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   Table of Contents    
CASE REPORT
Year : 2015  |  Volume : 19  |  Issue : 2  |  Page : 227-231  

Long palatal connective tissue rolled pedicle graft with demineralized freeze-dried bone allograft plus platelet-rich fibrin combination: A novel technique for ridge augmentation - Three case reports


Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India

Date of Submission27-Nov-2013
Date of Acceptance08-Oct-2014
Date of Web Publication23-Apr-2015

Correspondence Address:
Dr. Pathakota Krishnajaneya Reddy
Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-124X.149932

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   Abstract 

Replacement of missing maxillary anterior tooth with localized residual alveolar ridge defect is challenging, considering the high esthetic demand. Various soft and hard tissue procedures were proposed to correct alveolar ridge deformities. Novel techniques have evolved in treating these ridge defects to improve function and esthetics. In the present case reports, a novel technique using long palatal connective tissue rolled pedicle graft with demineralized freeze-dried bone allografts (DFDBAs) plus Platelet-rich fibrin (PRF) combination was proposed to correct the Class III localized anterior maxillary anterior alveolar ridge defect. The present technique resulted in predictable ridge augmentation, which can be attributed to the soft and hard tissue augmentation with a connective tissue pedicle and DFDBA plus PRF combination. This technique suggests a variation in roll technique with DFDBA plus PRF and appears to promise in gaining predictable volume in the residual ridge defect and can be considered for the treatment of moderate to severe maxillary anterior ridge defects.

Keywords: Demineralized freeze-dried bone allografts, localized residual ridge defect, roll pedicle graft platelet-rich fibrin


How to cite this article:
Reddy PK, Bolla V, Koppolu P, Srujan P. Long palatal connective tissue rolled pedicle graft with demineralized freeze-dried bone allograft plus platelet-rich fibrin combination: A novel technique for ridge augmentation - Three case reports. J Indian Soc Periodontol 2015;19:227-31

How to cite this URL:
Reddy PK, Bolla V, Koppolu P, Srujan P. Long palatal connective tissue rolled pedicle graft with demineralized freeze-dried bone allograft plus platelet-rich fibrin combination: A novel technique for ridge augmentation - Three case reports. J Indian Soc Periodontol [serial online] 2015 [cited 2021 Aug 2];19:227-31. Available from: https://www.jisponline.com/text.asp?2015/19/2/227/149932


   Introduction Top


Replacement of missing maxillary anterior tooth with residual ridge defect is challenging, considering the high esthetic demand. Esthetic outcome of fixed prosthetic denture depends on three dimensional emergence profile of the pontic design, tooth shape, and shade. Emergence profile of the pontic depends on residual alveolar ridge volume, width, and length. A detailed treatment planning is required for achievement of a predictable esthetic outcome for anterior ridge defects.

A localized residual alveolar ridge defect is characterized by deficiency of volume of bone and mucosal tissue. Seibert [1] classified the localized alveolar ridge defects into Class I, Class II and Class III based on horizontal, vertical ridge deficiency. Allen et al. [2] classified the ridge defects as mild: Depth <3 mm, moderate: Ranging from 3 mm to 6 mm and severe: >6 mm, considering the relation of depth of the deformity to the adjacent alveolar bone level.

Various soft and hard tissue procedures were proposed to correct alveolar deformities. [3] Hard tissue augmentation procedures include, autologous block grafts, bone grafts and substitutes [3],[4],[5] and guided bone regeneration. [6] The soft tissue ridge augmentation procedures include, onlay free mucosal, [7] inter positional connective tissue grafts, [8] pouch graft, [9] roll pedicle grafts [10] and modified roll pedicle grafts. [11],[12],[13]

