Incision design in implant dentistry based on vascularization of the mucosa

8/11/2019 Incision design in implant dentistry based on vascularization of the mucosa

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Incision design in implant dentistrybased on vascularization of the mucosa

Johannes KleinheinzAndreBuchter

Birgit Kruse-LoslerDieter Weingart

Ulrich Joos

Authors affiliations:Johannes Kleinheinz, AndreBuchter, Birgit Kruse-Losler, Ulrich Joos, Department of Cranio-Maxillofacial Surgery, University of Muenster,Muenster, GermanyDieter Weingart, Department of Maxillofacial andPlastic Surgery, Katharinenhospital, Stuttgart,Germany

Correspondence to:Johannes Kleinheinz

Department of Cranio-Maxillofacial SurgeryUniversity of Muenster Waldeyerstr.30 D-48149 MuensterGermanyTel.: 49 251 834 7003Fax: 49 251 834 7184e-mail: [email protected]

Key words: implant dentistry, incision design, supply area, vascularization

Abstract

Objectives: The delivery of an adequate amount of blood to the tissue capillaries for

normal functioning of the organ is the primary purpose of the vascular system. Preserving

the viability of the soft tissue segment depends on the soft tissue incision being properly

designed in order to prevent impairment of the circulation. A knowledge of the course of

the vessels as well as of their supply area are crucial to the decision of the incision. The aim

of this study was to visualize the course of the arteries using different techniques, to

perform macroscopic- and microscopic analyses, and to develop recommendations for

incisions in implant dentistry.

Material and methods: The vascular systems of seven edentulous human cadavers were

flushed out and filled with either red-colored rubber bond or Indian ink and formalin

mixture. After fixation a macroscopic preparation was performed to reveal the course,

distribution and supply area of the major vessels. In the area of the edentulous alveolar

ridge specimens of the mucosa were taken and analyzed microscopically.

Results: The analyses revealed the major features of mucosal vascularization. The main

course of the supplying arteries is from posterior to anterior, main vessels run parallel to the

alveolar ridge in the vestibulum and the crestal area of the edentulous alveolar ridge is

covered by a avascular zone with no anastomoses crossing the alveolar ridge.

Conclusion: The results suggest midline incisions on the alveolar ridge, marginal incisions in

dentated areas, releasing incisions only at the anterior border of the entire incision line,

and avoidance of incisions crossing the alveolar ridge.

Surgical disciplines are always confronted

with the problem of cutting and therefore

damaging healthy soft tissue in order togain access to the area of interest in the

human body. While the access require-

ments have not changed over time, the

incision techniques have changed (e.g. la-

ser (Mausberg et al. 1993; Bryant et al.

1998), electrosurgical knife (Mausberg

et al. 1993; Sinha & Gallagher 2003),

water scalpel (Siegert 2000) and piezosur-

gery (Shelley & Shelley 1986). Irrespective

of the applied technique, the surgical access

must provide for:

(1) optimal visualization of the key area;

(2) problem-free expansion of the soft tissue;

(3) mobilization of the overlying soft tis-sue to cover the surgical field;

(4) no placement over bony defects or

cavities;

(5) sufficient vascularization of soft tissue;

(6) minimum tissue damage;

(7) assured wound healing;

(8) minimum esthetic impairment and

(9) good tissue covering.

Mucosal closure has to protect the bone,

the implant or the augmentation material,Copyrightr Blackwell Munksgaard 2005

Date:Accepted 24 November 2004

To cite this article:

Kleinheinz J, Buchter A, Kruse-Losler B, Weingart D,Joos U. Incision design in implant dentistry based onvascularization of the mucosa.Clin. Oral Impl. Res.16, 2005; 518523doi: 10.1111/j.1600-0501.2005.01158.x

518


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to establish a connection to the local supply

systems as soon as possible, and to avoid

infections or dehiscences.

The consequences of any incision must

always be kept in mind. Unlike embryolo-

gical wound healing, where scarless healing

is possible (Gary & Longaker 2000), any

planned incision or injury of the covering

soft tissue after birth will result in scarring

which differs from regular skin or mucosa

in terms of esthetics, functioning or nutri-

tion and may be a weak point in the future.

Among many factors, vascularization has

proved to be decisive for any kind of tissue

regeneration (Arnold & West 1991; End-

rich & Menger 2000). Growth, maturation

or reconstruction of the body are conceiva-

ble without unimpaired vascularization

(Folkman & Shing 1992). A knowledge of

the course and of the supply area of the

arteries is the basis for selection of theappropriate incision.

