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The Edentulous Ridge in Fixed Prosthodontics
2/2   Vol.   II.   No.4,    JulylAug,   /98/


Continuing                 Education           Article   #2




David A. Garber, BDS, DMD
Director, Group Clinical Practice
Assistant Professor
Departments of Restorative Dentistry and
   Form and Function of the Masticatory System
Edwin S. Rosenberg, BDS, H Dip Dent, DMD
Director, Postdoctoral Periodontics
  and Periodontal Pro'sthesis

School of Dental Medicine
University of Pennsylvania                                      In those clinical situations in which missing teeth are replaced with f1Xed
Philadelphia, Pennsylvania                                    prosthodontics, the clinician is faced with the task of fabricating the pontics
                                                              to fulfill the requirements of esthetics, form and function, and oral
                                                              physiotherapy.
                                                                The relationship of the' 'dummy tooth' , or pontic to the underlying ridge
                                                              is inordinately complex, since the esthetic requirements invariably conflict
                                                              with those of function and hygiene. Although pontic designs have been
                                                              discussed in some depth in the literature, descriptions of the pontic form
                                                              assume the presence of an ideal recipient site. Little attention has been
                                                              directed to the problem of how the various pontic designs relate to the
                                                              deformed edentulous ridge or pontic recipient site.

                                                              Pontic Designs
                                                                  Following are the pontic designs most commonly described:
                                                                  I. Sanitary pontic. This form fulfills the prerequisites for the health of
                                                              the underlying attachment apparatus or periodontium, because it does
                                                              not come into any form of contact with the ridge and leaves the proximal
                                                              areas of the adjacent teeth or abutments free of encumbrances which
                                                              make oral physiotherapy difficult. The form is certainly not esthetic and
                                                              it may present a problem to many patients, since the space between the
                                                              pontic and the ridge becomes a depository for large pieces of food and a
                                                              site into which the tongue invariably strays.
                                                                  2. Ridge lap pontic (Fig IA). This pontic design presents problems due
                                                              to the inability of either the patient or clinician to keep the interface
                                                              between the pontic and the underlying ridge free of plaque. The tissue
                                                              becomes inflamed, loses its keratinized surface, and ulcerates. It is
                                                              generally considered inadvisable to use this type of pontic.
                                                                  3. Modified ridge lap pontic (Fig IB). This is the most commonly used
                                                               pontic design; the contact of the pontic with the underlying ridge is
                                                               maintained only on the buccal aspect of the ridge. This limited contact in
                                                               only one plane allows the area to be readily cleansed with dental floss and
                                                               maintained free of inflammation. This type of pontic fulfills most of the
                                                               needs of the restorative dentist in cases involving ideal edentulous ridges.
                                                                  4. Ovate pontic (Fig IC). This is a pontic form with a rounded base; it
                                                               is indicated when esthetics are of paramount importance. It also ideally
The EdentulousRidge in Fixed Prosthodontics 213

                                                                          tal peaks of bone (Radiograph I). This situation ob-
                                                                          viously is not ideal, because the bone in the center of this
                                                                          flat pontic site is now at a level more coronal to that
                                                                          point at which the maximal curvature of the cemen-
                                                                          toenamel junction (CEJ) normally would have been
                                                                          (Radiograph I).
                                                                              The rise and fall of the CEJ of any particular tooth
                                                                          form can be characterized as being highly scalloped or
                                                                           flat, corresponding to the underlying osseous topog-
                                                                          raphy and gingival form. The dimension of the addi-
                                                                          tional healing bone fill will equal the distance between
Fig l-Pontic   designs. A. Total ridge lap. B. Modified   ridge lap. c.   the tip of the interdental papilla and the most apical
Ovate.
                                                                          curvature of the free gingival margin. The net effect of
                                                                          this type of flat socket healing is inadequate space for a
fulfills the requirements of function and oral physi-                     pontic with dimensions similar to those of the adjacent
otherapy. However, it can be utilized only if the recip-                  teeth. The form of the pontic recipient area must,
ient site is initially prepared to receive it by some form                therefore, be assessed relative to that of the adjacent
of surgical procedure, or if the pontic is inserted into the              teeth, which may be highly scalloped or flat.
extraction socket at the time of tooth removal. The                           Ideally, the clinician should have the temporary
rounded base of the pontic must be accurately formed to                   bridge and pontic prepared at the time of extraction so
fit the prepared concave recipient site precisely. The                    that the ovate pontic can be immediately inserted into
intimate relationship allows floss to pass over the con-                  the socket and the attachment apparatus allowed to heal
vex base, simultaneously cleaning the pontic and the                      around this form. This will prevent the flat healing of
concave surface of the pontic recipient site.                             the socket straight across the tips of the interdental
   It is the authors' contention that the ovate pontic is                 osseous crests, and will result in an ideal concave pontic
the most useful pontic form. This article will discuss the                recipient site.
development of pontic recipient sites, in both the normal                     If the pontic is not inserted at the time of extraction
and deformed edentulous ridge, to accommodate the                         and esthetics are of prime importance, surgical reduc-
ovate pontic design.                                                      tion of the pontic recipient site may become necessary.
                                                                          Surgical Preparation of the Pontic Recipient Site
The Edentulous Ridge and Pontic Recipient Site                                If the level of the healing ridge is too far corbnal for
   The ultimate physical and anatomical form of the                       an esthetic pontic, the anatomical topography of the site
pontic recipient site is a direct result of the state of the              must be determined by needle probing under local
periodontium and the tooth prior to extraction. The                       anesthesia (Fig 2A). If there is a thickness of 3 or 4 mm
presence of periapical pathosis, periodontal disease, or                  of soft tissue above the alveolus in the center of the
trauma will have a direct influence, as will the age of the               ridge, it is necessary only to perform soft tissue
patient and the body's healing potential. It is the                       gingivoplasty, developing an anatomical configuration
responsibility of the exodontist to use judicious care in                 compatible with the two adjacent teeth. This is easily
removing any tooth, since too often the labial or buccal                  accomplished with a rotary diamond instrument (Fig
plates are fractured and removed along with the tooth or                  2B). A l-mm concavity for the base of the pontic,
sequestrated at a later date, resulting in iatrogenic                     further apical to the maximal curvature of the adjacent
deformities. Improper extraction should be particularly                   marginal gingiva, is developed. To fit into this area, the
avoided in the anterior region of the mouth, as it can                    temporary pontic is relined with self-curing acrylic,
create an unesthetic pontic-to-ridge relationship.                        trimmed, and polished, allowing the tissue to heal
   The pontic recipient site can, therefore, be defined as                around this ovate form (Fig 2C).
being potentially adequate or inadequate depending on                         If the needle probing reveals a soft tissue depth of
whether the ridge area is normal (flat) or deformed                       only 2 mm (Fig 3A and Radiograph I), a surgical
(collapsed), as viewed in an apicocoronal (vertical)                      procedure with osteoplasty of the ridge is invariably
dimension or a buccolingual (horizontal) dimension.                       necessary to develop the ideal pontic recipient site. A
   The preparation of the pontic recipient site in each of                full thickness mucoperiosteal flap is raised and the
the above situations requires individualized attention                    edentulous ridge is fully exposed (Fig 3B). The flap is
and specific considerations.                                              raised from the palatal aspect to prevent any subsequent
                                                                          unesthetic labial scarring. The interproximal tissue on
The Normal (Flat) Ridge                                                   the abutment teeth is not included in the dissection to
   For this type of ridge, it is first necessary to determine             ensure the constancy of the crown margin-to-tissue
the anatomical characteristics of the site. When the                      relationship. The "trapdoor" of tissue is gently dissected
tooth was removed there may have been osseous fill of                     towards the labial and the osteoplasty procedure per-
the healing socket, making it level with the two interden-                formed (Fig 3C and Radiograph 2).
214   The   C ompendium   of Continuing   Education