Roll pedicle graft technique proposed by Abrams [10] comprises de-epithelization of a palatal pedicle flap and exposure of palatal bone. This pedicle is rolled under the buccal mucosa to increase the buccolingual dimension of the edentulous ridge for later fabrication of a fixed prosthesis. The flap is released by two vertical incisions extended beyond the mucogingival junction. Modified roll technique using a "trap-door" approach was proposed to cover the palatal bone, [11] in which the epithelium over the palatal connective tissue is raised and preserved to cover the palatal bone. Barone et al. [12] further modified the roll technique with intrasulcular incisions forming a full thickness "envelope" on the buccal aspect instead of the two buccal releasing incisions. Gasparini proposed L shaped incision design on palate to harvest double fold connective tissue pedicle graft to increase the buccopalatal dimensions of the ridge defect. [13]

Platelet-rich fibrin (PRF) is a second generation platelet concentrate used in conjunction with bone grafts, which offers several advantages including promoting wound healing, bone growth and density, graft stabilization, wound sealing, hemostasis and improving the handling properties of graft materials. [14],[15],[16]

The present case reports demonstrate a novel technique using modified rolled palatal pedicle connective tissue graft with demineralized freeze-dried bone allograft (DFDBA) plus PRF combination to correct the localized maxillary anterior alveolar ridge defects.


   Clinical Description Top


Three systemically healthy patients reported to the Department of Periodontology with the chief complaint of missing tooth in maxillary anterior region. Intraoral examination revealed a severe alveolar ridge deformity in relation to missing maxillary left central incisor region [Figure 1]a-e and [Table 1]. The treatment options including autologous block grafting followed by implant placement and ridge augmentation followed by fixed partial denture were explained to the patient. All the patients opted for the second procedure, and informed consent was obtained from each patient. All the patients had undergone thorough oral prophylaxis prior to the surgical procedure.
Figure 1: (a, b) Preoperative facial and occlusal view showing localized Class III ridge deformity in maxillary left central incisor region of case 1. (c) Preoperative occlusal view showing localized Class III ridge deformity in maxillary left central incisor region of case 2. (d) Preoperative occlusal view showing localized Class III ridge deformity in maxillary left central incisor region of case 3. (e) Line diagram showing localized alveolar ridge defect

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After administration of local anesthesia (2% lignocaine with 1:80,000 epinephrine), partial thickness horizontal incision was made on the palatal aspect of ridge at mesial line angle of right central incisor to mesial line angle of lateral incisor. From the horizontal incision line, an oblique incision was placed from mesial line angle of left lateral incisor to 2 nd premolar [Figure 2]a and b. Care was taken to maintain at least 3 mm distance from the gingival margin of teeth to the oblique incision. The partial thickness flap was reflected from oblique incision line to expose the underlying connective tissue [Figure 3]a and b. The palatal connective tissue pedicle graft was then outlined by giving full thickness incision along the oblique incision line, and another parallel incision was given from the mesial line angle of central incisor. These parallel incisions were joined by a horizontal incision at the apical end. Care was taken to avoid damage to the nasopalatine, and greater palatine nerves and vessels. The length of the palatal connective tissue pedicle graft was approximately 2 times more than the apico coronal length of the ridge defect [Figure 4]a and b.
Figure 2: (a) Operative view showing incision lines for harvesting palatal connective tissue pedicle graft. (b) Line diagram showing incision lines for harvesting palatal connective tissue pedicle graft

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Figure 3: (a) Operative view showing palatal connective tissue after partial thickness flap reflection. (b) Line diagram showing palatal connective tissue after partial thickness flap reflection

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Figure 4: (a) Operative view showing long palatal connective tissue pedicle graft. (b) Line diagram showing long palatal connective tissue pedicle graft

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The palatal pedicle graft was reflected coronally up to the crest of the ridge defect. From the crest of the ridge defect a partial thickness incision was made extending beyond the line angles of adjacent incisors and mucogingival junction, leaving the periosteum on the bone [Figure 4]a and b. The pedicle graft was rolled from the apical end and secured with 5-0, prolene horizontal loop suture to the labial flap [Figure 5]a.
Figure 5: (a) Operative view showing pedicle graft rolled into labial flap. (b) Placement of demineralized freeze-dried bone allografts plus Platelet-rich fibrin into ridge concavity. (c) Line diagram showing placement of bone graft into ridge concavity