The aim of this study was to establish

recommendations for incisions, based on

reliable knowledge of the distribution pat-

terns and course of the vascular system in

the oral mucosa.

Material and methods

Two different techniques were used to

demonstrate the macro- and micro-archi-

tecture of the arterial vascular system in

seven edentulous human cadavers.

A separate description of the venous

system was not undertaken because it

follows the arterial pathways in most parts

of the body.

Vascular corrosion cast

A total of 150 ml of red-colored rubber

bond (MR Givuls Revultex, Heinrich

Wagner, Boblingen, Germany) was injected

into the external carotid arteries on both

sides after flushing out the vascular system

with streptolysin solution at a pressure of

200 mm Hg. The head was then immer-

sion-fixed. This technique allows the de-

monstration and macroscopic evaluation of

vessels ranging from small calibres upto a

diameter of 200mm. After solidification of

the elastic substance, the specimens were

frozen and cut in medio-sagittal direction.

The vascular system of the maxilla and

mandible was transected in the vestibular

and palatal/lingual planes. The course of

the vessels and their relationship to adja-

cent anatomic structures and tissues were

documented in layers.

Indian ink injection

In a second attempt 4 ml of colored Indian

ink and formalin (4%) mixture were in-

jected into the facial, lingual and maxillaryarteries after flushing out the vascular sys-

tem with streptolysin solution passing

through the capillary plexus. The colored

areas of the mucosa were inspected, photo-

graphed and resected in the edentulous area

of the alveolar ridge. After cleaning of

the specimens according to the method of

(Spalteholz 1911) microscopic evaluation

of the microvascularization was carried

out.

Macroscopic evaluation

Following macroscopic preparation, single

arteries were identified and their position

and relationship to adjacent structures and

their course from the exit from the bone up

to the capillary system were described. The

ink-stained areas of the mucosa were as-

sessed with respect to their extent and

borders and were assigned as a supply area

to one of the injected arteries.

Microscopic evaluation

The mucosa of the edentulous alveolar

ridge was evaluated microscopically with

respect to the distribution and orientation

of vessels. Special emphasis was placed on

the crestal area where vestibular and oral

parts of the mucosa are in direct contact.

Results

After preparation, the color-marked main

vessels were identified and their course and

relationship to other tissues and structures

described (Fig. 1). After dissolution of

the surrounding soft tissue the vessels were

demonstrated directly on the underlying

bony surface (Fig. 2). The points of exit

from the foramen and the anastomoses to

other vessels were shown. The results of all

cases are summarized in Fig. 3.

Vascular territories of the maxilla (Fig. 4)

In the posterior part of the maxilla the

vestibular gingiva was supplied by branches

of the infraorbital artery, and the palatal

mucosa by branches of the descending

palatine artery. Anteriorly, in the area of

the premaxilla, the supply was based on the

facial artery regarding the vestibular parts

Fig.1 . Course of main arteries in the maxilla after macroscopic preparation. Vessels filled with rubberbond can

easily be identified.

Fig.2 . After dissolution of soft tissue the relation of vessels and bone is demonstrated.

Kleinheinz et al . Incisions in implant dentistry

519 | Clin. Oral Impl. Res.16, 2005 / 518523


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and partially on the infraorbital artery. In

66% palatal parts were supported by the

descending palatine artery and in 33% by

the anterior superior alveolar artery.

Vascular territories of the mandible (Fig. 5)

The posterior lateral part of the alveolar

ridge was supplied by the facial artery, and

the anterior part by the inferior labial artery

and in 50% additionally by the mental

artery. In 73% of the cases the lingual

mucosa was supported exclusively by the

submental artery and in 27% additionally

by the sublingual artery. Regarding the

lingual supply there were overlappings of

both sides, whereas overlapping was found

in 20% of the cases in the vestibular part

covered by the facial artery.

Crossing area on the edentulous alveolarridge (Fig. 6a, b)

A visible vestibularoral separation line

between the two supply areas at the center

of the edentulous segments was demon-

strated in edentulous spaces, free-end situa-

tions and totally edentulous jaws.

Microscopic evaluation of the alveolarmucosa (Fig. 7a, b)

The demonstrated gingival branches are

arterioles or capillaries, which have the

characteristics not of end-arteries but of

net-arteries with numerous anastomoses.

There is an almost avascular zone in the

crestal area of the edentulous alveolar ridge.

