Aesthetic Soft-Tissue Ridge Augmentation

[drsushant]

 DISCUSSION

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