Radiograph 1-Flat osseous topography of the extraction site; i.e.,   Radiograph  2-0sseous   topography following   the   osteoplasty
healing across the tips of the two interdental osseous crests.       procedure. (Compare with Radiograph 1.)


   Depending on the type of pontic to be used, the flat              anatomical deformities which are ineffectively com-
osseous ridge is reshaped in one of two ways.                        pensated for prosthetically.
   Ovate Pontic- The flat ridge is reshaped so that when                The bone loss in any localized pontic area can be
viewed from the direct buccal aspect, it is in harmony               considered to be one of two distinct types: vertical or
with the scalloped osseous form of the adjacent teeth.               horizontal.
Next, a depression I mm deep and 5 mm in diameter is                    In vertical resorption, the resulting ridge is con-
created midway between the two abutments in line with                siderably shorter in an apicocoronal dimension than
the central fossa (Fig 3C).                                          that of the adjacent teeth. In the second type of bone
                                                                     loss, the resorption is more horizontal, taking place
   Modified Ridge Lap Pontic-The          flat ridge is de-          when the buccal plate is lost, and causing a concavity in
creased in width from the lingual aspect only, allowing              a buccolingual dimension. Either type of bone loss
the pontic to make contact predominantly on the buccal               results in an unesthetic situation in which the pontic
aspect, thereby facilitating oral physiotherapy. For                 needs to be considerably oversized as compared to the
esthetic reasons, an indentation is then created on the              adjacent teeth.
buccal aspect which permits the placement of a pontic                   To date, several methods have been utilized to at-
which is not in extreme labioversion and which blends in             tempt to compensate for this problem. The first, and
with the adjacent teeth (Fig 3D).                                    simplest, solution is to place a pontic that blends as well
   The flap is sutured in position over the reshaped                 as possible into the edentulous area. For more severe
alveolar ridge (the pontic recipient site) and held by the           deformities, it may be necessary to add pink-colored
pontic in close apposition to the concavity. Healing will            acrylic or porcelain to the apical end of the pontic to
result in either a pontic recipient site which is concave in         simulate normal gingivae. A third solution is to make a
both a buccolingual and a mesiodistal direction, and                 portion of the prosthesis (the gingival tissue) removable,
into which the ovate pontic can fit, or in a pontic                  as with an Andrew's bridge.2 Recently, an interesting
recipient site of correct dimension to accept a modified             concept of surgical ridge augmentation was described in
ridge lap.                                                           the literature,l and an extension of that approach is the
   Teeth with no antagonists invariably erupt into the               subject of the remainder of this article.
space in the opposing arch, bringing the alveolus and                Surgical A ugmentation of the Deformed Edentulous
attachment apparatus with them. If, for any reason,
                                                                     Ridge
these teeth are lost at a later stage, the resulting eden-             Several distinct types of surgical procedures are avail-
tulous area or potential pontic recipient site will be at a          able for treating the deformed residual edentulous ridge,
level coronally lower than the adjacent teeth. In such               depending on the nature of the deformity.
situations, the ostectomy and osteoplasty procedures                   Loss of Dimension ofa Vertical Nature-Two        perio-
necessary to recreate a dimension capable of receiving               dontal surgical plastic procedures are presently utilized
esthetic functional pontics will be identical to those               to augment ridges with a predominantly vertical de-
described above, but far more radical.
                                                                     formity.
                                                                        THE DE-EpITHELlALlZED CONNECTIVE TISSUE PEDI-
 The Deformed (Collapsed) Ridge                                      CLE GRAFT (Roll Technique)- This procedure has been
   The deformed pontic area or collapsed ridge (Fig 4)               described in detail in the literaturel (Fig SA). Basically,
has long posed a severe problem to the esthetically                  it is a form of contiguous grafting (pedicle graft} which
conscious restorative dentist. Due to the many factors               utilizes as the donor site only the connective tissue of the
involved in tooth loss, areas where teeth have been                  palate adjacent to the ridge. The epithelium over the
extracted can resorb severely, resulting in bizarre                  pedicle is first removed. This is readily done, using a
The Edenlulous Ridge in Fixed Proslhodonlics 215




