DOI: 10.7860/JCDR/2016/16606.

7192
Original Article

Anterior Ridge Extension Using

Dentistry Section

Modified Kazanjian Technique in

Mandible- A Clinical Study

Jagannadham Vijay Kumar1, Pandi Srinivas Chakravarthi2, Meka Sridhar3, Kolli Naga Neelima Devi4,
Vivekananad Sabanna Kattimani5, Krishna Prasad Lingamaneni6

ABSTRACT than 5mm of vestibular depth for MKV procedure. The results
Introduction: Good alveolar ridge is a prerequisite for were tabulated and statistical analysis was carried out to assess
successful conventional/ implant supported partial/complete vestibular depth achieved i.e. from crest of the ridge to junction
denture. Extensively resorbed ridges with shallow vestibule and of attached mucosa both pre and postoperatively. The study
high insertion of muscles in to the ridge crest, leads to failure results were compared with existing literature.
of prosthesis. Success of prosthesis depends on surgical Results: Healing of raw surface was uneventful with satisfactory
repositioning of mucosa and muscle insertions, which increases achievement of vestibular depth. The average gain in vestibular
the depth of vestibule and denture flange area for retention. depth was 11 mm. The patients had good satisfaction index for
So, the study was planned to provide good attached gingiva prosthesis.
with adequate vestibular depth using Modified Kazanjian Conclusion: Even in the era of implant prosthesis Modified
Vestibuloplasty (MKV). Kazanjian technique is worth to practice to achieve good
Aim: To evaluate efficacy of MKV technique for increasing results and overcorrection is not required as that of standard
vestibular depth in anterior mandible so that successful Kazanjian technique. It provides adequate attached gingiva for
prosthesis can be delivered. Efficacy of the technique successful prosthesis. Extension of vestibular depth enables
was evaluated through operating time required, vestibular fabrication of better denture flange with improved oral hygiene.
depth achieved, scarring or relapse and any postoperative This technique does not require hospitalization and additional
complications associated with the healing. surgery for grafts.
Materials and Methods: Total of 10 patients were included in
the study, who had minimum 20mm of bone height and less

Keywords: Pre-prosthetic surgery, Prosthesis, Ridge extension procedure, Vestibuloplasty, Vestibular depth

introduction Materials and Methods

Residual ridge reduction after extraction is well known biological Patients requiring vestibular deepening procedures presented
phenomenon and pattern of resorption is a well known fact [1]. to Department of Oral and Maxillofacial Surgery referred from
Extensive resorption of mandibuar ridge results in shallow buccal Department of Prosthodontics, Sibar Institute of Dental Sciences,
vestibule and high insertion of mentalis muscle in relation to crest India and were randomly selected for the study group during 2013
of the ridge, which leads to displacement of prosthesis [1-3]. Good to 2014.
functional denture or implant supported prosthesis needs adequate Selection Criteria: After clinical and radiographic examination,
vestibular depth and attached gingiva. Many vestibular deepening total of 10 patients with minimum 20mm of bone height and less
techniques have been described since beginning of the era of than 5mm of vestibular depth were allocated for study protocol as
surgery namely, Kazanjian, Godwin, Trauner, Clark, Obwegeser, determined by Department of Prosthodontics [Table/Fig-1]. Patient
Howe, Steinhauser, Tortorelli [4-12]. Vestibuloplasty repositions and attender were explained about surgical procedure and follow-up
mucosa, muscle insertions, and increases denture flange area in protocol to know their willingness for participation as volunteer for
turn stability of prosthesis [4]. All procedures are associated with the study. Quality of oral mucosa was examined clinically and bone
varying degree of success. Disadvantages associated with existing height was assessed radiographically. Radiographic assessment
procedures made the clinician to rethink for modifications, so was performed using Sirona digital panoramic radiographic
that the modifications can overcome the disadvantages [13-16]. machine at predetermined points (midline, bilaterally just 2mm
So, the study was planned to provide good attached gingiva and before mental foramen) by radiologist and surgeon [Table/Fig-2].
adequate vestibular depth using modified Kazanjian vestibuloplasty Indication for surgery was set by Department of prosthodontics.
technique.

Aim
The study was aimed to evaluate efficacy of MKV technique for
increasing vestibular depth in anterior mandible so that successful
prosthesis can be delivered. Efficacy of technique was evaluated
through operating time required, vestibular depth achieved, scarring
or relapse and any postoperative complications associated with the [Table/Fig-1]: Intraoral photograph showing Preoperative Vestibular reference
healing. Markings at midline, bilaterally just before mental foramen.[Table/Fig-2]: Preoperative
panoramic radiograph for measuring bone height.

