Case Report DOI: 10.

17354/cr/2015/62

Supplement the Base to Complement the Crown:

Localized Ridge Augmentation using Connective
Tissue Graft
Hemini Shah1, Mala Dixit Baburaj2
Post-graduate Student, Department of Periodontics, Nair Hospital Dental College, Mumbai, Maharashtra, India, 2Head & Professor, Department of
1

Periodontics, Nair Hospital Dental College, Mumbai, Maharashtra, India

Interdisciplinary approach should be contemplated as a long term solution for esthetic and functional dental rehabilitation of patients. To
obtain longevity of treatment, the therapeutic decisions must be based on a strong periodontal foundation. To prevent unacceptable esthetic
deformities due to lost oral tissues, a plethora of treatment modalities are available, to augment the alveolar ridge, and to improve the esthetic
outcome of the final prosthesis. Prior to the replacement of missing teeth, esthetic, and physiologic corrections of edentulous areas are critical
pre‑requisites. This article describes a surgical procedure to enhance a localized buccal ridge defect and create an emergence profile in relation
to the maxillary left central incisor region, prior to the construction of a fixed partial denture using a connective tissue graft.

Keywords: Connective tissue graft, Localized alveolar ridge defect, Ridge augmentation

INTRODUCTION gingival texture results if localized ridge defect is restored

with a long, oversized unesthetic restoration. There is a high
Soft tissue esthetics is a concern not only related to smile incidence of residual ridge deformity following anterior
design, but also to missing gingival tissues around a tooth tooth loss either due to traumatic teeth removal, severe
or beneath a fixed prosthesis. A  complete esthetic is a periodontal diseases, endodontic failure, implant failure,
proper blend of white as well as pink esthetics. Sound traumatic accidents, and developmental defects.1 The ridge
prosthetic rehabilitation requires a good, hard, and soft deformity is directly related with the volume of the root
tissue foundation for success. Localized ridge defects pose structure and associated bone that is missing or has been
a major problem in both esthetics and functionality of a destroyed.2
prosthesis. Localized alveolar ridge defect refers to the
volumetric deficit of the limited extent of the bone and Seibert (1983)3 classified the various types of ridge loss into
soft tissue within the alveolar process. Restoration of these three classes:
localized ridge defect is a challenging task for the clinician. Class I: Buccolingual loss of tissue with normal ridge height
in the apico-coronal dimension.
Restoration of deformed collapsed edentulous ridge with a Class II: Apico-coronal loss of tissue with normal ridge
fixed prosthesis results in a number of problems. Esthetic, width in a buccolingual dimension.
hygiene, and functional compromises such as “black Class III: Combination buccolingual and apico-coronal loss
triangles” interdentally, loss of buccal/facial contour, an of tissue, resulting in loss of normal height and width.
unesthetic thick pontic made to compensate the horizontal
ridge defect, food impaction in the open interdental spaces A ridge defect can be compensated for with a variety of
under the pontic, difficulty in speech, and unesthetic prosthetic approaches such as modified tooth coloured
pontic, pontic with a gingival-shaded cervical portion or
Access this article online removable flexible tooth “mask” made of flexible silicone.
However, such prosthetic corrections always compromise
Month of Submission : 02-2015 esthetics and make oral hygiene more difficult.
Month of Peer Review : 03-2015
Month of Acceptance : 03-2015 Various grafting procedures have been developed for
Month of Publishing : 04-2015
the reconstruction of a deformed ridge that provides a
www.ijsscr.com
functional, long-term improved esthetics for prosthesis. Soft

Corresponding Author:
Dr. Hemini Shah, 705/F, Agarwal Residency, Nr, Shankar Park, Shankar Gali, Kandivali (West), Mumbai - 400 067, Maharashtra, India.
Phone: +91 7738303818. E-mail: [email protected]

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 Shah and Baburaj: Localized Ridge Augmentation using Connective Tissue Graft

tissue autografts such as pedicle roll flap or subepithelial about 3 mm and 6 mm from gingival margin using a no.15
connective tissue graft in the form of pouch, interpositional scalpel blade. A wedge of the connective tissue of adequate
or onlay graft, and hard tissue grafts such as guided bone thickness was harvested by extending partial thickness
regeneration can be used for localized ridge augmentation.