Fig 2A- The normal ridge. Tissue more coronal than that of the            Fig 2B-Reduction    of excessive soft tissue with rotary diamond.
adjacent teeth. Hemorrhage       droplet  due to needle probing           An arcuate form of the adjacent teeth is first developed in the soft
indicates level of osseous crest and 3 to 4 mm of soft tissue below       tissue, and then a mild concavity for the base of the rounded
this.                                                                     pontic is developed    at the height of this curvature,     midway
                                                                          between the two abutments in both a buccolingual and a mesio-
                                                                          distal dimension.




fig 2C-final   esthetic result. Pontic appears to be "growing      out"   Fig 3A-Clinical    appearance  of a situation     with tissue more
of the gingivae with normal physiologic configuration.                    coronal than that of the adjacent teeth; i.e., a flat ridge without
                                                                          the normal degree of scallop or rise and fall of the adjacent teeth.
                                                                          Needle probing reveals the osseous form of this extraction site
                                                                          and a layer of only 1.5 mm of soft tissue above the osseous.




Fig 3B-Mucoperiosteal"trapdoor"     flap is raised from the palatal       Fig 3C-osteoplasty     of the ridge to develop   rise and fall similar to
aspect, providing access to the underlying flat osseous ridge.            that of the adjacent   teeth.




Fig JD-Final   result showing concave    pontic   recipient   site with   Fig 4-Clinical appearance of a typically deformed      ridge following
simulated interdental papillae.                                           extraction of two maxillary lateral incisors.
2 !6   The   Compendium   of Continuing   Education




Fig 58- The rolr tech nique showing de-epithelialized      palatal    Fig SC-Contiguous         graft sutured into position   and showing
contiguous    graft about to be rolled into position and sutured.     increase in vertical   dimension of the soft tissue.
Graft is easily recognized due to lack of pigmentation.




Fig SD-Pontic   of temporary restoration reduced, demonstrating       Fig 6A-Clinical  appearance of gross vertical loss in dimension of
dramatic increase in vertical dimension    of soft tissue prior to    a deformed edentulous ridge. (Courtesy of Dr. Jay Seibert, Uni-
recreating the concavities for the ovate pontic form.                 versity of Pennsylvania.)




 Fig 6B-Ridge    graft sutured in position. Note that no definitive   Fig 6C-Healing    2 weeks after wedge procedure.   Note the dif-
 shaping procedures are undertaken at this stage. (Courtesy of Dr .   ference in color between the normal tissue and the graft and the
 Jay Seibert, University of Pennsylvania.)                            reduced size of the central incisors and the upper left lateral
                                                                      incisor of the prosthesis to accommodate    the increase in soft
                                                                      tissue dimension.   (Courtesy of Dr. Jay Seibert, University   of
                                                                      Pennsylvania.)
The EdentulousRidge in Fixed Prosthodontics217

                                                                     The donor site from which the flap was rolled will
                                                                  initially heal as an epithelial-covered depression, which
                                                                  will slowly granulate in and fill.
                                                                     The pontic is reduced (Fig 5D), and the area is dressed
                                                                  and allowed to heal for 10 days, when the sutures are
                                                                  removed. The area is then redressed for I week, when a
                                               B                  plasty is done to prepare a concave pontic recipient site
              A
                                                                  for an ovate pontic. There are occasions when an ovate
                                                                  pontic can be placed at the time of the initial surgery and
                                                                  the tissue allowed to heal and form around it. Such
                                                                  situations usually require less gingivoplasty at a later
                                                                  date.
                                                                     This type of procedure is excellent if the loss of
                                                                  dimension is predominantly vertical. It also allows the
                                                                  mucogingival junction to be repositioned by the ex-
                                                                  tension of two vertical incisions out to the buccal surface
              c                                                   of the involved area.
                                                                     The procedure should not be used when there is
                                                                  inadequate thickness of palatal tissue available or when
                                                                  the edentulous ridge area is knifelike, with scant under-
                                                                  lying bone and soft tissue. That is, there must be a
                                                                  scaffold of underlying bone to support the graft; other-
                                                                  wise, excessive shrinkage could result. These situations
                                                                  can be assessed utilizing          needle probing      under
                                                                  anesthesia prior to surgery.
                                                                     THE A UTOGENOUS COMBINED EPITHELIAL AND
                                                                  CONNECTIVE TISSUE FREE GRAFT (Wedge Tech-

              u                                                   nique)-This    procedure is most useful in knifelikeeden-
                                                                  tulous ridge areas or when there is insufficient palatal
Fig SA-Diagrammatic    representation of the complete roll pro-   tissue available in the ridge area for use of the roll
cedure. (Courtesy of Dr. Leonard Abrams, University of Pennsyl-   technique. It is also particularly useful when a large
vania.J                                                           amount of gingiva must be added in a vertical dimension
                                                                  (Fig 6A). This technique, in contrast to that using the
non-epinephrine bearing anesthetic, by sharp dissection           pedicle graft, described above, requires the utilization of
or by use of a rotary diamond instrument. Free bleed-             a donor site distant from the ridge to be augmented. An
ing, permitted by the non-epinephrine anesthetic, is              excellent site, which invariably yields the required ade-
evidence of complete epithelial removal. The tissue is            quate thickness of donor tissue, is the tuberosity area
then infiltrated    with an anesthetic containing a               distal to the maxillary molars.
hemostatic agent, and a connective tissue pedicle flap is            The recipient site is prepared first by a partial
outlined through to the osseous, and then elevated from           thickness dissection which removes the epithelium and a
the palate within the de-epithelialized zone (Fig 58). In         nominal portion of the underlying connective tissue,
this procedure, it is important that the proximal                 resulting in a free bleeding surface. The amount of
marginal tissue of the adjacent abutment teeth is not             required tissue is then outlined on the tuberosity area
involved. This will ensure stability of the crown margin-         according to the measurements taken from the recipient
to-tissue relationship.                                           site, and a large wedge of both epitheliwn and connective
   A zone of tissue is de.epithelialized corresponding to         tissue is removed. This wedge, the undersurface of which
the amount of augmentation required, and the pedicle              is shaped to conform to the ridge to be augmented, is
may even be rolled in upon itself twice before being              sutured in position (Fig 6B). It is essential to expedite
placed on the apex of the residual osseous ridge. Next, a         this stage of the procedure, allowing for rapid coapta-
pouch on the labial aspect of the ridge is created by             tion of the free graft and the development of adequate
blunt dissection and the flap is inverted upon itself and         nutrient circulation.
placed into it.                                                      Sutures are removed at 12 days (Fig 6C). At this stage,
   A specific suturing technique is used to maintain              the resulting tissue may not blend in perfectly with the
stability of the pedicle graft. The needle is initially           tissues above and lateral to it. A gingivectomy or
inserted from the buccal surface through the rolled               gingivoplasty invariably is required to blend in the
pedicle to the palatal side and then back through the             donor tissue and to develop the concave form of the
pedicle and the pouch, through to the buccal surface              pontic recipient site. It should be emphasized that these
once again, where the suture is tied off (Fig 5C).                plasty procedures should not be done at the time of
2/8   The   Compendium   of Continuing   Education


