15 CONNECTIVE TISSUE TISSUE.pdf · 3,4MDS, Periodontics & Implantology, Reader, Babu Banarasi Das...
Transcript of 15 CONNECTIVE TISSUE TISSUE.pdf · 3,4MDS, Periodontics & Implantology, Reader, Babu Banarasi Das...
ABSTRACT : An ideal emergence profile is vital for maintaining gingival health and
developing esthetics. The ovate pontic which mimics a natural tooth gives the most appropriate
emergence profile. For a successful ovate pontic restoration, an alveolar ridge of sufficient height
and width is necessary to enhance the deficient ridge and to achieve an esthetic emergence
profile. Interpositional graft was carried out along with ovate pontic to achieve an ideal esthetic
restoration. After three months of the postoperative period, there was an increased horizontal
dimension in the deficient ridge and an esthetic emergence profile. Interpositional graft
technique is a simpler and predictable technique for pontic site development in moderate cases of
bucco-lingual ridge deficiency.
1Dr. Indu Singh, 1MDS, Periodontics & Implantology, Private Practitioner 2MDS, Periodontics & Implantology, Senior Lecturer, Babu Banarasi
Das College of Dental Sciences, Lucknow,3,4MDS, Periodontics & Implantology, Reader, Babu Banarasi
Das College of Dental Sciences,Lucknow
2 3 4Dr. Pranav Kumar Singh, Dr. Sunil Chandra Verma, Dr. Ashish Saini
INTRODUCTION : Stein and Kuwata described
“emergence profile” in 1977 as contours of tooth and crown
as they traversed through soft tissue and rose interproximally
towards the contact area and height of contour facially and
lingually.1
Two important aspects related to emergence profile are
gingival health and esthetics.
An improper creation of emergence profile creates a protected
area that is difficult to clean leading to plaque accumulation
and hence marginal inflammation whereas contralateral teeth
that have not been restored remains healthy.2 Careful
attention to developing the proper emergence profile in the
final restoration will help reduce plaque retentive areas and
will thus reduce iatrogenic inflammation. This in turn
prevents the unsightly dark spaces and triangles in the area
near the gums and between the teeth.3
A proper emergence profile becomes even more important if
the restoration is planned in anterior maxilla or if the patient
has a high smile line.
The ovate pontic has been suggested as a more accurate
duplication of emergence profile for natural teeth to provide
esthetics, the goal of which is to create an illusion that the
tooth is emerging from the gingiva with a cuff of tissue
surrounding it on the facial aspect.4
For successful ovate pontic restoration, alveolar ridge of
sufficient height and width is a pre-requisite, which is in terms
of interproximal height, free gingival margin and facial
prominence. Augmentation of any of the deficiencies is
needed to accommodate the pontic.5
This case report describes two cases of deficient alveolar
ridge being augmented by interpositional connective tissue
graft and finally restored by ovate pontic.
Case Report 1- A 50 year old female patient reported to the
Department of Periodontics with the chief complaint of
mobile upper front teeth. Intra-oral examination revealed
grade II mobile 12, with root canal treated 12, 11, 21, 22 and
deep bite (Fig. 1). Cone beam C.T. scan revealed horizontal
fracture at the cervical third of the root with respect to 12 (Fig.
2), making the endodontic prognosis poor. CBCT also
revealed absence of buccal bony wall upto the apical third of
the root and also a large periapical radiolucency, so it was
decided to place an ovate pontic immediately following
extraction. Meanwhile, the patient fractured her tooth and
visited a private dentist for restoration of the same. Unhappy
with the restoration she visited us again, on examination the
pontic was sitting onto the ridge with collapse of the ridge
CONNECTIVE TISSUE GRAFT FOR ESTHETIC MANAGEMENT OF RESORBED RIDGE IN ANTERIOR MAXILLA- A CASE REPORT
Key Words :
Emergence profile,
interpositional graft
technique, ovate pontic
Source of support : Nil
Conflict of interest: Non
Journal of Dental Sciences
University
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 71
University J Dent Scie 2017; No. 3, Vol. 2
Case Report
bucco-palatally (Fig. 3 & 4). So to increase the bucco-palatal
dimensions and for pontic site development an interpositional
graft procedure was planned. Horizontal incision not
extending till the adjacent papillae was placed slightly buccal
to the crest of the ridge and an supra-periosteal pouch was
created (Fig. 5), connective tissue graft was harvested from
palate using trap-door technique (Fig. 6) and was transferred
into the buccal pouch and sutured using 6-0 polypropylene
suture (Fig. 7). Immediate provisionalisation was done using
patients lateral incisor which was fractured using a wire splint
(Fig. 8). Post-operatively there was an increased bucco-
palatal width of the ridge and a cuff of tissue was seen for
ovate pontic (Fig. 9, 10). 3 months later this provisional
restoration was replaced by a three-unit fixed partial denture
with a cantilevered 22(Fig. 11).
