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ISSN : 0976-951X

ESTHETIC LOCALIZED SOFT TISSUE RIDGE AUGMENTATION IN A FIXED PARTIAL DENTURE A CASE REPORT
Dr. Alaap D. Shah Dr. Somil Mathur Dr. Vishal Sahayta Dr. Alkesh Shah Dr. Rakesh Makwana Dr. Meena Shah M.D.S. M.D.S. M.D.S. M.D.S. M.D.S. M.D.S.

Abstract The replacement of teeth by a fixed partial denture in esthetically demanding areas requires prosthesis of correct form and shade, along with establishment of a natural appearance of the periodontal tissue surrounding the restorations. Esthetically correct treatment of an alveolar ridge defect is a frequent challenge in fixed prosthodontics . Such defects can be over come by soft tissue ridge augmentation. The onlay graft technique is primarily designed to gain the ridge height, but it also contributes to ridge width as in Seiberts Class II and Class III defects. A case report has been presented over here for a patient with alveolar ridge defect in the maxillary anterior region corrected with soft tissue ridge augmentation followed by a metal ceramic fixed prosthesis for the replacement of missing upper central incisor. Key Words : Soft Tissue Ridge Augmentation, Onlay Graft, Fixed Partial Denture, Localized Alveolar Ridge Defect.

Introduction The end point of fixed prosthesis design is an esthetic and functional pontic that is compatible with soft tissue health.1 The replacement of teeth in esthetically demanding areas requires prosthesis of correct form and shade, along with establishment of a natural appearance of the periodontal tissue surrounding the restorations.2 Esthetically correct treatment of an alveolar ridge defect is a frequent challenge in fixed prosthodontics.3 Such defects can be over come by soft tissue ridge augmentation and periodontal surgical techniques to regenerate the lost periodontium.4 Seibert classified three types of ridge deformities3. 1. Class I = Bucco-lingual loss of tissue contour with a normal apicocoronal height 2. Class II = Apico-coronal loss of tissue with normal bucco-lingual contour 3. Class III = A combination of bucco-lingual and apcic-ocoronal loss The ridge may be further described according the depth of loss: Lecturer Professor & Head Reader Department of Prosthodontics, Faculty of Dental Science, Dharmsinh Desai University, Nadiad - 387 001. Gujarat, India Lecturer Department of Periodontics, Faculty of Dental Science, Dharmsinh Desai University, Nadiad-387 001. Gujarat, India

The periodontal plastic surgical procedures can effectively improve the ridge contour and there by the mucogingival esthetics and pontic ridge relationship. It is designed to establish the best hard and soft tissue bases for prosthetic appliances. One of the simplest and most predictable procedures is the roll flap technique which is primarily designed to gain the ridge height, but also contributes to ridge width as in Seiberts Class II and Class III defects.5 It is a thick gingival graft harvested from the partial thickness palatal donor sites. Since the amount of height of ridge augmentation can only be as thick as the graft, the procedure may have to be repeated several times to reestablish the normal residual ridge height.1 This case report describes the technique and successful use of onlay graft with roll flap technique for esthetic repair of a pontic area defect. Case report A female patient aged 20 years reported to the Department of Prosthodontics, Faculty of Dental Science, Nadiad with the chief complain of the missing upper front tooth. Dental history revealed trauma on the maxillary anterior region before two years resulting in a non-vital maxillary right central incisor for which she underwent endodontic treatment. The tooth was extracted before six months as a result of chronic endodontic failure. Address of correspondence: Dr. Alaap D. Shah Department of Prosthodontics, Faculty of Dental Science, Dharmsinh Desai University, College Road, Nadiad - 387 001. Gujarat, India

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ISSN : 0976-951X
A thorough clinical and radiographic examination revealed a Sieberts Class III defect in the edentulous region. She presented with a moderate horizontal and a severe vertical ridge defect. Considerable buccolingual and apicocoronal tissue loss accompanied the extraction (Illustration 1). She Strongly desired replacement of teeth with a fixed prosthesis. The outline of the roll flap was marked with a number 15 scalpel blade by provoking light bleeding. (Illustration 2)

Illustration 2 A trapezoid shaped area was marked. Then the mucosal surface within this trapezoid was deepithelized with no.15 scalpel blade up to a depth of 1 mm keeping the blade parallel to the surface. The deepithelized pedicle flap was elevated by sharp dissection, the plane of dissection was kept as close to the periosoteum as possible and in order to obtain maximum amount of supraperiosteal connective tissue and to preserve the blood supply (Illustration 3).

Illustration 1 A Fixed partial denture (hereafter known as FPD) restoration with a pontic with a long crown height would be required to fill the gap between the occlusal area and alveolar ridge; however, this type of restoration would not provide optimal esthetics. Her medical history revealed no significant findings. Restorative options were discussed and explained to the patient, soft tissue augmentation of the defect area in the maxillary alveolar ridge was selected to improve the esthetics to be carried out in the Department of Periodontia, Faculty of Dental Science, Nadiad. Upper and lower impressions were recorded with alginate (Neocolloid, Zhermack SpA, Badia Polesine(PO), Italy) and diagnostic study models were prepared and analysed, after which it was decided to increase the cervico-incisal height by 5 mm and buccal-lingual width by 3 mm for the alveolar ridge defect. Pre-surgical procedure: Upper and lower alginate impressions were recorded and diagnostic casts were prepared. Shade selection was carried out in northern sky daylight following the ideal protocol using Vitapan Classical shade guide (Vitapan Inc,Rio De Jeneiro,Brazil). Tooth preparation for provisional restoration was carried out on the diagnostic casts following the ideal principles of tooth preparation. The alveolar ridge defect was blocked and shaped with wax as per the desired post surgical contour. Heat cure acrylic resin (DPI Heat cure resin, Dental Products of India, Mumbai, India) provisional restoration was fabricated for the FPD (12, 11, 21) with shade close to B1. Later, the tooth reduction for a metal ceramic FPD for the abutment teeth, (12, 21) was carried out in the patient following the ideal principles of tooth preparation. The heat cure provisional FPD prepared in advance, was tried in on the prepared teeth and relined chairside as per the requirement. Surgical Procedure After anaesthetizing the surgical site, the vertical and horizontal measurement and volume of the defect was ascertained. Length and width of the graft and recipient site was determined on the basis of apicocoronal ugmentation intended.