The descriptions can be summarized intothree main vascularization characteristics:

(1) The main course of the supplying

arteries is from posterior to anterior.

(2) These vessels run parallel to the al-

veolar ridge in the vestibulum most

of the time, only gingival branches

stretch to the alveolar ridge.

(3) The crestal area of the edentulous

alveolar ridge is covered by a 12 mm

wide avascular zone with no anasto-

moses crossing the alveolar ridge.

Recommendations for the incision(Fig. 8 ad)

Because of divergent dentitions and, es-

thetic zones, as well as different parts of

the gingiva (marginal, propria, mucosa) it is

necessary to define and distinguish differ-

ent parts of the incision line. The three

decisive areas are:

the crestal part of the edentulous re-

gion,

the bordering papilla in cases of par-

tially dentated jaws, the area of the releasing incision at

the anterior and posterior limit of the

incision.

The midcrestal incision seems to be the

ideal choice for the edentulous area of the

planned implantation. Making the cut in

the area of the avascular zone prevents the

risk of cutting through anastomoses or

cutting out avascular areas of the mucosa.

Fig.3 . Overview after macroscopic preparation of the arteries in the maxilla and mandible. The main courses,

distributions and relations are demonstrated.

Fig.4 . Vascular territories of the maxilla. The colorsshow the supply areas of different arteries: blue

infraorbital artery, red descending palatine artery,

black facial and infraorbital arteries, green

descending palatine and anterior superior alveolar

arteries.

Fig.5 . Vascular territories of the mandible. The

colours show the supply areas of different arteries:

blue facial artery, red submental and sublingual

arteries, black inferior labial and mental arteries.

Fig.6 . After Indian ink injection a vascular separation line is visible in the center of the edentulous alveolar

ridge.




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For esthetic reasons, only marginal inci-

sions should be used in the frontal region.

Releasing incisions in the vestibulum

should be avoided because they will cut

obliquely through defined esthetic zones

and not at their borders. Releasing inci-

sions should be carried out, if at all, only at

the anterior border of the incision line to

avoid cutting through the vessels coming

from posterior to anterior. Trapezoid flaps

with anterior and posterior releasing inci-

sions are avoidable in most cases because

the surgical field can be adequately visua-

lized, and mobilization using incising of

the periosteum can be achieved by anterior

incision only.

If it is essential not to touch the marginal

mucosa, an incision in the vestibulum

parallel to the alveolar ridge with tunneling

preparation is recommended.

The papilla will be included in the inci-

sion in the anterior maxilla and recon-

structed using microsurgical techniques

during preparation and wound closure. In

the lateral or posterior segment or in the

event of a single posterior tooth in a free-

end situation the papilla can be left un-

touched by making the releasing incision

in front of the papilla.

Discussion

The different factors to be taken into ac-

count when planning a mucosal incision

include esthetic aspects, plastic-reconstruc-

tion potential and blood-supply require-

ments. In a defect situation, the focus is

on criteria relating to plastic reconstruction

(e.g. preparation and mobilization of local

flaps for coverage or reconstruction pur-

poses). Most flap preparation limitations

are because of inadequacy of the supporting

vascular system.

Esthetic aspects play a decisive role,

especially in the anterior part of the max-

illa. It is essential to make an incision onlyat the border of esthetic zones or areas and

to avoid damaging, displacement or redu-

cing local tissue, because any substitute

tissue is distinctive in its color, consis-

tency, and surface structure.

Among all planning principles, the vas-

cular-nutritive principle seems to be the

most important one. The vascular system

at the margin of a wound represents the

most important nutritional structure for

survival and the basis for reliable wound

healing and therefore must not be damagedunder any circumstances (Arnold & West

1991; Endrich & Menger 2000; Filippi

2001).

Consideration of the vessels involved in

any soft tissue incision should be based on

the extent and boundaries of the areas of

supply of single major vessels. The ana-

tomic principle of the vascular territories

referred to in the literature under the

term angiosomes (Taylor & Palmer 1987;

Houseman et al. 2000). Evaluations of the

vascularization of specific areas of the oral

mucosa have also been carried out (Kin-

dlova & Scheinin 1968; Mormann & Cian-

cio 1977; Piehslinger et al. 1991; Bavitz

et al. 1994; Kerdvongbundit et al. 2003)

but only few studies have referred to total

assessment and a subdivision into angio-

somes (Whetzel & Saunders 1997).

