56 dentaltown.comMay 2005

Periodonticstowntownie clinical

Sub-Pontic CTG Under Maryland FPD

This patient, an attractive female in her 30s, has a long-standing Maryland bridgeand cannot afford a new one. She came to my office with a black hole in her bridgeand a high smile line.

Figure 1: Initial presentation. Patient is packing food under her bridge and she displays ahole here.

Figure 2: Tunneling procedure under bridge using a 12-blade and curettes.

Figure 3: Note probe under flap, splitdissection.

Figure 4: CTG without epithelium.

Figure 5: Case sutured with 5-0Monocryl externally and 5-0 Gut inter-nally. Coronally-advanced flap with sling sutures.

Figure 6: External bevel of frenal attach-ment to help prevent collapse.

Figure 7: Wide-zoom photo.

Figure 8: 3 or 4-month occlusal viewshowing facial gain of tissue.

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Periodontist, Scott Erikson As posted on the Case Presentation section of www.dentaltown.com, followed by Townie Comments

Figure 9: Another final photo. I believe these photos are only 4-months out, so tissue erythema should improve with time and maturity, as blood vessels mature. Of course, a new bridge would be the ideal or an implant. Not with this patient, however.

Conclusion: Surgery was relatively easy and the cost to the patient was a little morethan half the cost of a new bridge. I went back and injected local steroids (Decadron)to help reduce scarring and asked the dentist to consider incisal adjustment of pontic,but I am not sure how the case looks now. Hopefully it looks better.

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bevans1 | Brian | Total Posts: 183 | Posted 2/5/2005 1:19:16 PM Two questions: 1. Have you used AlloDerm for this type of procedure? And if so, would you do it any different? 2. How long do you expect this esthetic result to remain? I’m curious of your thoughts.

serikson | Scott | Total Posts: 67 | Posted 2/5/2005 2:13:04 PM Brian, I have used AlloDerm but hate it. Never seem to get the bulk I need. Always use CTGs and

sometimes bone under these cases for esthetic augmentation. About 25% resorption/shrinkage rate after thefirst 6-8 weeks unless you or Hack2 have better info than I do. Whatever is left over should remain almostindefinitely as it would in non-grafted sites.

Tom Bailey | Total Posts: 85 | Posted 2/5/2005 6:29:11 PM My questions: Are you a periodontist or a restorative dentist? Why is she selecting an esthetic result that

is an obvious compromise to that which could be available to her? Are you preparing her for a futureimplant? Is she your wife? Nice looking tissue––Same poor color, same long tooth. Same occlusal wear onthe adjacent cuspid. Nice solution to the collapsing tissue, but where do you think the tissue will be in acouple of years?

serikson | Scott | Total Posts: 67 | Posted 2/5/2005 9:33:15 PM Tom, I am a periodontist and sometimes you get what you get. The point of the case is that you can

gain soft-tissue under things that are not the best and make them better. The ideal treatment plan is a verysimple one: do a new bridge with shorter incisal length, longer gingival one and better color match.However, she did not want this and we had to treat based on her desires. I feel your pain.

jmaya | Total Posts: 3278 | Posted 2/6/2005 6:06:16 AM This is one of those cases where I cringe just before the initial incision, but you made it work nicely. If it looks

like this at 4 months, little change should occur. I like the way you approached the case and the flap design.While I agree that pontic sectioning and an implant would have resolved the matter (maybe nicer?) at

least you resolved the problem at this time. Your phrase “you get what you get.” Interestingly only periodontists qualify for it. When a GP says that,

everyone questions why the pt wasn’t referred to the periodontist. One may laugh, but it’s true.

bevans1 | Brian | Total Posts: 183 | Posted 2/6/2005 11:34:22 AMScott, just wanted to add I think you handled this the right way. The patient was given options and

chose to have, in most of our minds here on Dentaltown.com, the less optimum esthetic choice. It’s a goodexample of us, as clinicians, always wanting to give the patient the best treatment that will ultimately lookthe best in our minds. What’s really important is meeting the patient’s chief complaint and expectations andyou did it beautifully here.