This case report describes the treatment of a localized ridge

defect using autogenous subepithelial connective tissue
graft in the anterior maxillary region to achieve optimal
esthetics maintaining periodontal health.

CASE REPORT

A 32 year male patient reported to the Department of

Prosthodontics, Nair Hospital Dental College for replacement
of his upper front left missing teeth. Patient’s dental history
revealed that his maxillary left central incisor was extracted
before the 1-year following trauma. Intraoral examination
revealed missing left central incisor with Seibert’s Class I
alveolar ridge defect (Figure 1). The bucco-palatal loss of tissue
Figure 1: Pre-operative view of missing maxillary left central incisor with Siebert
was more pronounced which may cause food impaction in Class I ridge defect
future if it was restored with fixed partial denture. Moreover,
esthetics would also have been compromised due to long
pontic and lack of emergence profile. To provide a fixed
prosthesis without any functional or esthetic compromise,
the patient was referred to the Department of Periodontics
for localized ridge augmentation.

All restorative and surgical options were thoroughly

explained to the patient. After thorough discussion, it was
decided to correct the ridge contour using autogenous
connective tissue graft harvested from the palate.
A provisional restoration was made prior to surgery. The
shape of the teeth, an axial inclination, emergence profile,
and embrasure form for the provisional restoration was
made exact to the prototype of final prosthesis (Figure 2).
The provisional prosthesis was used to help in shaping the
outline of augmented ridge to desired form during healing. Figure 2: Provisional restoration fabricated as per final prosthesis to be delivered
shows the amount of ridge deficiency
Informed consent of the patient was obtained.

Immediately prior to the surgical procedure the patient

was instructed to rinse for 30 s with 0.2% chlorhexidine
gluconate solution. The area subjected to surgery was
anesthetized by nerve block and infiltration anesthesia
using local anesthetic solution 2% xylocaine with 1:100,000
epinephrine. The connective tissue graft was harvested
from palate from maxillary right premolar and molar
region. The length of the graft was in accordance to
the length required at the recipient site measured by a
template (Figure 3).

The surgical protocol was adopted from the method

of Langer and Calagna 4 who described subepithelial
connective tissue graft using “trap door” technique. Two
parallel partial thickness horizontal incisions were made Figure 3: Template used to harvest connective tissue graft from the palate

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 Shah and Baburaj: Localized Ridge Augmentation using Connective Tissue Graft

incisions apically. Two vertical releasing incisions were chlorhexidine gluconate mouth rinse. Patient was recalled
given at mesial and distal end of the horizontal incision after 1  week, 15  days, and 1  month for reevaluation. At
to free the terminal of graft. To completely free the graft, 1 month, there was a substantial improvement in the labial
a horizontal incision was made at the most apical border contour of the alveolar ridge (Figure 9). Donor site area also
where two horizontal incisions meet. Care was taken to healed very well.
avoid damage to the palatal artery. On removal, connective
tissue graft was placed on saline moistened gauze sponge Three unit porcelain fused metal crown was fabricated using
(Figure 4). The split-thickness flap was then replaced over maxillary right central and left lateral incisor as an abutment
bone, completely covering the bone, and sutured in place
to obtain primary closure of donor site except epithelial
collar harvested with a connective tissue graft (Figure 5).
Periodontal dressing was placed and donor site was secured.

Recipient Site Preparation

A subepithelial pouch was created in maxillary left central
incisor region using a no.15 scalpel blade. Partial thickness
incision was given mid crestally extending deep up to the
mucogingival junction to permit coronal repositioning of
the flap. Subepithelial connective tissue graft harvested from
palate was placed in the pouch thus created after removing Figure 6: Subepithelial pouch created at recipient site and placement of
the epithelial collar and flap was sutured coronally using connective tissue graft

vicryl resorbable sutures (Figures 6 and 7).

The provisional acrylic resin bridge, which was fabricated

pre-surgically was placed over the abutment teeth, so that
post-operatives swelling will cause the tissue to contour to
the shape of pontic (Figure 8).