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 Jagannadham Vijay Kumar et al., How Good is Modified Kazanjian Technique? www.jcdr.net

[Table/Fig-3]: Intraoperative photograph showing mucosal incision. [Table/Fig-4]: Intraoperative photograph showing and labial incision bi-pedicled mucosal flap. [Table/
Fig-5]: Intraoperative photograph showing polyethylene tube sutured to mucosal flap.

of them were blinded for time duration of follow-up to prevent bias.

Surgical procedure: Modified Kazanjian vestibuloplasty was
performed under local anaesthesia (Lignocaine-2% with 1:80000
adrenaline- Lignox-2% Indoco, India) developed by AL Belasy FA
[13]. An intraoral Trans mucosal curvilinear incision was performed
on alveolar ridge at the junction of attached mucosa [Table/Fig-3]
till periosteum and another on labial mucosa approximately 12-
[Table/Fig-6]: Intraoperative photograph showing final vestibular depth and 15mm away from the attached mucosa between inter-foraminal
placement of tube for suturing and percutaneous sutures in place extra orally. area [Table/Fig-4]. Careful sharp supra periosteal dissection of
muscle and connective tissue attachments were carried out till
the desired depth. Bi-pedicled flap was elevated [Table/Fig-4]. The
wound was irrigated with normal saline and local haemostasis was
achieved. Flap was advanced apically and secured to desired depth
of vestibule using poly ethylene tube; [Table/Fig-5] which was fixed
to vestibular depth using percutaneous sutures around cotton rolls
[Table/Fig-6]. Labial and alveolar sides of flap were sutured to the
lip and periosteum respectively using horizontal mattress 3.0 silk
[Table/Fig-7]: Postoperative intraoral photograph showing desired vestibular depth
sutures, starting from midline and ended bilaterally.
with markings.[Table/Fig-8]: Postoperative photograph showing cast with metal Resultant raw surface was covered using betadine moistened
scale in place for measurement of ridge height.
gauze which was left for secondary epitheliazation. Dry gauze
The minimum ridge height required for vestibular surgery ranged pack dressing was placed gently over the submental area to cover
from 15-20 mm according to the published literature [2]. It is an percutaneous sutures. All patients were put on Postoperative oral
essential bone height required to withstand normal occlusal forces antibiotic and anti-inflammatory drugs (Cap.Amoxicillin-500mg 8th
and retention of prosthesis; which is a prerequisite to perform hourly and Tab. Ketorol DT, 12th hourly for 5 days). Patients were
any vestibular deepening procedures [2]. Less bone height leads instructed to maintain soft diet and warm saline rinses after meals
to compromised denture function, stability and inability to insert for minimum duration of four weeks.
implants and sometimes may lead to fracture of hasal bone. Patients were examined during 1st week, 1st, and 3rd month
Such bone deficiency requires augmentation surgery followed by follow up visits for healing and undue complications. The clinical
deepening procedures [2]. So selection criteria opted was to have evaluation included healing of mucosal flap, scarring of lip, effective
maximum amount of bone height required to deepen the vestibule vestibular depth achieved at first week, 1st month and 3rd month
without undue complications. Patients with ASA (American Society of surgery. Sutures & poly ethylene tube removal were done seven
of Anaesthesiology) class I and II conditions were involved in the days postoperatively. The clinical parameters were evaluated
study. Patients with systemic disorders like hepatic, respiratory, consecutively for three months [Table/Fig-7] and for every six months
cardiac, endocrine, or metabolic impairment which make the up to 18 months after insertion of denture. Postoperative discomfort
patient unfit for surgical procedure were excluded from study. Study and pain was assessed using visual analogue scale. Sensation of
protocol was approved by institutional ethical committee. lip and chin were assessed using two point discrimination. Depth
Procedure was explained to healthy patient volunteers followed measurements were done using digital caliper and metal scale. The
by informed consent. Preoperative clinical assessment was done comparison of pre and postoperative height were also done on pre
using calipers and cast. Preoperative cast was arbitrarily scraped and postoperative casts using standard metal scale [Table/Fig-8].
till the preplanned depth to prepare a clear acrylic surgical splint. Clinically ridge was measured at three predetermined reference
Vestibuloplasty procedure was performed by single surgeon under points i.e. midline, bilaterally just 2 mm before mental foramen
local anaesthesia, postoperatively assessed by two observers. Both [Table/Fig-9]. These points were checked by two investigators and

Time points for follow up Pre -op Immediately After surgery 1st week post op 1st month post op

