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Table of Contents
SHORT COMMUNICATION
Year : 2012  |  Volume : 2  |  Issue : 2  |  Page : 138-140

A pre-prosthetic soft tissue augmentation using a simplified technique


1 Department of Periodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
2 Department of Prosthodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India

Date of Web Publication4-Sep-2012

Correspondence Address:
Jothi Varghese
Department of Periodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.100610

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   Abstract 

Despite the increased demands for single tooth implants, many patients still opt for fixed partial dentures to close the edentulous spaces . Prior to the replacement of missing teeth, aesthetic and physiologic corrections of edentulous areas are critical pre-requisites. This case describes a simple method to enhance a localized buccal ridge defect and create an emergence profile in relation to the maxillary right premolar region, prior to the construction of a fixed partial denture. This technique involved using a connective tissue and platelet rich fibrin membrane for soft tissue augmentation, so as to obtain a natural form and maintain a healthy periodontium.
Clinical Relevance to Interdisciplinary Dentistry

  1. Role of pre-prosthetic periodontal surgery to achieve improved aesthetics.
  2. Use of Connective tissue graft and PRF for a more predictable outcome. This simple technique enabled the simultaneous preparation and augmentation of the ridge.

Keywords: Aesthetics, connective tissue graft, emergence profile, ovate pontic, platelet rich fibrin


How to cite this article:
Jadhav T, Varghese J, Hassija J, Bhat G S, Bhat K M. A pre-prosthetic soft tissue augmentation using a simplified technique. J Interdiscip Dentistry 2012;2:138-40

How to cite this URL:
Jadhav T, Varghese J, Hassija J, Bhat G S, Bhat K M. A pre-prosthetic soft tissue augmentation using a simplified technique. J Interdiscip Dentistry [serial online] 2012 [cited 2019 Dec 16];2:138-40. Available from: http://www.jidonline.com/text.asp?2012/2/2/138/100610


   Introduction Top


Soft tissue aesthetics is a concern not only related to smile design but also to missing gingival tissues around a tooth or beneath a fixed prosthesis. Alveolar bone resorption is a typical physiologic response following tooth extraction, creating clinical problems in the aesthetic zone. Siebert [1] classified alveolar ridge deformities, according to their morphology into three categories, based on the horizontal and vertical defect. Surgical soft-tissue augmentation techniques have been effective in developing the soft-tissue architectures that facilitate aesthetic restorations. Another factor that requires critical evaluation is the pontic design. The ovate pontic provides excellent aesthetics and emergence profile. [2] However, the design requires ridge augmentation if the ridge is collapsed. [3] The selection of the technique depends on the extent and severity of the ridge defect and the type of the prosthetic treatment. [4],[5] Recently, the use of Choukrouns' platelet rich fibrin (PRF) membrane for ridge augmentation has been utilized. [6] This case report describes a simple novel technique of soft tissue ridge augmentation for ovate pontic placement using the excised tissue as a connective tissue graft and PRF membrane. The correction of the ridge defect was planned pre-prosthetically, so as to achieve maximum aesthetics and maintainable the periodontal health.