surgery but only at a subsequent visit, following the              this donor tissue is placed on saline-soaked gauze. Next,
"take" of the graft.                                               the initial envelope flap is sutured back.in position and
   Loss of Dimension of a Horizontal Nature (Fig 7)-               held in close apposition with the underlying bone for 6
The subepithelial connective tissue graft generally is             or 7 minutes. This covers the denuded bone, facilitating
used to augment ridges with a predominantly horizontal             healing with only a mild depression that will fill to its
deformity. Depending upon the anatomy of the de-                   normal level over a period of time, at the same time
formity, two types of surgical plastic procedures are              decreasing both the amount of pain associated with the
available to the clinician: the flap or the pouch (single or       exposed bone and the problems associated with dressing
double).                                                           the area.
  The basis of all these procedures is the placement of a             The connective tissue graft can now be placed in a
graft of only connective tissue from a remote site,                prepared recipient site and sutured in position.
subepithelially, in the area of the ridge requiring                    REClPIENT SITE PREPARATION--Preparation of the
augmentation.                                                      recipient site for both the flap and pouch procedures will
    Dhe-decision about which type of procedure to use in           be discussed.
any given case depends upon whether there is an                        I. F/ap procedure. This is the most useful procedure
alteration in the mucogingival junction line of the ridge          for correcting deformities in the horizontal dimension
relative to the adjacent teeth, and on the number of teeth         when the mucogingival junction has moved coronally,
involved, that is, the lateral dimension of the graft.             leaving insufficient masticatory mucosa for pontic re-
    The flap procedure (Fig 8) is indicated only if the            ception directly over the ridge.
mucogingival junction in the deformed area is to be                   A split thickness flap is first elevated on the buccal
repositioned. This type of situation arises from prob-             aspect of the deformed ridge, leaving the periosteum and
lems associated with tooth extraction and the ultimate             a portion of the connective tissue overlying the alveolar
healing of the mucogingival junction at a level more               ridge (Fig SA). The vertical incisions extend in an
coronal than that of the adjacent teeth. However, if it is         oblique fashion on either side of the deformed ridge and
in line with the mucogingival junction of the adjacent             into the labial fold as high as is necessary to reposition
teeth, one of the pouch procedures is more suitable.               the mucogingival junction. The horizontal incision is
    The double pouch procedure (Fig 9) generally is used           made on the pa/ata/ aspect of the ridge so as to increase
only when the deformity crosses the midline or is of too           the zone of masticatory mucosa available for reposition-
great a dimension to allow all the donor tissue to be              ing. The connective tissue from the donor site is placed
placed in through a unilateral incision.                           on this somewhat concave base and, if necessary,
    In all of these procedures, the removal of the connec-         sutured in position with resorbable gut (Fig SB). The
tive tissue graft from the donor site is similar; the only         elevated split thickness flap is then sutured down over
differences are in recipient site preparation, as will be          the connective tissue to immobilize it in the desired
demonstrated below.                                                position and realign the mucogingivaljunction      (Fig SC).
     DONOR SITE PREPARATION-The most readily avail-                This overlying flap, together with the underlying con-
able sources of donor tissue are found in the lateral              nective tissue base, should provide an adequate source
aspects of the palate and in the tuberosity region. The            of nutrients for the connective tissue graft.
tissue for the graft may be removed from these areas                  The sutures are removed at 10 days and the area
either as part of a maxillary periodontal surgical pro-            redressed with a periodontal pack. Next, the required
cedure (secondary flap) or as an individual procedure              pontic      recipient  concavities   are created in the
( envelopeflap ). In the first case, the tissue for the graft is   augmented ridge, and the pontics of the provisional
 removed either as part of the wedge and ledge procedure           restoration relined with acrylic and adapted to these
 or in the thinning out of the primary palatal flap. After         concavities.
the secondary flap is removed, it is de-epithelialized of             2. Pouch procedures. The pouch procedure is used in
marginal gingiva and inflamed sulcular tissue.                     those situations in which the dimensional loss of the
     In the case of the envelope flap, a rectangular form is       ridge is predominantly horizontal (Fig 10A), and the
 first outlined in the posterior aspect of the palate. The         mucogingival junction is essentially in line with that of
 base of the flap is towards the midline of the palate and         the adjacent teeth. There are two approaches to place-
 the most coronal aspect approaches within 2 to 3 mm of            ment of the initial incision: a vertica/ ob/ique incision or
 the free gingival margin, but does not encroach upon it.          a horizonta/ incision.
 The lateral dimension of the flap depends upon the                   In the first approach, preparation of the recipient site
 recipient site deformity and the amount of tissue needed.         is initiated by a vertical oblique incision extending from
 The split thickness envelope flap is then raised: by a            the ridge apex, just mesial to one of the abutment teeth,
 procedure similar to that used for taking a free epithelial       and up towards the vestibular fornix (Fig 10B). The
 graft for mucogingival procedures. The epithelium and             integrity of the interproximal marginal tissue should not
 connective tissue are not removed, however, but are left          be disturbed, in order to maintain the crown margin-to-
 attached along the midline. The underlying connective             tissue relationship. Through this initial incision, a split
 tissue is then removed down to the palatal osseous, and           dissection of the tissue overlying the ridge is performed.
The Edentulous Ridge in Fixed Prosthodontics 219




Fig 7-Clinical'appearance      of typical horizontal loss in dimension              Fig 8A-Surgical    approach to flap procedure. Split thickness flap is
of a deformed edentulous ridge, due to loss of buccal plate during                  raised to reposition mucogingival junction and to provide a base
extraction of lateral incisors.                                                     on which to place the connective tissue graft. (Courtesy of Dr. E.S.
                                                                                    Rosenberg, University of Pennsylvania.)