In agreement with the results of other

study groups, the midcrestal incision in the

edentulous area of the alveolar ridge seems

to be indisputably the safest and most

reliable method (Scharf & Tarnow 1993;

Fig.7 . The histologic section of the alveolar mucosa shows a main arterial vessel and the gingival ramification

in thelateral aspectof thealveolarmucosa (a). The avascular zone is in themiddle of the alveolar ridge. There is

only one anastomosis running over the midline (b).

Fig.8 . Recommendations for the incision (a) edentulous areas, (b) edentulous areas: tunneling preparation, (c)

free-end situation and (d) single tooth gap.




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Cranin et al. 1998; Heydenrijk et al. 2000).

Incisions, which will repeatedly cross the

alveolar ridge will create small mucosal

areas with uncertain vascularization, lead-

ing to disturbed wound healing, bone re-

sorption and mucosal necrosis.

If the covering soft tissue has to be

extended, e.g., in cases of lateral or vertical

augmentation, this can be achieved with a

periosteal incision and broad undermining

mobilization.

The creation of a trapezoid flap with an

anterior and posterior releasing incision can

be avoided in cases without the necessity of

extended coverage of augmented sites be-

cause sufficient visualization and mobili-

zation can also be achieved using one single

releasing incision. To prevent accidental

cutting into the vessels running from pos-

terior to anterior in the jaws, it seems

appropriate to place the releasing incisionat the anterior border of the midcrestal

incision.

The inclusion of the papilla adjacent to

the edentulous area is controversially de-

bated. Reports of shrinkage and loss of

interproximal bone have led to recommen-

dations for parapapillary incisions (line an-

gle to line angle) (Gomez-Roman 2001;

Velvart 2002). These alternatives, designed

for primary preserving of the papilla, will

not allow unrestricted visualization of the

lateral marginal bone and the adjacenttooth. In the event of augmentation, lateral

mobilization of the gingiva is almost im-

possible.

The marginal incision including the pa-

pilla allows a complete overview of the

entire edentulous alveolar ridge and exact

placement of the implant equidistant from

the neighboring teeth. This incision is

recommended especially for esthetically

problematic areas in the upper incisor re-

gion (Wachtel et al. 2003; Erpenstein et al.

2004). Using microsurgical techniques for

preparation of flaps and reconstruction of

the papilla (Burkhardt & Hurzeler 2000),

shrinkage can be avoided when the under-

lying alveolar bone is not reduced and the

contact point of the prosthodontic treat-

ment is not too far from the alveolar bone

(Tarnow et al. 2003).

From angiologic aspects the papilla is

different from the adjacent edentulous al-

veolar mucosa because the papilla is sup-

plied by vascular anastomoses crossing the

alveolar ridge. This key point allows differ-

ent incisions including or excluding the

papilla. The decision has to be made indivi-

dually, with aspects of esthetics and plastic

reconstruction being taken into account.

Resume

Fournir une quantiteadequate de sang auxcapillaires

pour un fonctionnement normal de lorgane est le

but premier du systeme vasculaire. Preserver la

viabilitedu segment de tissu mou depend de linci-

sion du tissu mou qui doit etre effectuee de maniere

precise pour prevenir la deterioration de la circula-

tion. Une connaissance de geographie des vaisseaux

ainsi que de leurs aires de reserve sont essentiels

pour la decision de lincision. Le but de cette etude a

etede visualiser les arteres en utilisant differentes

techniques afin deffectuer des analyses tant

macro- que microscopiques et pour developper des

recommandations pour les incisions lors de la pose

dimplants dentaires. Les systemes vasculaires de

sept cadavres humains edente

s ont e

te

vide

s etremplis avec soit de lencre de Chine ou unesolution

rouge et du formol. Apres fixation une preparation

macroscopique a ete effectuee pour mettre en evi-

dence le cours, la distribution et laire de reserve des

principaux vaisseaux. Dans la zone du rebord al-

veoaire edentedes specimens des muqueuses ont ete

preleves et analyses microscopiquement. Les ana-

lyses ont mis en evidence les principaux caracteres

de la vascularisation de la muqueuse. Le cours

principal des arteres converge de larriere vers

lavant, les vaisseaux principaux courent parallele-

ment au rebord alveolaire dans le vestibule et laire

crestale des rebords alveolaires edentes et sont cou-

verts parune zone non-vascularisee sans anastomose

traversant le rebord alveolaire. Ces resultats sugger-ent donc des incisions au milieu de la ligne du rebord

alveolaire, des incisions marginales dans les zones

dentees, des incisions dacces seulement dans la

frontiere anterieure de la ligne dincision generale et

labstention dincision traversant la crete alveolaire.