   Case Report Top


A 36-year old female patient was referred to the Department of Periodontology, complaining of unesthetic appearance of a fixed prosthesis in relation to the upper right back region. Oral examination revealed a fixed partial denture (FPD) in relation to the maxillary canine and second premolar in the region. Following this, a thorough clinical and radiographic examination revealed an inadequate emergence profile of the edentulous ridge (Seibert Class 1) beneath the existing pontic [Figure 1]a. Based on the prosthetic evaluation, the replacement of the FPD with an ovate pontic for the missing maxillary right first premolar was recommended, in order to obtain the required emergence profile. Hence, modification of the ridge and consequent soft tissue augmentation for the buccal defect was planned. A full thickness buccal mucoperiosteal flap was raised to expose the buccal ridge deficiency in the region between the maxillary canine and second premolar. Following this, the narrow wedge of tissue outlined by the two parallel incisions was de-epithelized, and separated from the underlying bone [Figure 1]b. This excised tissue was used as a connective tissue graft for the soft tissue augmentation of the buccal ridge defect [Figure 1]c. The platelet rich fibrin clots were obtained from 20 ml of the patients' blood.The clots were compressed with gauze based on the Choukrouns' technique for preparation of PRF membranes. These PRF membranes were then adapted over the connective tissue graft [Figure 1]d, and the flap was drawn coronally and sutured. A provisional bridge was cemented at the site after the surgery [Figure 1]e. [6] The patient was advised to follow routine post-operative instructions. Systemic antibiotics and analgesics were prescribed (Amoxicillin 500 mg, thrice daily for 5 days; Ibuprofen 400 mg, thrice daily for 3 days). The sutures were removed 10 days after surgery [Figure 1]f. At the post-operative recall, the surgical site demonstrated a good emergence profile and the contour was acceptable for placement of a permanent all ceramic three unit prosthesis. Patient was then recalled after 3 months, and the healing was found to be satisfactory [Figure 1]g.
Figure 1: (a) Pre-operative occlusal view showing missing maxillary first premolar with a deficient buccal ridge. (b) Two parallel incisions across edentulous area and placement of excised connective tissue graft on bone. (c) Placement of excised de-epithelialized tissue as connective tissue graft on bone. (d) Adaptation of Platelet rich fibrin membranes. (e) Graft sutured in position. (f) Post-operative occlusal view at 10 days which shows healed ridge augmentation with the prosthesis. (g) Post-operative 3 month follow-up

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   Discussion Top


In the present case, the soft tissue buccal defect was minimal (Seibert Class 1) with adequate ridge height. Literature shows that for small or moderate defects, soft tissue augmentation may be indicated, especially when an FPD is intended. [4],[5] Therefore, a soft tissue augmentation was planned for the present case. A connective tissue graft is a predictable ingredient for soft tissue augumentation, and is useful in the treatment of ridge deformities, especially in cases of mild or moderate ridge defects. [7] Prior to placement on alveolar bone, the excised tissue was de-epithelialized for improved integration with the overlying flap. Additionally, PRF membranes consisting of a matrix of autologous fibrin enmeshed with platelet and leukocyte cytokines were used to enhance the defect and healing properties. [8] This technique is advantageous as there is no need for a second surgical site to obtain the graft, and results in minimal post-operative discomfort and has an improved patient acceptance.


   Conclusion Top


Alveolar ridge modification is a pre-requisite for both the implant and/or fixed prosthesis. It improves both the gingival and the bone architecture for aesthetic and functional purposes. In this case, the ridge defect being minimal, the present technique was advantageous to both the patient and clinician, as it helped in creating the optimal aesthetics; there was a lesser time consumption, single surgical site of operation and use of patients' own blood for PRF membrane thus removing any scope for graft rejection. Thus, this technique capitalizes on minimal chances of disease transmission and expeditious healing which permits faster prosthetic rehabilitation.

 
   References Top

1.Seibert 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.  Back to cited text no. 1
    
2.Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Dent 1980;1:205-14.  Back to cited text no. 2
[PUBMED]    
3.Liu CL. Use of a Modified Ovate Pontic in Areas of Ridge Defects: A Report of Two Cases. J Esthet Restor Dent 2004;16:273-83.  Back to cited text no. 3
[PUBMED]    
4.Miller PD Jr. Periodontal plastic surgery. Curr Opin Periodontol 1993;2:136-43.  Back to cited text no. 4
    
5.Prato GP, Cairo F, Tinti C, Cortellini P, Muzzi L, Mancini EA. Prevention of Alveolar Ridge Deformities and Reconstruction of Lost Anatomy: A Review of Surgical Approaches. Int J Periodontics Restorative Dent 2004;24:434-45.  Back to cited text no. 5
[PUBMED]    
6.Toffler M, Toscano N, Holtzclaw D, Del Corso M, Dohan Ehrenfest D. Introducing Choukrouns Platelet rich Fibrin (PRF) to the Reconstructive Surgery Milieu. J Implant Adv Clin Dent 2009;1:21-32.  Back to cited text no. 6
    
7.Seibert JS, Salama H. Alveolar ridge preservation and reconstruction. Periodontol 2000 1996;11:69-84.  Back to cited text no. 7
    
8.Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:37-44.  Back to cited text no. 8
    


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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
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