Illustration 3 When the plane of dissection reached the labial aspect a supraperiosteal pouch was prepared on the buccal aspect of the ridge taking care not to create an opening at apical border of the pouch. A thick free gingival graft (Illustration 5) of partial thickness was harvested from hard palate near the free gingival margin of the second premolar-first molar region (Illustration 4) and was placed in this pouch and held in place in the keratinized gingiva with one or two single knot sutures. The 3-0 silk suture was placed as high in the mucobuccal fold as possible, in order to pull the pedicle up to the apical portion of the pouch. (Illustration 6)

Illustration 4

Illustration 5

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A periodontal dressing (COE PAK ,GC America Inc., ALSIP, IL 60803, USA) was placed on the donor site while no dressing was placed on the labial side to allow the graft to swell and adapt to contours of the pontic (Illustration 7).

Illustration 7 The preadjusted acrylic surgical stent was given to the patient to be used to prevent the periodontal dressing from getting dislodged. (Illustration 8) The patient was examined on the tenth post operative day. Periodontal dressing on the donor site was carefully removed and surgical area was flushed with saline, sutures were gently removed.

Illustration 8 After the eighth week, on clinical examination, the cervicoincisal and buccal-palatal contours of the alveolar ridge soft tissues were now acceptable to place an esthetic FPD. (Illustration 9)

Illustration 9 At the end of 8 weeks definitive impressions were made with putty wash technique using A-silicone impression material (Aquasil Soft Putty/Regualar set, Dentsply DETREY GmbH, Konstanz,Germany) Impression was disinfected in 2% glutaraldehyde (BM 28 PLUS, BM Group Inc., Montreal, Canada) for 10 minutes. Shade selection was carried out in Northen sky daylight using Vitapan Classical shade guide (Vitapan Inc,Rio De Jeneiro,Brazil) following the ideal protocol and B1 shade was selected for the final prosthesis. Work authorization sheet was duly filled with specifications and dispatched with master casts to the dental laboratory. A three unit metal -ceramic FPD was fabricated. The fit of the restoration was confirmed and necessary occlusal adjustments were performed prior to cementation. The prosthesis was cemented using Type I glass ionomer cement. (GC FUJI I, GC America Inc, ALSIP, IL 60803, USA) (Illustration 10)

Illustration 10 Home care instructions were reviewed again and patient was scheduled for recall appointments after 2 weeks, 3 months and 6 months. On recall visits, there was no relapse of the augmented area and esthetics and function of the restoration were satisfactory. Conclusion There are various prosthetic and surgical options for improving esthetics in the patient with ridge deformities. Long pontic design or gingival (pink) ceramic in the cervical region can enhance esthetics in such cases to an xtent.6 Surgical procedures using soft tissue autogenous graft, various alloplastic materials, autogenous bone graft and guided tissue regeneration can correct such type of ridge defects.7.8 In the present case, the loss of ridge width was more evident with a little loss of ridge defect. Hence an autogenous connective tissue graft was used to augment the ridge defect. Examination of the patient on 6 month recall visit showed the clinical success of the procedure performed, restoring esthetics, function and health of the patient. Correction of localized alveolar ridge defects through roll flap technique is a valuable method for fixed prosthodontic treatment. It not only improves the mucogingival esthetics of the pontic region but also improves phonetics and reduces food lodgement in the pontic region. References: 1. Johnson GK, Leary JM. Pontic design and localized ridge augmentation in fixed partial denture design. Dent Clin North Am. 1992 Jul; 36(3): 591-605 2. Shillingburg HT, Hobo S , Whitsett LD. Fundamentals of Fixed Prosthodontics.3 ed; 1997.p.491-6 3. Studer S, Naef R, Scharer P. Adjustment of localized ridge defects by soft tissue transplantation to improve mucogingival esthetics. Quintessence Int. 1997 Dec; 28 (12) 785-805 4. Rosenberg ES, Cutler SA. Periodontal considerations for esthetics : edentulous ridge augmentation. Curr Opin Cosmet Dent. 1993 : 61 6 5. Siebert JS. Reconstruction of deformed ,partially edentulous ridges, using full thickness onlay grafts, Part I Technique and wound healing. Compend Contin Educ Dent. 1983; 4 ; 437-53 6. Mishra N, Singh BP, Rao J, Rastogi P. Improving prosthetic prognosis by connective tissue ridge augmentation of alveolar ridge. Indian J Dent Res 2010;21: 129-31 7. Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed Prosthodontics. 3 ed; 2001.P 513-5 8. Taskonat B, Ozkan Y. An alveolar bone augmentation technique to improve esthetics in anterior ceramic FPDs : clinical report. J. Prosthodont. 2006 Jan-Feb;
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