Post-surgical Instructions
Systemic antibiotics and analgesics were prescribed for
3 days post-surgically. The patient was also prescribed 0.2%

Figure 7: Recipient site secured with vicryl 4-0 resorbable sutures

Figure 4: Harvested connective tissue graft placed on a moist gauze

Figure 5: Donor site after harvesting of graft secured with vicryl 4-0 resorbable Figure 8: Provisional restoration placed post surgically so as post-operative
sutures swelling helps the ridge to contour as per shape of pontic

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 Shah and Baburaj: Localized Ridge Augmentation using Connective Tissue Graft

for replacing left central incisor (Figure 10). The esthetic, treatment of a localized alveolar ridge defect is an important
function, and comfort of the restoration were adequately mucogingival - esthetic challenge. A plethora of treatment
restored. On subsequent appointments, it was noticed that, modalities are available for correction of ridge defects
there was no relapse of the augmented area (Figure 11). depending on volume of tissue required to eliminate the
ridge deformity, type of graft procedure to be used, timing
DISCUSSION of various treatment procedures, design of the provisional
restoration, potential problems with tissue discolorations,
Recognition of esthetic mucogingival problems and a and matching tissue color.5
plan for their correction are the prerequisites for esthetic
success in prosthodontics rehabilitation. Prosthetic In the present case, Siebert Class I defect was present with
a severe bucco-palatal defect that might lead to the esthetic
compromise of fixed partial denture and food impaction
in the pontic region. As emergence profile of pontic region
was prime purpose subepithelial, connective tissue graft
was considered as treatment modality rather than opting
for hard tissue augmentation. Connective tissue grafts
are preferred surgical option for soft tissue augmentation
due to ease of handling, good prospects of success better
chance of survival than free grafts such as a bone graft or a
non-resorbable membrane over poor or non-vascularized
areas.6 Connective tissue grafts preserve the coloration and
characteristics of overlying mucosa resulting in the better
esthetic blend in the potentially highly visible area.
Figure 9: Post-operative view at 1 month recall showing substantial increase in
buccolingual width of alveolar ridge
A major disadvantage of connective tissue graft is a need for
the second surgical site however leaving palatal epithelium
with a base of connective tissue will allow the site to heal
by primary intention, thereby minimizing post-operative
complications. Moreover, alveolar ridges augmented with
connective tissue grafts have demonstrated stability for
7-12 years.7,8

Other treatment options like pedicle roll flap technique was

not considered due to limited availability of connective
tissue on the palatal aspect of ridge defect. Onlay graft
procedures also have limitations such as insecure prognosis
of the gain in volume, compromised vascular supply, and
esthetically unsatisfactory shade and texture as they retain
their palatal mucosal characteristics.9
Figure 10: Three unit porcelain fused metal crown was fabricated using maxillary
right central and left lateral incisor as abutment for replacing left central incisor Provisional restoration was given to the patient that helped
in creating anatomy of interdental papillae in accordance
to the gingival embrasure. Furthermore, provisional
restoration fulfilled the esthetic demand of patient during
a healing phase of the surgical site.

Thus, grafting along with the bridge placement, enhanced

the esthetic outcome in the patient, and improved the
patients required post-therapy care.

CONCLUSION

Alveolar ridge modification is a pre‑requisite for both

Figure 11: Final prosthesis delivered the implant and/or fixed prosthesis. It improves both

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 Shah and Baburaj: Localized Ridge Augmentation using Connective Tissue Graft

the gingival and the bone architecture for esthetic and 5. Studer S, Naef R, Schärer P. Adjustment of localized alveolar ridge
functional purposes. In this case, ridge defect being defects by soft tissue transplantation to improve mucogingival
esthetics: A proposal for clinical classification and an evaluation
horizontal, connective tissue grafting gave good, and of procedures. Quintessence Int 1997;28:785-805.
predictable results. A firm, the rounded alveolar ridge was 6. Khoury F, Happe A. The palatal subepithelial connective tissue
obtained to support the long-term survival of prosthesis. flap method for soft tissue management to cover maxillary defects:
A clinical report. Int J Oral Maxillofac Implants 2000;15:415-8.
7. Mesimeris V, Davis G. Use of subepithelial connective tissue grafts
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Complement the Crown: Localized Ridge Augmentation using Connective
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Source of Support: Nil, Conflict of Interest: None declared.
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