Groups A1 B1 C1 A2 B2 C2 A3 B3 C3 A4 B4 C4
Minimum in mm 1.00 2.50 2.50 4.00 6.00 6.00 5.00 7.00 7.00 3.50 6.00 6.00
Maximum in mm 4.50 5.00 6.00 20.00 20.00 20.00 16.00 15.00 15.00 14.00 14.00 14.00
Mean 3.25 3.55 3.55 11.25 11.55 11.65 9.90 9.70 9.95 8.70 8.95 8.75
#SD 0.98 0.76 0.98 5.18 4.55 4.69 3.38 2.79 8.75 3.54 3.17 2.93
*p-Value .00 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000
(S)** (S) (S) (S) (S) (S) (S) (S) (S) (S) (S) (S)
[Table/Fig-9]: Showing vestibular depth at point A, B, and C. with different time intervals.
# Standard deviation, * p-value less than 0.05 is considered statistically significant, S** - Significant

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www.jcdr.net Jagannadham Vijay Kumar et al., How Good is Modified Kazanjian Technique?

data corrected for marking errors if any. Values were tabulated technique, Lipswitch vestibuloplasty was advocated. In this
and analysed for test of significance (p value less than 0.05 was technique mucosal flap will cover the bare bone and periosteal flap
considered as statistically significant value). Data on demographics will cover the labial side, so that epithelization of periosteum occurs
and denture satisfaction were recorded and computed for evaluation in 2-3 weeks without scarring [2,9,15].
using modified questionnaire (Annexure-1) based on M Gargari et Further Clark and Obwegeser modified secondary epithelization
al., study [17]. technique [7,8]. Modifications were based on the principles of
plastic surgery i.e. raw surface contracts less if covered with
Results epithelium, raw surface overlying bone do not contract, sufficient
Increased vestibular depth was seen with MKV technique. Average undermining is necessary to prevent tension while fixing and firm
age of patients involved in the study was 56.75 years in males and
fixation is necessary to prevent the relapse [2,7,8]. Clarks technique
50.83 years in females [Table/Fig-10]. Postoperative depth obtained
is considered reverse of Kazanjian as incision was made on the
in relation to point A, B, and C were significant when compared
alveolar crest with supra periosteal dissection till desired depth.
to preoperative measurements [Table/Fig-9]. Healing of raw surface
was seen in 60% of cases within a week and by the end of second The mucosal flap was sutured to lip leaving the bone covered
week healing was satisfactory in all the cases [Table/Fig-11]. with periosteum for secondary epithelization [7]. Later Obwegeser
Scarring was minimal and postoperative pain score observed were modifies Clarks technique primarily for maxillary vestibuloplasty [8].
ranged between 2-3 during 1st week and gradually reduced 0-1 at Tortorelli further modifies Clark’s technique as periosteal fenestration
the end of 2nd week. All patients were completely relieved from the to prevent relapse at the base of the vestibule [11]. Periosteum was
pain by the end of 3rd week. incised horizontally at the desired depth of vestibule and inferior
periosteal margin elevated which was sutured to mucosal flap. So
Gender Number of Mean age in SD of Age # Mean operating SD #
patients years time in minutes that bare bone healing was delayed by 2-3 weeks than bone covered
Female 6 50.83 6.05 29.50 1.52 with periosteum; this difference in healing period was effective in
preventing relapse [11]. Later grafting vestibuloplasty advocated
Male 4 56.75 22.54 29.00 4.24
overcoming drawbacks associated with healing and patient
Total 10 53.20 14.11 29.30 2.71
discomfort during these periods [12]. Insufficient bone available
[Table/Fig-10]: Showing demographic data and mean time taken for surgery.
#
Standard deviation for sub mucosal and overcorrection of secondary epithelization
prompted the use of epithelial grafting [2,11]. Grafting requires
Parameters Time Points Description No.of cases % second surgery to harvest graft under general anaesthesia which
Healing after 1 week Satisfactory 6 60 increases cost, hospitalization and patient discomfort [2]. Drawback
Unsatisfactory 4 40 of skin graft is hair growth in oral cavity and poor graft take up
Lip scaring after 1 month Positive 4 40
on exposed cortical bone [2]. Skin grafting procedure is technique
sensitive. Xenografts were also tried with varying rate of success
Negative 6 60
using porcine skin [2]. However, limitations of all surgical procedures
[Table/Fig-11]: Showing healing and lip scarring at different time intervals.
involved once again made the rethinking for modification of existing
techniques.
Discussion
Ideal ridge should have adequate, uniform bone height without any Kazanjian Technique is considered to be prototype and practiced
protuberance, undercuts, sharp ridges, redundant soft tissue and by many surgeons. To overcome postoperative complications
hypertrophy [1,2]. Ridge should be free from any bone pathology associated with Kazanjian technique, few modifications were
[3-6]. Millard started pre prosthetic surgery for reduction of suggested recently [13-16]. Even in the era of implant supported
interdental papilla and alveolar margins immediately after extraction denture, successful denture rehabilitation require sound attached
[3]. Later prototype vestibuloplasty was advocated by Kazanjian [4]. gingiva. Different surgical procedures were developed to create
Many surgical procedures were described in published literature better anatomical environment and to create proper supporting
by clinicians with varying results [4-12]. Vestibuloplasty techniques structure for denture reconstruction. Ultimate goal is good functional
can be generally categorized as mucosal advancement, secondary rehabilitation and aesthetics. Our study was aimed to achieve this
epithelization and grafting vestibuloplasty [2]. Physical status and goal. So, we had performed AL Belasy’s MKV technique to validate
age of patient are prime important factors for the selection of published literature [13,15,16]. Vestibular depth obtained was in
technique involved [2]. Success of sub mucosal vestibuloplasty
accordance with AL Belasy [13]. It also prevented sharp V depth
depends on availability of adequate bone, free mobile mucosa so
of extended vestibule. In our study mean increase in vestibular
that deepening can be achieved without tension [7,8]. If mucosa
depth was noted ranged from 11.25 mm to 11.65 mm one week
available is not adequate or of poor quality then submucosal
vestibuloplasty is not indicated. Instead secondary epithelization postoperatively and 8.70mm to 8.95mm one month postoperatively
technique will be preferred [4-7]. at predetermined reference points and were statistically significant
(p-0.000) [Table/Fig-8]. The results were better when compared to
Kazanjian first described secondary epithelization technique in
AL Belasy [13]. The mean or overall depth achieved was 10 mm
mandible to overcome poor quality of mucosa viz. hyperplastic
mucosa, scar tissue and so [4], labial incision performed and large which was statistically significant (p-0.000) [Table/Fig-9].
flap reflected so that mucosal flap was transposed on to the bone Mean operating time was 29.30 minutes [Table/Fig-10]. Complete
and sutured to desired vestibular depth [2,4]. Raw surface of lip healing of wound was observed at 28.2 +/- 2.1days. One patient
heeled by granulation, secondary epithelization and contracture with pus discharge showed complete healing after topical antibiotic
[2,4]. Later Godwin modified Kazanjian technique by vestibular ointment (Soframycin) application after seven days. The advantage
deepening through sub periosteal stripping instead of supra with this technique is no relapse in the vestibular depth [13,16]. Our
periosteal dissection [5]. Vestibular mucosa was placed against study showed well acceptance by patients. The amount of anterior
the bare bone and sutured to connective tissue by excising or vestibular depth attained was 10.4mm which was measured from
pushing down periosteum and connective tissue [5]. Disadvantages
most superior point. In our study we have not had much scarring
associated with both the techniques are scar contracture and loss
which will alter the effective vestibular depth in contrast to results of
of sulcus depth [2,4,5]. Catheter and suture removal were done at
AL Belasy [13].
7-11 days postoperatively. To overcome the drawback of Kazanjian

