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.

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