Aesthetic Soft-Tissue Ridge Augmentation

[drsushant]

 

Figure 1. Preoperative view shows the interim bridge with a large pontic in site No. 5. The buccal and crestal deformity of site No. 5 was evident.

Figure 2. With interim bridge removed, inflamed soft-tissue and ridge deformities could be seen.

Figure 3. Clinical view of vertical incision opening to lateral pouch.

Figure 4. Acellular dermal matrix (ADM) was sutured in a manner that facilitated its placement into the lateral pouch.

Figure 5. ADM was secured within the lateral pouch. Figure 6. With vertical incision sutured closed, expansion of the deformity buccally and crestally was evident. Figure 7. The old fixed partial denture was recemented as an interim prothesis. The pontic was adjusted to accommodate the increased ridge volume. Figure 8. Following one week of healing, the site was healing with increased volume in both buccal and crestal dimensions. Figure 9. Following about 8 weeks of healing, the site was healing well and maintaining its expanded volume. Figure 10. Approximately one year following surgery, the soft-tissue architecture appeared stable and natural in appearance. Site No. 5 was restored with a pontic that was appropriate in size and shape.

        

[drsushant]

 DISCUSSION

Alveolar bone resorption and subsequent residual ridge deformities are the normal physiologic response following tooth removal. In response to this aesthetic problem, several soft-tissue ridge augmentation techniques have been developed to reestablish a natural appearing soft-tissue architecture.
     The “Roll” and similar procedures use a de-epithelialized palatal connective tissue pedicle graft that is contiguous with the buccal gingiva. The palatal tissue is rolled and tucked into a buccal gingival pouch. The results of this treatment can be aesthetic, but the technique can be difficult to perform because the donor tissue must come from palatal tissue adjacent to the recipient site. This donor site may not be satisfactory due to anatomic considerations and finite tissue thickness.
     Onlay epithelialized palatal grafts maintain their epithelium over the connective tissue. The graft is secured with its connective tissue base in contact with the de-epithelialized recipient site. Significant residual ridge defects can be corrected with this technique. Color blending with adjacent tissues can be a problem due to color differences between palatal and gingival tissues. 
     Subepithelial connective tissue grafting techniques correct residual ridge deformities by placing palatal connective tissue below the mucogingival flap. Unlike onlay epithelialized palatal grafts, tissue color blending is not a problem. In addition, palatal donor sites for connective tissue grafting have been associated with less discomfort than for free gingival grafts. 
     Onlay-interpositional grafts attempt to maximize the benefits of onlay epithelialized palatal grafts and subepithelialized CGTs. The epithelial layer is not removed from the superficial border of the connective tissue graft. This graft is secured below the mucogingival flap, leaving its epithelium exposed. This technique can correct residual ridge deformities, expand the zone of keratinized gingiva, and minimize tissue color blending problems.
     While all the techniques described have been shown to be successful, they are also limited by palatal considerations. Palatal anatomy, including neurovascular bundles, limits the amount of tissue that can be harvested. In addition, postoperative palatal discomfort has been reported. This can be an obstacle to treatment, especially if multiple procedures are required. 
     ADMs free the clinician from the limitations of palatal donor tissue. ADM does not have fatty tissue, epithelium, or ragged borders that may need to be trimmed. They are provided with a uniform thickness of 0.89 to 1.54 mm. ADM can be rolled upon itself to increase its thickness. The collagen and elastin matrices do not initiate a rejection or inflammatory response. Healing occurs by repopulation and revascularization from adjacent tissues.Other than the presence of elastin fibers, not generally found in gingival, the histologic appearance of ADMs and CTGs is similar. ADMs have been successfully used in the treatment of gingival recession, bone regeneration, and soft-tissue ridge augmentation.
     In the case presented, it was determined that folding the ADM only once was sufficient to correct the defect. A lateral pouch technique was used to access the ridge defect. A suture attached to the mid-portion of the ADM helped maintain the graft’s fold and positioning within the lateral pouch. The ADM was folded with the matrix surface facing outward to facilitate revascularization. ADM orientation has been shown not to be required, however. The ADM was pulled into a buccal position along the crest of the residual ridge and secured with the suture. This graft position was designed to improve both the buccal and crestal dimensions of the ridge. A second suture was used to close the vertical incision with primary closure. Following approximately 8 weeks of healing, sufficient healing and improvement in the ridge was determined to permit referral back to the restorative dentist. 
     At approximately 12 months following surgery and 9 months following restoration, the treatment site was found to be full, healthy, and stable (Figure 10). Teeth Nos. 3 to 6 were restored with a fixed partial denture having a pontic in site No. 5. The newly established soft-tissue architecture permitted the restoration to be highly aesthetic and natural in appearance. Edentulous site No. 5 appeared to be full and harmonious with adjacent sites. As a result, the fixed partial denture, including the pontic in site No. 5, had a natural and aesthetic appearance.

CONCLUSION
This article demonstrates the treatment of an unaesthetic ridge deformity using ADM. The folded ADM provided adequate volume to establish a natural appearing soft-tissue architecture. The lateral pouch technique facilitated the ease of graft placement and aesthetic results.

        

[Anonymous]

 

Allografts

The soft-tissue allograft procedure is performed to create or augment the gingiva, with or without root coverage. This may be used to eliminate the pull of the frena and muscle attachments, to extend the vestibular fornix, and correct localized gingival recession. There is no donor site.      The additional material (graft) is coming from someone, or somewhere, other than the patient (when there is no donor site available). The procedure is billed per site and is to be specified on the claim. Submit this procedure with a preoperative diagnostic photo, as the radiograph is useless in confirming the need since we are talking about a soft-tissue issue. The payer may well request a radio­graph in order to rule out additional benefits being paid for continued treatment of an osseous defect. This procedure should never be used to address any type of hard-tissue condition. The photo is the key. The material used should always be specified in both the clinical notes as well as claim (one in the same), but it is not billed separately. This is an all-inclusive procedure.

        

[Drsumitra]

Deformities in the upper or lower jaw can leave you with inadequate bone in which to place dental implants. This defect may have been caused by healing following extraction, periodontal disease, wearing dentures, developmental defects, injury or trauma. Not only does this deformity cause problems in placing the implant, it can also cause an unattractive indentation in the jaw line near the implant restoration that may be difficult to clean and maintain.

To correct the problem, the gum is lifted away from the ridge to expose the bony defect. The defect is then filled with bone, or bone substitute, to build up the ridge. Dr. Gouldin will explain the graft options prior to the procedure. The graft options are based on the extent and location of the defect. Once the graft is secure and contained, the incision is closed and healing is allowed to take place. Depending on your individual needs, the bone will usually be allowed to develop for about four to six months before implants are placed. In some cases, the implants can be placed at the same time the ridge is modified.

The patient shown below had an abscess on her upper left central incisor which destroyed the entire "cheek-side" wall of bone. Dr. Gouldin performed extraction and subsequent hard tissue ridge augmentation with a procedure known as block grafting to allow enough new bone formation for implant placement. After Dr. Gouldin placed the implant, the restoring dentist placed 2 new crowns, one on the natural tooth, and one on the implant. Can you tell which crown is supported by the implant?

 

        

[Author]

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