About AlloDerm, I’ve been to several Pat Allen courses and we used it a lot in residency. One of the rea-sons I brought it up is the plastic surgeons use it a lot for lip augmentation. Same concept as treatment inyour case. I used it once in a case like yours and didn’t observe any clinical difference in shrinkage asopposed to cases where I used CTG. But that’s just a clinical impression. I’ve also used many times for rootcoverage, but as you know, the challenge is completely covering and no real increase in KG width, just thick-ness. The area I’ve used more than any is GBR and ridge aug. Instead of aggressive periosteal release to getprimary closure over other membranes, with AlloDerm, I purposely leave exposed and have gotten goodresults. Yes, it turns white and smells awful, but as long as patients know this does not mean their mouth isrotting away, they haven’t had a problem with acceptance. Sorry to get off on a tangent, I just thought itwould be a good topic of discussion.

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Townie Comments as posted on the Dentaltown Case Presentation section:www.dentaltown.com/gold/case.asp?id=2540

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danmelker | Danny | Total Posts: 1535 | Posted 2/6/2005 1:55:09 PM Serikson, great case for what you and the patient wanted to accomplish! Beautiful improvement. Do you

do any root reshaping? I think you would love it with the skills you have. Helps to remove a lot of problemswith the root. Thanks for the great cases.

serikson | Scott | Total Posts: 67 | Posted 2/6/2005 4:40:18 PM Thanks everyone for your feedback. I thought this was a neat case to post. I tunneled under the mid-cre-

stal portion using a Buser elevator, and yes, I did actually release the flap palatally, probably blunt releasehere. Stopped just past the crest I think. Sutured one layer of the graft internally to the facial and crestalportion and then advanced the entire unit occlusally, while at the same time doubling the graft inside itselfonce one of its layers was sutured to the flap and the space was created.

Hey Brian, interesting points you make. So how would you use the AlloDerm here? Would you createsome sort of similar flap and then roll the sheet internally to create the bulk needed? I guess AlloDerm isgreat, but in my humble experience, takes more time to soak the stuff than it does to harvest the graft,which usually takes so little time in all of our hands. I simply feel better with autografted tissue assumingthat the bulk needed is not extensive to cause more harm than good. Maybe I’ll try it, but unsure about thecellular turnover and resorption with it.

bevans1 | Brian | Total Posts: 183 | Posted 2/7/2005 7:53:55 AMScott, yes, I would use AlloDerm in the same way you used CTG here. Just fold the AlloDerm to the

thickness desired. As far as cellular turnover, AlloDerm has no cells. It’s actually an acellular skin allograft that serves as a

matrix for recipient cells. With exposure, this stuff definitely resorbs and boy does it smell. Looks like afailed CTG. That’s why it’s advocated to keep it covered. I just learned in residency that leaving it partiallyexposed as a biologic barrier for ridge aug eliminates excessive periosteal release and flap tension when tryingto achieve primary closure. In my hands using it this way, I’ve gotten good results.

danmelker | Danny | Total Posts: 1535 | Posted 2/7/2005 10:23:43 AM Have you ever looked at AlloDerm down the road. Many times you do not even know a procedure was

undertaken. I have redone quite a few for patients who saw no difference. We have a periodontist in our areawho is afraid of the palate and only uses AlloDerm. I keep redoing procedures he did. Personally, I hate thestuff and use it only when the patient does not [have] palatal tissue to use. Just a personal opinion.

bevans1 | Brian | Total Posts: 183 | Posted 2/7/2005 5:52:41 PM Danny, thanks for the input. I usually do not use [it] for root coverage procedures for the same reasons—

when given choice of CTG vs AlloDerm for root coverage, I choose CTG every time. AlloDerm is a very ver-satile material we have at our disposal with advantages of on donor site; but definitely technique sensitive.

Scott Erikson graduated from dental school at the University of North Carolina–Chapel Hill in 1996; hereceived his MS in oral biology/certificate in Periodontics at the University of North Carolina in 1999 and waschief resident. Since his graduation in periodontics, Dr. Erikson has been a practicing periodontist in High Point,NC. He is currently president of the Guilford County Dental Society, vice-president of Lexington County DentalSociety, an active member of North Carolina Society Of Periodontists, American Academy of Periodontology,American Dental Association, and the Southern Academy of Periodontics. Dr. Erikson’s interests include implant

and advanced bone reconstruction, as well as soft-tissue and esthetic surgery.