                         ~




                                      ~     [ ,c         J

                'f                                    c c~
                                                         r
                  l


                                            ./!n.~
Fig 8B-Diagrammatic        representation      of flap procedure.       Connec-     Fig 8C-Diagrammatic      representation     of elevated flap sutured
tive tissue graft is sutured    onto the     periosteum    of the     deformity.    back into position over the connective    tissue graft in such a way as
                                                                                    to realign the mucogingival junction.




                                       Fig 9-Diagrammatic     representation   of double pouch procedure
                                       extending across the midline. The lateral extent of the deformed
                                       ridge requires that grafts must be placed in position through a
                                       bilateral incision on either side of the midline.




Fig lOA-The   preoperative      appearance           of horizontal   bone loss in   Fig 10B-Clinical appearance of the vertical oblique    incision.   Note
an edentulous ridge.                                                                that the marginal integrity is left undisturbed.
220   The   Compendium     of Continuing   Education




Fig      10C-Split
thickness dissection of
tissue over the entire                                                   Fig 10D-Connective
deformity to develop a                                                   tissue   graft     being
pouch into which con-                                                    slipped into the pouch
nective    tissue grafts                                                 and tried in position
may be placed.                                                           prior to suturing.


It extends through the masticatory mucosa and the                        pouch (Figs IOD and E). It may be necessary to try one
mucogingival junction into alveolar mucosa.                              or more pieces of connective tissue to ascertain if the
   The tissue over the entire deformity and slightly                     amount of augmentation is adequate and of the correct
beyond is elevated to create a pouch (Figs lOC and E).                   form. The tissue graft is sutured in position as described
The fact that the deformity is concave permits the                       below (Figs IOF and G), dressed, and allowed to heal for
elevation of the tissue towards the buccal aspect without                4 weeks when the pontic concavities are developed. The
any tension being placed on it.                                          temporary restoration is relined and recemented, and 13
   The connective tissue from the donor site is cut into                 weeks is allowed to elapse before the augmented ridge
the appropriate size and tried in position within the                    (Fig IOH) is ready for the final prosthesis.




                                                                         Fig 10F-Diagrammatic       representation  of suturing   technique.
Fig 10E-Cross-sectional      diagrammatic representation   of connec-    Note that the connective tissue graft is not yet in position within
tive tissue graft in position, subepithelially.                          the pouch. It will be pulled into the pouch utilizing the two loose
                                                                         ends of the suture and will be stabilized in a position which
                                                                         depends upon the initial entry of the "bite" of the first suture.




Fig 10G-Diagrammatic          representation    of pouch closure with    Fig 10H-Augmented     ridge with    depression   created   for ovate
interrupted  sutures,    following    insertion   of connective tissue   pontic. (Compare with Fig 10A.)
grafts.
The Edentulous Ridge in Fixed Prosthodontics 221




Fig 11A-Clinical  appearance     of horizontal   incision at the crest of   Fig 11B-Diagrammatic      representation of horizontal incision. In.
edentulous ridge.                                                           cisal view.




                                                         "       ,
                                                             ~




Fig 11C-Diagrammatic      representation of horizontal incision with        Fig llD-Clinical     appearance   of the small initial     incision   and
pouch development.      Dissection has been extended laterally and          pouch.
apically over the entire deformity via the initial incision.




Fig 11E-Connective      tissue being placed into the pouch                  Fig 11F-Connective     tissue graft sutured   into position.




Fig 11G-Clinical     view of preoperative   ridge.                          Fig llH-Postoperative   view of the same ridge following augmel
                                                                            tation. Note the dramatic increase in horizontal dimension.
222   The   Compendium   of   Continuing   Education


   In the second approach, a horizontal incision is made
at the base of the edentulous ridge and extends apically
through the entire length of the deformity (Figs IIA and
B). The pouch is then developed by extending the split
thickness incision laterally in order to elevate the tissue
lying within the area of the deformity and slightly
beyond (Fig II C).
   Next, the donor tissue is slipped through the primary
horizontal incision into position in an inciso-apical
direction (Figs IID, E, and F).
   Healing takes place as with the vertical incision, and            Fig 12A-Cross-sectional     diagrammatic     representation  of place-
                                                                     ment of horizontal incision on the palatal aspect of the ridge at a
the augmented. ridge (Figs IIG and H) undergoes a
                                                                     more apical level, This facilitates a certain amount of drape to the
gingivoplasty to develop the concave pontic recipient                pouch, which is created by extending this incision horizontally
site.                                                                toward the buccal aspect and then apically around the osseous
                                                                     crest Following placement of connective tissue within this pouch,
  If the deformity has an added vertical component as                the augmentation     will be in both a horizontal        and a vertical
well (Fig 12D), the placement of the horizontal incision             dimension,




Fig 12B-Clinical view of incision similar to that shown in Fig 12A   Fig 12C -Clinical   view showing connective tissue graft in position.
                                                                     It was slipped in through the initial palatal incision over the
                                                                     osseous crest and around onto the buccal aspect of the deformity,
                                                                     leaving the base of the graft overlying the actual crest of the
                                                                     osseous ridge. This will facilitate augmentation     in a horizontal
                                                                     dimension as well as a vertical dimension. Note, however, that the
                                                                     initial incision cannot be closely coapted and should not be tightly
                                                                     tied off. This area must heal by secondary intention.       Note the
                                                                     donor site on the right side of the palate.