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Later periosteum from crest of the defect was reflected up to vestibular fornix for the placement of DFDBA (Tata memorial, >500 to < 1040 μm) bone graft material mixed with PRF. PRF was prepared just preceding to surgery; intravenous blood from the antecubital vein was collected in a 10-ml sterile tube without anticoagulant and instantly centrifuged at 3,000 revolutions per minute for 10 min. PRF was easily separated from red corpuscles base using a sterile tweezers and scissors and then transferred onto a sterile dappen dish. PRF was mixed with DFDBA and then placed onto the ridge defect [Figure 5]b and [Figure 5]c.

Prior to placement, bleeding points were induced on the bone to enhance the blood supply. Later labial flap and palatal flap were approximated with external horizontal mattress suture; independent direct sutures were placed along the oblique incision on the palate from mesial line angle of lateral incisor to 2 nd premolar region using 5-0 prolene suture [Figure 6]a-c. Temporary ovate pontic Maryland bridge was made to create an emergence profile on the ridge, and periodontal pack was placed on the palatal aspect [Figure 7].
Figure 6: (a) Operative view showing placement of suture on the incision line palatally. (b) Operative view showing placement of external horizontal mattress suture on the labial aspect. (c) Line diagram showing placement of suture on the incision line

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Figure 7: Postoperative view showing temporary ovate pontic Maryland bridge

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The patient was prescribed 500 mg amoxicillin every 8 h for 5 days and 800 mg ibuprofen every 6 h as needed. The patient was advised to rinse using 0.12% chlorhexidine gluconate mouthwash twice daily for 3 weeks. Written and verbal postoperative instructions were given to the patient.

Clinical outcome

Healing of the augmented ridge and palatal donor sites was uneventful with no postoperative complications. The sutures were removed after 2 weeks. 2 months postoperative evaluation showed a considerable amount of ridge augmentation with soft tissue emergence profile [Figure 8]a-d and [Table 1].
Figure 8: (a, b) 2 months postoperative view showing increased ridge dimension of case 1. (c) 2 months postoperative view showing increased ridge dimension of case 2. (d) 2 months postoperative view showing increased ridge dimension of case 2

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Table 1: Preoperative and postoperative dimensions of ridge defects


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   Discussion Top


The present technique was proposed for the correction of severe maxillary anterior alveolar ridge defect by utilizing modified rolled palatal connective tissue pedicle graft and DFDBA with PRF. Abrams's roll technique employed for the correction of mild ridge defects leaves exposed palatal bone. [10] Modified roll technique, which was proposed by Scharf and Tarnow, covers the palatal bone, [11] but the tissue obtained in these techniques is sometimes minimal and not suitable for correction of moderate to severe ridge defects.

Gasparini proposed a double fold connective tissue technique, with L shaped incision given at right angle to the gingival margin of the adjacent tooth on the palate. The palatal pedicle graft achieved in this technique was more than the defect depth and double folded to the buccal flap. This technique was used for the moderate maxillary premolar ridge defects. [13]

The present technique, instead of L shaped incision an oblique incision was given from the line angle of adjacent lateral incisor up to second premolar. The oblique incision facilitates harvesting of maximum possible length of pedicle graft; the length of the pedicle should be >2 fold to the defect depth. The palatal pedicle connective tissue graft reduces the risk of graft necrosis due to its intact blood supply.

The present technique used PRF and DFDBA combination, which was earlier used for periodontal regeneration, [17] extraction socket and ridge preservation. [18],[19] PRF contains growth factors and accelerated tissue healing due to effective neovascularization, enhanced wound closing with swift tissue remodeling and bone formation. [14],[15],[16] DFDBA helps in new bone formation through osteoconductive and osteoinductive property. [17] The present technique resulted in predictable ridge augmentation, which can be probably attributed to the soft and hard tissue augmentation with a connective tissue pedicle and DFDBA plus PRF combination.