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 Jagannadham Vijay Kumar et al., How Good is Modified Kazanjian Technique? www.jcdr.net

limitation References
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[3] Shelton DW. Critical review of preprosthetic surgery, in Irby WB: Current Advances
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consideration of soft tissue parameters along with the height of
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fabrication of denture flange and improved oral hygiene. Our study Kazanjian Vestibuloplasty Technique. J Oral Maxillofac Surg. 1997;55:1057-60.
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Acknowledgements [16] Ponzoni D, Jardim EC, de Carvalho PS. Vestibuloplasty by modified Kazanjian
Authors acknowledge authorities of Dr.NTR University of Health technique in treatment with dental implants. J Craniofac Surg. 2013;24(4):1373-75.
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completing the study protocol. a follow up of 1 year. Oral Implantol (Rome). 2012;5(4):86–91.

Questionnaire for patient/ Grading Poor Not bad Okay Good Excellent

How do you rate the aesthetics of your smile?

How do you rate the quality of your mastication?
How do you rate the facility of cleaning of the prosthesis?
How do you rate the facility of removal and insertion of your denture?
In the last year how many times did you need to change the prosthesis
for trouble, fracture or other problems?
[Annexure-1]: Patient satisfaction questionnaire modified from M. Gargari et al., study.

PARTICULARS OF CONTRIBUTORS:
1. Ex-Post Graduate Student, Department of Oral and Maxillofacial Surgeon, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
2. Professor, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
3. Professor, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
4. Professor, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
5. Reader, Department of Oral & Maxillofacial Surgery, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
6. Principal, Professor & Head of Department, Department of Oral & Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Vivekananad Sabanna Kattimani,
Reader, Department of Oral & Maxillofacial Surgery, SIBAR Institute of Dental Sciences, Guntur,
Andhra Pradesh -522509, India. Date of Submission: Sep 03, 2015
E-mail : [email protected] Date of Peer Review: Oct 10, 2015
Date of Acceptance: Nov 06, 2015
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Feb 01, 2016

24 Journal of Clinical and Diagnostic Research. 2016 Feb, Vol-10(2): ZC21-ZC24