Fig 12D-Preoperative   view with provisional restoration in place    Fig 12E-Postoperative    view of the same site following     ridge
and pink acrylic on the apical end of the provisional restoration.   augmentation.    Note the dramatic amount of vertical as well as
                                                                     horizontal  ridge augmentation.   Note, too, that the provisional
                                                                     restoration has been cut back on its apical end to allow for the
                                                                     increase in ridge dimension.
The Edentu/ous Ridge in Fixed Prosthodontics 223

must be changed. It should now be made on the palatal        incision is still easily closed (Fig lOO) despite the
side of the edentulous ridge, at a more apical level,        plumping, because elevation of the pouch from within
corresponding to the crest of the underlying alveolus        the concavity of the deformity results in an extra
(Fig 12A).                                                   dimension of available tissue to bridge the gap:"
   The dissection is made horizontally from the palate          The sutures are removed at 10 days and the area
towards the buccal surface and then onward, around the       redressed. After a further 2 weeks, the augmented
alveolus in an apical direction (Fig 128). The tissue        deformity can be shaped with a diamond stone to
coronal to the primary incision will now drape some-         develop the concave form for the pontic. The temporary
what incisally, which will add vertical dimension to the     pontic is relined with self-curing acrylic and placed while
ridge. The dissection is completed by extending it later-    still soft into this newly formed concave recipient site.
ally over the complete area of the deformity. The donor      The acrylic, once set, is trimmed, the ovate base
graft is slid in through the incision around the alveolus    polished, and the temporary bridge recemented in posi-
and onto the buccal surface (Fig 12C). The base of the       tion; The whole complex is allowed to heal a further 8
graft will remain on the crest of the alveolus, augment-     weeks before final impressions for the prosthesis are
ing it in both a vertical and horizontal dimension. The      taken.
initial incision should not be sutured back into close
apposition or the net gain in a vertical dimension will be   Summary
lost. It should be allowed to heal by secondary intention       The techniques described in this paper can be utilized
or by placing a connective tissue graft with a small base    to augment edentulous ridge concavities, irregularities,
of epithelium, which will fill the void created by the       and deformities in those cases in which esthetics is of
drape of the pouch (Figs 12D and E).                         prime importance or in which the deformed ridge
   Ridge deformities may be bizarre, requiring augmen-       interferes with the function of speech or the ability to
tation in varying dimensions and planes; consequently,       perform oral physiotherapy. The resulting soft tissue
several separate incisions may be necessary, depending       areas closely mimic normal gingival contours and form
upon where the pouch is to be developed and where the        a concave soft tissue pontic recipient site for the desired
tissue is to be placed in the augmentation process. A        convex pontic. These procedures are extremely useful
deformity may require, therefore, the utilization of both    adjuncts for correcting esthetic and functional problems
vertical and horizontal incisions, in both the palatal and   in fixed prosthesis.
buccal aspects.
   SUTURING TECHNIQUE-A suturing technique is re-
quired which accurately localizes and stabilizes the         The author would like to acknowledge               Elissa Berardi   for
connective tissue grafts in the positions decided upon       her work on the drawings        in this article.
during the try-in phase of the procedure.
   The needle is inserted from the labial surface at the
point at which it is desired to anchor one of the
connective tissue grafts. It then passes through the
undersurface of the pouch and out through the initial
                                                                                      REFERENCES
incision. The needle is next passed through the donor
connective tissue, back through the initial incision, into   I. Abrams L: Augmentation        of the deformed residual edentulous
the pouch, and out onto the labial surface (Fig 1OF).           ridge for fixed prosthesis. Compend Contin Educ Gen Dent
                                                                1(3):205-214, 19.80.
The two ends of the suture are now gently pulled and the     2: Dilmmer PT , Gidden J: The upper anterior sectional denture. J
connective tissue graft is eased through the primary            Prosthet Dent 41: 146, 1979.
incision into the pouch in the position determined by the    3. Eissman HJ, RadkeRA, Noble WH: Physiological design criteria
                                                                for fixed dental restorations. Dent Clin North Am 15:3, 1971.
placement of the initial insertion of the suture needle.     4. Goldstein RE: Esthetics in Dentistry. Philadelphia, JB Lippincott
The suture is now tied off in the usual manner (Fig             Co, 1976, pp 90-122.
                                                             5. Langer B, Calagna L: The subepithelial connective tissue graft. J
 100).                                                          Prosthet Dent 44:363; 1980.
   It is important to the cosmetic success of the pro-       6. Nery EB, Lynch KL, Rooney GE: Alveolar ridge augmentation
cedure that the donor tissue be immobilized accurately          with tricalcium phosphate ceramic. J Prosthet Dent 40:668, 1978.
in position and held there; The tissue can be im-            7. Risch JR, White JG, Swenson HM: The esthetic labial gingival
                                                                prosthesis. Jlndiana Dent Assoc 56:15; 1977.
mobilized in two or three different positions which will     8. Stein RS: Pontic-residual ridge relationships: A research report. J
result in a specifically shaped pontic area. The initial        Prosthet Dent 16:283, 1966.
224    The   Compendium      of   Continuing   Education



                                                   ARTICLE   #2 REVIEW     QUESTIONS
  The article you have read qualifies for Ih hour of Continuing Education Credit from the University of
  Pennsylvania School of Dental Medicine. For your reference, record your answers on this page and then transfer
                          them to the registration form inserted in The Compendium.

