNAN

in an effort basic questions re-

to answer 14. Chaiken, B., Personal Communication, 1958.
garding surgical techniques for vestibulär 15.Fox, L., Personal Communication, 1959.
extension. A method utilizing roentgeno- 16. Goldman, H. M-, Schluger, S., Fox, L., and
graphic cephalometry was devised for this Cohen, D. W., PERIODONTAL THERAPY, Ed.
2. St. Louis, 1960, C. V. Mosby Co., p. 342.
purpose. This report concerns the first
method tested, the "complete denudation" 17. Ochsenbein, C, Newer Concepts of Muco-
gingival Surgery. J. Periodont. 31:175 (July) 1960.
procedure. Increased vestibulär depth rang- 18. Grant, J., Histologie Study of Repositioning
ing from 3.5 to 5.5 mm., with a mean gain the Attached Gingiva. Thesis, State University of
of 5.1 mm., was achieved for the six pa- Iowa Dental School (August) 1956.
tients included in this section of the series. 19. Grant, J., Histologie Study of Repositioning
Approximately 45% of the operative ex- the Attached Gingiva in Periodontal Therapy. Iowa
tension was retained at the end of the D. J. 44:62, 1958.
twenty-six week period of the study. Of 20. Ivancie, G. P., Experimental and Histological
the 5 5 % of the operative extension lost Investigation of Gingival Regeneration in Vestibulär
during the healing process, practically all Surgery. J. Periodont. 28:2 59, 1 957.
21. Bradley, R. E., Grant, J., and Ivancie, G. P.,
(90%) loss occurred within the first four Histologie Evaluation of Mucogingival Surgery. Oral
post-operative weeks. Surg., Oral Med., Oral Path. 12:1184, 1959.
BIBLIOGRAPHY 22. Kohler, C. A., and Ramjford, S. P., Healing
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PERIODONTAL THERAPY. St. Louis, 1956, Cephalometric Roentgenography Introduced by
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