Zusammenfassung

Die Gestaltung der Inzision in der dentalen

Implantologie aufgrund der Vaskularisierung der

Mukosa

Ziele: Das erste Ziel des Gefasssystems ist es, eine

adaquate Menge Blut zu den Kapillaren zu fuhren,

um eine normale Funktion des Organs zu gewahr-

leisten. Der Erhalt der Lebensfahigkeit des Weich-

teilsegments hangt von der Weichgewebsinzision ab,

welche sauber gestaltet sein sollte, um die Zirkula-

tion nicht zu beeintrachtigen. Die Kenntnis des

Verlaufs und der Versorgungsgebiete der Gefasse ist

fur die Wahl der Inzision entscheidend. Das Ziel

dieser Studie war, den Verlauf der Arterien mittels

verschiedener Techniken sichtbar zu machen, um

makroskopische und mikroskopische Analysen

durchfuhren zu konnen und um Empfehlungen fur

Inzisionen in der oralen Implantatchirurgie zu en-

twickeln.

Material und Methoden: Das Gefasssystem von 7

zahnlosen menschlichen Kadavern wurde ausge-

spult und entweder mit rot gefarbter Gummiflus-

sigkeit oder mit indischer Tinte und einer

Formalinmixtur aufgefullt. Nach der Fixierung

wurde eine makroskopische Praparation durchge-

fuhrt, um den Verlauf, die Verteilung und die Ver-

sorgungsgebiete der grossen Gefasse aufzuzeigen. Im

Bereich des zahnlosen Alveolarkammes wurden

Proben der Mukosa entnommen und mikroskopischanalysiert.

Resultate: Die Analysen zeigten die generellen Ei-

genschaften der Vaskularisation von Schleimhauten.

Die Hauptrichtung der versorgenden Gefasse ver-

lauft von posterior nach anterior, die Hauptgefasse

liegen parallel zum Alveolarkamm im Vestibulum

und die Kammregion des zahnlosen Alveolar-

kammes wird durch eine avaskulare Zone ohne

den Alveolarkamm uberkreuzende Anastomosen

bedeckt.

Schlussfolgerung: Aufgrund der Resultate werden

Inzisionen im Bereich der Kammmitte des zahnlo-

sen Alveolarkammes und marginale Inzisionen

im bezahnten Bereich vorgeschlagen. Entlastungssch-

nitte sollten nur an der anterioren Grenze der

gesamten Inzisionslinie gelegt werden. Inzisionen,

welche den Alveolarkamm uberkreuzen, sollten

vermieden werden.

Resumen

Objetivos: El suministro de una cantidad adecuada

de sangre a los capilares tisulares para el funciona-

miento normal de un organo es el proposito primario

del sistema vascular. La preservacion de la viabilidad

del segmento de tejido blando depende en la incision

del tejido blando que debe estar debidamente disen-

ada en orden a prevenir mermas en la circulacion.

Un conocimiento del curso de los vasos al igual que

del areade suministro es crucial para la decisiondela

incision. La intencion de este estudio fue visualizar

el curso de las arterias usando diferentes tecnicas,

para realizar analisis macro- y microscopicos, y

desarrollar recomendaciones para incisiones en

odontologa de implantes.

Material y metodos: Se vaciaron los sistemas vas-

culares de 7 cadaveres humanos edentulos y relle-

nados con pegamento de goma de color rojo o con

una mezcla de tinta india y formalina. Tras la

fijacion se llevoa cabo una preparacion macrosco-

pica para revelar el curso, distribucion y area de

suministro de los vasos principales. En el area de la

cresta alveolar edentula se tomaron especmenes y

se analizaron microscopicamente.

Resultados: Los analisis revelaron las principales

caractersticas de la vascularizacion mucosa. El

curso principal de las arterias de suministro as desde

posterior a anterior, los vasos principales corren

paralelos a la cresta alveolar en el vestbulo y el

area crestal de la cresta alveolar esta cubierta por una

zona avascular sin anastomosis que crucen la cresta

alveolar.

Conclusion: Los resultados sugieren incisiones en la

cresta alveolar, incisiones marginales en areas den-

tadas, incisiones liberadoras solo en el borde anterior

de la lnea completa de incision, y evitar las inci-

siones que crucen la cresta alveolar.




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Incision design in implant dentistry based on vascularization of the mucosa

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