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Authors: Dr. B.S. Jagadish Pai, Dr. Srinivas M.

INTRODUCTION

Deformities of the dentoalveloar ridge are usually the result of developmental defects, periodontal disease, trauma, or surgical insult. During healing, the overlying soft tissue collapses into the bone defects, creating contours that make it difficult or impossible to make esthetic functional prostheses. Excessive bone resorption is commonly found when teeth are extracted. This problem anteriorly, will result in an unesthetic long pontic on a narrow, hollowed out ridge.

Seibert (1983) classified the various types of ridge losses into three classes:

  • Class I - buccolingual loss of tissue with normal ridge height in apicocoronal dimension.
  • Class II - apicocoronal loss of tissue with normal ridge width in buccolingual dimension.
  • Class III - combination of I and II resulting in loss of both the normal height and width.

Special techniques have been developed to treat problems of vertical and horizontal ridge resorption

SUBEPITHELIAL CONNECTIVE TISSUE GRAFT FOR RIDGE AUGMENTATION

Langer & Calagna (1980,1982) designed a procedure for ridge augmentation that uses a combination of a partial thickness flap (buccally & palatally) & a connective tissue graft.

Advantages:
  1. Versatility
  2. Primary closure
  3. Good vascularity
  4. Maybe combined with adjacent root coverage procedures.
  5. Reduced trauma
Disadvantages:
  1. Technically difficult
  2. Possible need for secondary mucogingival surgery due to altered coronal position of the mucogingival junction
Indications:

For correction of all types of ridge deformities.

This clinical report describes the use of a maxillary alveolar ridge augmentation technique by using palatal connective tissue graft with metal ceramic restorations to achieve the maximum esthetic outcome.

CASE REPORT

A 32-year-old male patient reported to the Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet with missing left maxillary central incisor. His medical history did not reveal any systemic disease. The dental history revealed that his left maxillary incisor was extracted following an accident 4 years back.

The clinical and radiographic examinations revealed a Seibert’s Class-III alveolar ridge defect in the edentulous region. A fixed partial denture (FPD) restoration will result in elongated pontics and further their apical end will be depressed. This type of restoration would not provide optimal esthetics.

Various restorative options such as removable prosthesis, implants and conventional fixed partial denture with ridge augmentation were discussed and explained to the patient, who selected soft tissue augmentation of the defective area in the maxillary alveolar ridge followed by conventional FPD to improve the esthetics.

The definitive treatment plan includes the following: a subepithelial connective tissue graft ridge augmentation followed by a metal ceramic FPD to replace the missing tooth.

SURGICAL PROCEDURE

The ridge augmentation was performed in the Department of Periodontics. A crestal incision was made under local anesthesia with a No. 15 scalpel blade, extending from the distal aspect of right central incisor to mesial aspect of the left lateral incisor over the deformity. No vertical releasing incision was made to make the surgical procedure more conservative. By using a blunt dissection, the flap was separated from the alveolar bone to create the pouch.

The donor site in the patient for the connective tissue graft was the right lateral half of the hard palate in the second premolar and the first molar region. The approximate size of the graft required to correct the defect was marked on the donor site using a surgical marking pencil. With a No. 15 blade, a trap-door incision was made and the partial thickness flap comprising the epithelium and a thin layer of connective tissue was reflected. The connective tissue graft was obtained by carefully incising the tissue from the donor site using the No. 15 blade and tissue forceps. The connective tissue graft was transferred to the recipient site and inserted into the pouch and horizontal mattress sutures were placed using 3-0 ethicon resorbable sutures. An acrylic resin plate retainer with 0.8 mm stainless steel wire clasps given on the premolars and molars bilaterally was placed on the palate with a relieving spacer in the donor site to prevent trauma to the area. Antibiotics and analgesics were prescribed and post surgical instruction were given. The patient was re examined after 2 weeks and the sutures were removed. No post surgical complications were revealed in the recipient and donor site. Uneventful healing & satisfactory results were seen in both sites. Both the recipient and donor sites were well healed with firm and resilient mucosal coverage. The labial contour of the alveolar ridge improved substantially with a noticeable improvement in the height.










DISCUSSION

Autogenous soft tissue augmentation techniques are options for restoring the esthetics and function in patients with alveolar bone defects. The replacement of teeth in esthetically demanding areas requires prosthesis of correct form and shade along with the establishment of the natural appearance of the periodontal tissue surrounding the restorations.

A clinical report was presented that combined fixed prosthodontics with the soft tissue ridge augmentation for a patient with localized alveolar ridge defect to attain maximum esthetics and functions.

There are various surgical treatment options for the correction of localized alveolar ridge defects. The surgical methods include the following:

Soft tissue autogenous ridge augmentation

Augmentation using various alloplastic materials such as tricalcium phosphate, hydroxyapatite, calcium sulphate and glass ionomer cement

Autogenous bone graft

Guided bone regeneration.

In this case, an autogenous connective tissue graft was taken from the palatal region to augment the localized ridge defect followed by rehabilitation with a metal ceramic FPD.

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