Interdisciplinary approach to enhance the esthetics of maxillary anterior region using soft- and hard-tissue ridge augmentation in conjunction with a fixed partial prosthesis.

Favorable esthetics is one of the most important treatment outcomes in dentistry, and to achieve this, interdisciplinary approaches are often required. Ridge deficiencies can be corrected for both, soft- and hard-tissue discrepancies. To overcome such defects, not only a variety of prosthetic options are at our disposal but also several periodontal plastic surgical techniques are available as well. Various techniques have been described and revised, over the year to correct ridge defects. For enhancing soft-tissue contours in the anterior region, the subepithelial connective tissue graft is the treatment of choice. A combination of alloplastic bone graft in adjunct to connective tissue graft optimizes ridge augmentation and minimizes defects. The present case report describes the use of vascular interpositional connective tissue graft in combination with alloplastic bone graft for correction of Seibert's Class III ridge deficiency followed by a fixed partial prosthesis to achieve a better esthetic outcome.

INTRODUCTION

In today's world, patient demands for optimum functional and esthetic prosthetic restorations have increased. Therefore, replacement of teeth in esthetically demanding areas such as the maxillary anterior region not only requires restorations and prosthesis of correct form and shade but also establishment of natural appearance of the surrounding periodontal tissues and the pink esthetic. One of the major problems faced by prosthodontists is inadequacy of alveolar ridges or deformed ridges. Inadequate ridge contours are a common outcome following the loss of teeth, traumatic teeth removal, severe periodontal disease, endodontic failure, implant failure, traumatic accidents, and developmental defects.[1] Morphologically, Seibert classified the alveolar ridge defects into three groups (1983).[2] Later, Allen introduced a classification with subgroups to indicate the severity of alteration in millimeters.[3]

To overcome the problem of alveolar ridge deficiency either pontic teeth can be made too long or pink ceramics can be added. There is a possibility that such modifications might lead to unesthetic appearance and also food and plaque retention, which further would lead to inflammation followed by periodontal disease. It may also lead to unesthetic open gingival embrasures (black triangles) and cause phonetic, masticatory, and oral hygiene difficulties.[4] Therefore, surgical correction of the ridge deficiencies is necessary not only for the correction of esthetic problems but also for optimum functioning of prosthesis.

Vascular interpositioned connective tissue (VIP-CT) flap was introduced by Sclar in 2003; it is an anteriorly based pediculated tissue of palatal submucosa that is composed of periosteum and connective tissue allied for ridge augmentation.[5] The advantages of the VIP-CT graft technique is that it allows reconstruction of large soft-tissue deficiency, with less constriction postoperatively. Furthermore, it facilitates improved hard-tissue augmentation due to additional blood supply and improved healing. Furthermore, this flap minimizes the risk of reduction of attached gingiva which is secondary to ridge augmentation procedures.

In major ridge defects such as Sibert's Class III mild subtype C, soft-tissue augmentation alone does not satisfactorily fill the ridge defect; hence, hard-tissue augmentation in the form of alloplastic bone graft in conjunction with soft-tissue grafting should be the treatment of choice. The following clinical report describes a soft-tissue and hard-tissue ridge augmentation technique for correction of maxillary anterior ridge defect by using the VIP-CT graft along with alloplastic bone graft, followed by prosthetic rehabilitation, to achieve maximum esthetic outcome.

CASE REPORT

A 45-year-old male patient was referred to the Department of Periodontology from Department of Prosthodontics, Government College of Dentistry, Indore, for correction of a ridge defect in maxillary right anterior region so that prosthetic rehabilitation can be planned in harmony with surrounding soft tissues, which is ideal. The patient did not have any positive relevant medical history. The dental history revealed that his maxillary right central and lateral incisor teeth had mobility due to trauma and road traffic accident and were extracted three to 4 months prior. The alveolar ridge defect was a Siebert's Class III, Allen's mild Type C, between maxillary right canine and maxillary left central incisor [Figure 1]. After thorough evaluation of the history, clinical condition, and radiological investigations, surgical correction of the defect area by VIP-CT graft, harvested from the palate, in combination with alloplastic (hydroxyapatite and β tricalcium phosphate) bone graft was planned since hydroxyl appetite is a slow-resorbing alloplastic bone graft material; it will help in maintaining the volume of defect fill. Surgical options were discussed and explained to the patient, and written consent was obtained for the same, before the treatment.