I. The physical and anatomical form of the pontic recipient                 solutions to the problem of the deformed residual eden-
   site is influenced by                                                    tulous ridge?
    a. the state of the extracted tooth.                                     a. blending of pontic to ridge area with poor axial
    b. the mode of tooth removal.                                               angulation
    c. the patient's age.                                                    b. Andrew's bridge
    d. the healing potential of the body.                                    c. ridge augmentation
    e. all of the above                                                      d. all of the above
2. The ovate (egg-shaped) pontic design can be used only if
   the pontic recipient site is first prepared by some form of           8. Which of the following pontic-residual ridge designs has
                                                                            been presented as the most desirable in the anterior part of
      surgical procedure.
       a. true                                                              the mouth?
                                                                             a. total ridge lap with concave pontic surface in contact
       b. false
                                                                                with convex ridge tissue
3. Horizontal ridge deformities can be corrected utilizing                   b. modified ridge lap with convex pontic surface in
   a. the flap procedure.                                                       contact with convex ridge tissue
   b. the single pouch procedure.                                            c. ovate pontic surface in contact with concave ridge
    c. the double pouch procedure.                                              tissue
   d. all of the above                                                       d. modified ridge lap with no tissue contact to allow for
4. The flap is the most useful procedure for correcting those                   self-cleaning
                                                                             e. none of the above
    horizontal ridge deformities in which the mucogingival
   junction needs to be elevated.
                                                                         9. The roll technique is contraindicated when
     a. true
                                                                             a. there is inadequate osseous scaffolding.
    b. false
                                                                            b. there is very thin soft tissue covering the alveolar ridge.
5. The most readily available sources of donor tissue are                    c. the edentulous ridge is knifelike.
   found in the lateral aspects of the palate and in the                    d. the defect is predominantly horizontal.
      tuberosity   region.                                                   e. all of the above
       a. true
       b. false                                                          10. Which one of the following statements regarding the
                                                                             process of de-epithelialization   for the roll technique is
 6. The autogenous combined epithelial and connective tissue
                                                                             correct?
    free graft is most useful
                                                                              a. Epinephrine-bearing anesthetics are used to control
     a. in knifelike ridge areas.
     b. when there is insufficient palatal tissue available for a                bleeding during de-epithelialization.
                                                                              b. Non-epinephrine bearing anesthetics are used to en-
        de-epithelialized connective tissue pedicle graft.
     c. when a large amount of gingiva must be added in a                        courage bleeding during de-epithelialization.
                                                                              c. The choice of anesthesia is unimportant in the de-
        vertical dimension.
     d. all of the above                                                         epithelialization process.
                                                                              d. Anesthetic injections are necessary to distend tissue
 7. Which of the following              methods have been offered as             during de-epithelialization.

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The Edentulous Ridge in Fixed Prosthodontics