   Conclusion Top


The present technique can be considered for the treatment of moderate to severe maxillary anterior alveolar ridge defects.

 
   References Top

1.
Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part II. Prosthetic/periodontal interrelationships. Compend Contin Educ Dent 1983;4:549-62.  Back to cited text no. 1
    
2.
Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 1985;56:195-9.  Back to cited text no. 2
    
3.
Seibert JS, Salama H. Alveolar ridge preservation and reconstruction. Periodontol 2000 1996;11:69-84.  Back to cited text no. 3
    
4.
Fugazzotto PA. Report of 302 consecutive ridge augmentation procedures: Technical considerations and clinical results. Int J Oral Maxillofac Implants 1998;13:358-68.  Back to cited text no. 4
    
5.
Fiorellini JP, Nevins ML. Localized ridge augmentation/preservation. A systematic review. Ann Periodontol 2003;8:321-7.  Back to cited text no. 5
    
6.
Buser D, Dula K, Belser U, Hirt HP, Berthold H. Localized ridge augmentation using guided bone regeneration 1. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent 1993;13:29-45.  Back to cited text no. 6
    
7.
Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Dent 1983;4:437-53.  Back to cited text no. 7
    
8.
Seibert JS. Treatment of moderate localized alveolar ridge defects. Preventive and reconstructive concepts in therapy. Dent Clin North Am 1993;37:265-80.  Back to cited text no. 8
    
9.
Cohen ES. Ridge augmentation utilizing the subepithelial connective tissue graft: Case reports. Pract Periodontics Aesthet Dent 1994;6:47-53.  Back to cited text no. 9
    
10.
Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Gen Dent 1980;1:205-13.  Back to cited text no. 10
    
11.
Scharf DR, Tarnow DP. Modified roll technique for localized alveolar ridge augmentation. Int J Periodontics Restorative Dent 1992;12:415-25.  Back to cited text no. 11
    
12.
Barone R, Clauser C, Prato GP. Localized soft tissue ridge augmentation at phase 2 implant surgery: A case report. Int J Periodontics Restorative Dent 1999;19:141-5.  Back to cited text no. 12
    
13.
Gasparini DO. Double-fold connective tissue pedicle graft: A novel approach for ridge augmentation. Int J Periodontics Restorative Dent 2004;24:280-7.  Back to cited text no. 13
    
14.
Choukroun J, Adda F, Schoeffler C, Vervelle A. Une opportunité en paro-implantologie: Le PRF. Implantodontie 2001;42:55-62.  Back to cited text no. 14
    
15.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44.  Back to cited text no. 15
    
16.
Sánchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. Int J Oral Maxillofac Implants 2003;18:93-103.  Back to cited text no. 16
    
17.
Markou N, Pepelassi E, Kotsovilis S, Vrotsos I, Vavouraki H, Stamatakis HC. The use of platelet-rich plasma combined with demineralized freeze-dried bone allograft in the treatment of periodontal endosseous defects: A report of two clinical cases. J Am Dent Assoc 2010;141:967-78.  Back to cited text no. 17
    
18.
Simon BI, Gupta P, Tajbakhsh S. Quantitative evaluation of extraction socket healing following the use of autologous platelet-rich fibrin matrix in humans. Int J Periodontics Restorative Dent 2011;31:285-95.  Back to cited text no. 18
    
19.
Simon BI, Zatcoff AL, Kong JJ, O'Connell SM. Clinical and histological comparison of extraction socket healing following the use of autologous platelet-rich fibrin matrix (PRFM) to ridge preservation procedures employing demineralized freeze dried bone allograft material and membrane. Open Dent J 2009;3:92-9.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]



 

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