Case report: The presented case report shows a 58-year-old patient who was pre-treated alio loco with tumour radical surgery and subsequent radiotherapy for squamous cell carcinoma of the anterior mandible. The vestibule was restored by means of a split skin graft from the thigh, and then an implant-supported prosthetic restoration was attached. After 6 weeks, fixed gingiva had developed and a prosthesis bed was formed. A definitive bar-supported prosthesis was then created. The prosthetic also resulted in an improvement in the mouth opening and soft tissue profile.
Discussion: Studies show that implant-supported mandibular prostheses are a reliable and effective method of reconstructing the edentulous mandible, with high patient satisfaction and significantly improved masticatory function.
Due to advanced mandibular atrophy and the preceding tumour radical surgery, there is an encroachment of the mentalis muscle and the tissue attachments at the alveolar ridge as well as a reduction in the size and shape of the mandible, especially in the vestibular depth. Vestibuloplasty is therefore indicated for long-term stable retention with implants.
It is generally recommended to perform vestibuloplasty 2 months prior to placement of endosseous implants. Alternatively, vestibuloplasty can be performed at the time of implant placement. The use of palatal grafts often results in postoperative pain and the graft size is limited. Split skin grafts are recommended especially when a large graft is required. Immobilisation and adhesion of the split skin graft are critical factors along with adequate vascularisation of the recipient area. In addition, micro-movements during chewing cause local inflammation. Saliva collects under the graft and can separate it from the graft bed. Complications at the donor site are rare. The grafted skin is firm, immobile, stable and can withstand the functional stresses of the prosthesis.
A contraindication exists in patients who require an alveoplasty in addition to the split skin graft. Since the split skin graft is placed supraperiosteally, it precludes simultaneous alveoplasty.
Summary: Without an adequate vestibule, prosthetic rehabilitation in the severely atrophied jaw is almost impossible. To enable a long-term stable implant restoration, a sufficient soft tissue bed with a stable peri-implant tissue and a good hygiene ability must be created. The gold standard for vestibuloplasty is the oral mucosa graft. However, this is only available in limited quantities, so that the split skin graft can be used to cover extensive soft tissue deficits as a result of tumour therapy.
Keywords: Split skin graft, vestibuloplasty, soft tissue replacement