Figure 1

Intraoral preoperative view showing Seibert's Class III defect

Surgical procedure

Following a presurgical rinse with chlorhexidine and administration of local anesthesia (2% lidocaine with 1:100,000 epinephrine), a labial full-thickness flap was elevated by giving crestal incision extending from maxillary right canine to maxillary left central incisor followed by two vertical releasing incisions, and the ridge defect was exposed [Figure 2a]. A VIP-CT pedicled graft was harvested from the palate [Figure 2b]. The surgical outline for VIP-CT graft is given in Figure 3.[6] After thorough debridement of the bony defect and removal of all the granulation tissue present, alloplastic bone graft (Sybograft-plus [Eucare Pharmaceuticals(p) Limited, Chennai, India]) (hydroxyapatite and β tricalcium phosphate) was condensed into the defect using a graft carrier, thus increasing the width in the buccal palatal aspect [Figure 4a]. The VIP-CT graft which was harvested at the beginning of the procedure was then placed and sutured [Figure 4b] over the bone graft, to increase the width as well as the apicocoronal height of the ridge. The flap was sutured back with 3–0 silk suture [Figure 4c].

Figure 2

(a) A labial full-thickness flap was elevated; (b) Vascular interpositional connective tissue pedicled graft

Figure 3

Surgical outline for harvesting vascular interpositional connective tissue pedicled graft

Figure 4

(a) Placement of bone graft in defect; (b) vascular interpositioned connective tissue graft was placed and sutured; (c) the flap was sutured back with 3-0 silk suture

The patient was instructed for daily chlorhexidine mouth rinsing, and 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 after 10 days [Figure 5], and the patient was recalled for follow-up every month. The final fixed prosthesis was cemented after 6 months once adequate soft- and hard-tissue healing of the defect, leading to improved esthetics of the patient [Figure 6], was seen. The patient was recalled after 3 months and 6 months for regular follow-ups [Figure 7a and b].

Figure 5

Postoperative view after 10 days

Figure 6

Immediate after porcelain fused to metal restoration with 13 12 11 21

Figure 7

Postoperative view (a) after 3 months, (b) after 6 months

DISCUSSION

Ridge deformities secondary to trauma are frequently encountered by dentists and can affect the overall esthetic and the restorative outcome of planned treatments. Although autogenous bone grafts (as block or particulate form) remain the gold standard for ridge augmentation, donor site morbidity and the need for second surgery associated with block graft harvest have turned attention toward the use of alloplastic graft materials. Connective tissue and onlay grafts have been the most frequently used procedures for Type II and III Seibert's ridge deformities. However, the onlay graft proposes certain drawbacks and limitations, including postoperative necrosis and unpredictable shrinkage of the graft. Subepithelial connective tissue graft is still considered the gold standard.[7] In severe ridge defects, the combined use of an alloplastic bone graft and connective tissue graft provides additional augmentation not achievable with either of the procedures alone. Simultaneous hard- and soft-tissue augmentation is possible by the use of VIP-CT graft concomitant with bone grafting. VIP-CT being a pedicled graft protects the underlying bone graft, nourishes it, and simultaneously vertically augments the region. It also preserves the color and characteristics of overlying mucosa resulting in a better esthetic blend, especially in a potentially highly visible area. VIP-CT graft eliminates the need for membrane and reduces the cost, along with improving the histology of ridge crest.[8] Therefore, it is a reliable method for reconstruction. Previous techniques used for the ridge augmentation procedure were associated with less gain in volume, as the graft size was limited; furthermore, the use of large onlay grafts may results in lack of blood supply leading to necrosis.[910] In case of larger graft changes of necrosis is more and also leads to more of an injury to the donor site.[11] A full thickness onlaygraft can be harvested to a limit therefore, larger defect cannot be treated with a full thickness onlay graft. VIP-CT graft favors less injury to the donor site and a good amount of graft size.

CONCLUSION

This clinical report suggests that soft-tissue augmentation with VIP-CT graft from the palate in combination with an alloplastic bone graft is a viable and predictable treatment procedure to provide an ideal gingival contour and soft-tissue profile, thereby precluding the need for modifications or compromises in the final prosthesis, and thus enhance the overall result.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.