Fig. 1. Pre-operative
Fig. 2. CBCT depicting buccal dehiscence, horizontal root
fracture and a large periapical radiolucency
Fig. 3. Buccal view of the cantilevered restoration placed
immediately after crown fracture and root extraction at a
private clinic
Fig. 4. Incisal view, depicting a bucco-palatal loss of ridge
Fig. 5. Supra-periosteal pouch created
Fig. 6. Trap door technique for graft harvesting
Fig. 7 Graft pouched into the buccal pouch created
Fig. 8. Immediate provisionalisation using wire splint
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 72
University J Dent Scie 2017; No. 3, Vol. 2
Fig. 9 Incisal view to depict the increased dimension of the
ridge
Fig. 10. Ovate Pontic site
Fig. 11 Final Prosthesis
DISCUSSION : Preserving interproximal soft tissues and
avoidance of alveolar bone collapse following tooth
extraction still remains a challenging situation. It is prudent to
preserve the socket size, shape and the gingival tissue height,
with provisionalisation with a pontic that supports the
gingival contours and eliminates the “black triangle.”6
Various soft tissue procedures for improving ridge
deformities are available. Free gingival onlay graft was
advocated by Seibert to enhance ridge height and replace
traumatized tissue.7 Although easier in technique, it has its
own disadvantages, including post-operative necrosis in case
of inadequate blood supply, unpredictable shrinkage of grafts,
and unaesthetic appearance.8
Later Langer and Calagna described subepithelial connective
tissue graft to preserve tissue color and the texture of the
underlying mucosa, resulting in better esthetics.9 Thoma in
his review suggested that subepithelial connective tissue
grafts provided greater soft tissue volume than free gingival
grafts, also due to increased vascularity there are decreased
chances of necrosis. However, need for second surgical site,
and unpredictable shrinkage are the disadvantages.10
Ovate pontic along with soft tissue procedure was used to
mimic the emergence profile. The advantage of ovate pontic
is to achieve maximum esthetics alongwith positive tissue
contact.4 However, sufficient faciolingual width and
apicocoronal thickness are required for housing the ovate
pontic. Hence, additional surgical procedures are frequently
required to augment the edentulous ridge. The ovate pontic of
the provisional FPD should be adjusted in light contact with
underlying soft tissue following surgical augmentation.
Regular follow up appointments must be scheduled to adjust
the interim FPD and guide the soft tissue to an ideal contour.5
REFERENCES :
1. Stein RS, Kuwata M. A dentist and a dental technologist
analyze current ceramo-metal procedures. Dent Clin N
Amer 1977;21:729-49.
2. Parkinson CF. Excessive crown contours facilitate
endemic plaque nichess. J Prosthet Dent 1976;35:424-
429.
3. Yuodelis RA, Weaver JD, Sapkos S. Facial and lingual
contours of artificial complete crown restorations and
their effects on the periodontium. J Prosthet Dent
1972;29:61-66.
4. Abrams L. Augmentation of the deformed residual
edentulous ridge for fixed prosthesis. Compend Contin
Educ Gen Dent 1980;1:205-13.
5. Garber DA, Rosenberg ES. The edentulous ridge in fixed
prosthodontics. Compend Contin Educ Dent
1981;2:212-23.
6. Mhatre S, Gala A, Ram SM, Shah N. Modified Ovate
Pontic Design for Immediate Anterior Tooth
Replacement. J Contemp Dent 2012;2:64-68.
7. Seibert JS, Reconstruction of deformed, partially
edentulous ridges, using full-thickness onloy grafts. Part
II. Prosthetic/ periodontal interrelationships. Compend
Cont Ed Gen Dent 1983;4:549-62.
8. Langer B, Langer L. Subepithelial connective tissue graft
technique for root coverage. J Periodontol 1985;66:715-20.
9. Langer B, Calagna L. the subepithelial connective tissue
graft. J Prosthet Dent 1980;44:363-7.
10. Thoma DS, Benic GI, Zwahlen M, Hammerle CH, Jung
RE. A systematic review assessing soft tissue
augmentation techniques. Clin Oral Implants Res
2009;20 Suppl 4:146-65.
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 73
University J Dent Scie 2017; No. 3, Vol. 2