Aesthetic Soft-Tissue Ridge Augmentation

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.

INTRODUCTION
Alveolar bone resorption is the normal physiologic response following tooth removal.¹ Residual ridge defects present important challenges for aesthetic dentistry. Prosthetic tissue replacement has been one method of replacing tissue loss.² Alternatively, surgical soft-tissue augmentation techniques have been effective in developing soft-tissue architectures that facilitate aesthetic restorations.
     Soft-tissue ridge augmentations using palatal grafts have been thoroughly documented in the management of residual ridge deformities. “Roll” techniques,³ onlay epithelialized grafts,4 subepithelial connective tissue grafts (CTGs),^5,6 and onlay-interpositional palatal grafts7 have all been used to correct ridge defects. The anatomy of the palate, however, can introduce limitations to the ability to harvest palatal donor tissue.8 In addition, palatal donor sites have been associated with postoperative complications, including discomfort.⁹
     An acellular dermal matrix (ADM) (AlloDerm [BioHorizons]), being derived from donated human skin, does not have the limitations in availability that palatal donor tissue does. Implanted ADMs maintain their ultrastructural acellular matrix integrity and do not initiate a rejection or inflammatory response in host tissues.^10,11 ADMs have been used in a variety of medical procedures, including burn treatment.¹⁰ In dentistry, ADMs have been used for the correction of gingival recession,^12-15 bone regeneration,^16,17 and soft-tissue ridge augmentation.^18,19
     This article demonstrates how an acellular dermal matrix with a lateral pouch technique can be used to atraumatically augment an edentulous site and facilitate its aesthetic restoration. In the case presented, a residual ridge defect is augmented using an ADM. A lateral pouch technique used. The purpose of the soft-tissue ridge augmentation was to create a natural appearing soft-tissue architecture that would permit aesthetic replacement of tooth No. 5 using a fixed partial denture.

CASE REPORT
Diagnosis and Treatment Planning
A 63-year-old female nonsmoker reported with a chief concern of an unaesthetic tooth site (Figure 1). She reported that following removal of tooth No. 5, the site healed with a “deep notch in the gums.” As a result, the patient considered the pontic in this site unaesthetic and too large.
     The edentulous tooth site No. 5 was found to have a mild to moderate buccal and coronal ridge deformity. Teeth Nos. 3, 4, and 6 had already been prepared and restored with an interim acrylic fixed denture. After discussing the findings and treatment plan options with the patient, she chose to have site No. 5 treated with a soft-tissue ridge augmentation and a new fixed partial denture.

Operative and Surgical Procedure
Profound local anesthesia was achieved with 7.2 cc lidocaine (1:100,000 epinepherine). The interim fixed denture was removed and excess cement was removed from the abutment teeth (Figure 2). Using a No. 15 Bard-Parker surgical blade, a vertical incison was made on the mesial to the buccal deformity. The incision extended from the interdental papillae into the mucosa of the vestibule. Using an Orban knife, a full thickness buccal gingival pouch was raised (Figure 3). The pouch extended to the distal aspect of site No. 5 and above the crest of the residual ridge.
     The ADM was trimmed to approximately 5×5 mm and folded in half. A 4.0 chromic gut suture was secured midway in the fold (Figure 4). The needle of this suture was passed into the pouch and out through the palatal gingival. The ADM was maneuvered into a buccal coronal position within the pouch by pulling the suture through the palate (Figure 5). This suture was passed between teeth Nos. 3 and 4 then secured to the buccal gingiva. The lateral pouch opening was completely closed and secured with a continuous 4.0 chromic gut suture (Ethicon [Patterson Dental]) (Figure 6).
     The pontic of the interim fixed partial denture was adjusted to accommodate the increased volume of edentuluous site No. 5 (Figure 7). Enough space was established to permit any additional swelling. The interim fixed partial denture was re-cemented and any excess cement was meticulously removed.
Postoperative instructions included the use of 600 mg ibuprofen every 6 to 8 hours as needed for discomfort. To prevent infection, the patient was instructed to take 875 mg amoxicillin every 12 hours for 10 days. The patient rinsed with a 0.12% chlorhexadine solution (clorhexadine gluconate rinse [Peridex, OMNI Preventive Care, a 3M ESPE Company; or PerioGard, Colgate]) for 30 seconds 2 times a day for 7 days.

POSTSURGICAL APPOINTMENTS AND RESTORATIVE TREATMENT
At the one-week post-op appointment, the surgical site was found to be healing well (Figure 8). Buccal and coronal improvements in the defect were noted. Remaining sutures were removed. The patient was instructed to discontinue the rinse and begin gentle tooth brushing.
     At 8 weeks, the surgical site was found to be healing well with minimal inflammation (Figure 9). No decrease in tissue volume was noted. The patient was instructed to maintain excellent oral hygiene and return to her general dentist for the final restoration.

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.

DISCUSSION
Alveolar bone resorption and subsequent residual ridge deformities are the normal physiologic response following tooth removal.¹ 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 procedures³ 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.⁴ 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.^5,6 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.⁷ 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.⁸ Palatal anatomy, including neurovascular bundles, limits the amount of tissue that can be harvested. In addition, postoperative palatal discomfort has been reported.⁹ 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.^10,11 The collagen and elastin matrices do not initiate a rejection or inflammatory response. Healing occurs by repopulation and revascularization from adjacent tissues.^10,11 Other than the presence of elastin fibers, not generally found in gingival, the histologic appearance of ADMs and CTGs is similar.^18,20 ADMs have been successfully used in the treatment of gingival recession,^12-15 bone regeneration,^16,17 and soft-tissue ridge augmentation.^18,19
     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.^6,19 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.¹² 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.

Acknowledgment
The author would like to thank John W. Harre, DDS, for delivering the excellent final restoration.

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Dr. Mahn is a periodontist in private practice in Manassas, Va. He graduated from SUNY Stony Brook Dental School in 1990 and completed his periodontal residency at the MCV School of Dentistry in 1992. He also completed a residency on temporomandibular disorders/orofacial pain at NYU College of Dentistry in 1996. Dr. Mahn’s practice emphasizes perioplastic, regenerative, and dental implant therapies. He has several publications and has lectured on these topics. He can be reached at (703) 392-8844 or dmahn@cox.net.

Disclosure: Dr. Mahn reports no conflicts of interest.