  • 2. 2/2 Vol. II. No.4, JulylAug, /98/ Continuing Education Article #2 David A. Garber, BDS, DMD Director, Group Clinical Practice Assistant Professor Departments of Restorative Dentistry and Form and Function of the Masticatory System Edwin S. Rosenberg, BDS, H Dip Dent, DMD Director, Postdoctoral Periodontics and Periodontal Pro'sthesis School of Dental Medicine University of Pennsylvania In those clinical situations in which missing teeth are replaced with f1Xed Philadelphia, Pennsylvania prosthodontics, the clinician is faced with the task of fabricating the pontics to fulfill the requirements of esthetics, form and function, and oral physiotherapy. The relationship of the' 'dummy tooth' , or pontic to the underlying ridge is inordinately complex, since the esthetic requirements invariably conflict with those of function and hygiene. Although pontic designs have been discussed in some depth in the literature, descriptions of the pontic form assume the presence of an ideal recipient site. Little attention has been directed to the problem of how the various pontic designs relate to the deformed edentulous ridge or pontic recipient site. Pontic Designs Following are the pontic designs most commonly described: I. Sanitary pontic. This form fulfills the prerequisites for the health of the underlying attachment apparatus or periodontium, because it does not come into any form of contact with the ridge and leaves the proximal areas of the adjacent teeth or abutments free of encumbrances which make oral physiotherapy difficult. The form is certainly not esthetic and it may present a problem to many patients, since the space between the pontic and the ridge becomes a depository for large pieces of food and a site into which the tongue invariably strays. 2. Ridge lap pontic (Fig IA). This pontic design presents problems due to the inability of either the patient or clinician to keep the interface between the pontic and the underlying ridge free of plaque. The tissue becomes inflamed, loses its keratinized surface, and ulcerates. It is generally considered inadvisable to use this type of pontic. 3. Modified ridge lap pontic (Fig IB). This is the most commonly used pontic design; the contact of the pontic with the underlying ridge is maintained only on the buccal aspect of the ridge. This limited contact in only one plane allows the area to be readily cleansed with dental floss and maintained free of inflammation. This type of pontic fulfills most of the needs of the restorative dentist in cases involving ideal edentulous ridges. 4. Ovate pontic (Fig IC). This is a pontic form with a rounded base; it is indicated when esthetics are of paramount importance. It also ideally
  • 3. The EdentulousRidge in Fixed Prosthodontics 213 tal peaks of bone (Radiograph I). This situation ob- viously is not ideal, because the bone in the center of this flat pontic site is now at a level more coronal to that point at which the maximal curvature of the cemen- toenamel junction (CEJ) normally would have been (Radiograph I). The rise and fall of the CEJ of any particular tooth form can be characterized as being highly scalloped or flat, corresponding to the underlying osseous topog- raphy and gingival form. The dimension of the addi- tional healing bone fill will equal the distance between Fig l-Pontic designs. A. Total ridge lap. B. Modified ridge lap. c. the tip of the interdental papilla and the most apical Ovate. curvature of the free gingival margin. The net effect of this type of flat socket healing is inadequate space for a fulfills the requirements of function and oral physi- pontic with dimensions similar to those of the adjacent otherapy. However, it can be utilized only if the recip- teeth. The form of the pontic recipient area must, ient site is initially prepared to receive it by some form therefore, be assessed relative to that of the adjacent of surgical procedure, or if the pontic is inserted into the teeth, which may be highly scalloped or flat. extraction socket at the time of tooth removal. The Ideally, the clinician should have the temporary rounded base of the pontic must be accurately formed to bridge and pontic prepared at the time of extraction so fit the prepared concave recipient site precisely. The that the ovate pontic can be immediately inserted into intimate relationship allows floss to pass over the con- the socket and the attachment apparatus allowed to heal vex base, simultaneously cleaning the pontic and the around this form. This will prevent the flat healing of concave surface of the pontic recipient site. the socket straight across the tips of the interdental It is the authors' contention that the ovate pontic is osseous crests, and will result in an ideal concave pontic the most useful pontic form. This article will discuss the recipient site. development of pontic recipient sites, in both the normal If the pontic is not inserted at the time of extraction and deformed edentulous ridge, to accommodate the and esthetics are of prime importance, surgical reduc- ovate pontic design. tion of the pontic recipient site may become necessary. Surgical Preparation of the Pontic Recipient Site The Edentulous Ridge and Pontic Recipient Site If the level of the healing ridge is too far corbnal for The ultimate physical and anatomical form of the an esthetic pontic, the anatomical topography of the site pontic recipient site is a direct result of the state of the must be determined by needle probing under local periodontium and the tooth prior to extraction. The anesthesia (Fig 2A). If there is a thickness of 3 or 4 mm presence of periapical pathosis, periodontal disease, or of soft tissue above the alveolus in the center of the trauma will have a direct influence, as will the age of the ridge, it is necessary only to perform soft tissue patient and the body's healing potential. It is the gingivoplasty, developing an anatomical configuration responsibility of the exodontist to use judicious care in compatible with the two adjacent teeth. This is easily removing any tooth, since too often the labial or buccal accomplished with a rotary diamond instrument (Fig plates are fractured and removed along with the tooth or 2B). A l-mm concavity for the base of the pontic, sequestrated at a later date, resulting in iatrogenic further apical to the maximal curvature of the adjacent deformities. Improper extraction should be particularly marginal gingiva, is developed. To fit into this area, the avoided in the anterior region of the mouth, as it can temporary pontic is relined with self-curing acrylic, create an unesthetic pontic-to-ridge relationship. trimmed, and polished, allowing the tissue to heal The pontic recipient site can, therefore, be defined as around this ovate form (Fig 2C). being potentially adequate or inadequate depending on If the needle probing reveals a soft tissue depth of whether the ridge area is normal (flat) or deformed only 2 mm (Fig 3A and Radiograph I), a surgical (collapsed), as viewed in an apicocoronal (vertical) procedure with osteoplasty of the ridge is invariably dimension or a buccolingual (horizontal) dimension. necessary to develop the ideal pontic recipient site. A The preparation of the pontic recipient site in each of full thickness mucoperiosteal flap is raised and the the above situations requires individualized attention edentulous ridge is fully exposed (Fig 3B). The flap is and specific considerations. raised from the palatal aspect to prevent any subsequent unesthetic labial scarring. The interproximal tissue on The Normal (Flat) Ridge the abutment teeth is not included in the dissection to For this type of ridge, it is first necessary to determine ensure the constancy of the crown margin-to-tissue the anatomical characteristics of the site. When the relationship. The "trapdoor" of tissue is gently dissected tooth was removed there may have been osseous fill of towards the labial and the osteoplasty procedure per- the healing socket, making it level with the two interden- formed (Fig 3C and Radiograph 2).
  • 4. 214 The C ompendium of Continuing Education Radiograph 1-Flat osseous topography of the extraction site; i.e., Radiograph 2-0sseous topography following the osteoplasty healing across the tips of the two interdental osseous crests. procedure. (Compare with Radiograph 1.) Depending on the type of pontic to be used, the flat anatomical deformities which are ineffectively com- osseous ridge is reshaped in one of two ways. pensated for prosthetically. Ovate Pontic- The flat ridge is reshaped so that when The bone loss in any localized pontic area can be viewed from the direct buccal aspect, it is in harmony considered to be one of two distinct types: vertical or with the scalloped osseous form of the adjacent teeth. horizontal. Next, a depression I mm deep and 5 mm in diameter is In vertical resorption, the resulting ridge is con- created midway between the two abutments in line with siderably shorter in an apicocoronal dimension than the central fossa (Fig 3C). that of the adjacent teeth. In the second type of bone loss, the resorption is more horizontal, taking place Modified Ridge Lap Pontic-The flat ridge is de- when the buccal plate is lost, and causing a concavity in creased in width from the lingual aspect only, allowing a buccolingual dimension. Either type of bone loss the pontic to make contact predominantly on the buccal results in an unesthetic situation in which the pontic aspect, thereby facilitating oral physiotherapy. For needs to be considerably oversized as compared to the esthetic reasons, an indentation is then created on the adjacent teeth. buccal aspect which permits the placement of a pontic To date, several methods have been utilized to at- which is not in extreme labioversion and which blends in tempt to compensate for this problem. The first, and with the adjacent teeth (Fig 3D). simplest, solution is to place a pontic that blends as well The flap is sutured in position over the reshaped as possible into the edentulous area. For more severe alveolar ridge (the pontic recipient site) and held by the deformities, it may be necessary to add pink-colored pontic in close apposition to the concavity. Healing will acrylic or porcelain to the apical end of the pontic to result in either a pontic recipient site which is concave in simulate normal gingivae. A third solution is to make a both a buccolingual and a mesiodistal direction, and portion of the prosthesis (the gingival tissue) removable, into which the ovate pontic can fit, or in a pontic as with an Andrew's bridge.2 Recently, an interesting recipient site of correct dimension to accept a modified concept of surgical ridge augmentation was described in ridge lap. the literature,l and an extension of that approach is the Teeth with no antagonists invariably erupt into the subject of the remainder of this article. space in the opposing arch, bringing the alveolus and Surgical A ugmentation of the Deformed Edentulous attachment apparatus with them. If, for any reason, Ridge these teeth are lost at a later stage, the resulting eden- Several distinct types of surgical procedures are avail- tulous area or potential pontic recipient site will be at a able for treating the deformed residual edentulous ridge, level coronally lower than the adjacent teeth. In such depending on the nature of the deformity. situations, the ostectomy and osteoplasty procedures Loss of Dimension ofa Vertical Nature-Two perio- necessary to recreate a dimension capable of receiving dontal surgical plastic procedures are presently utilized esthetic functional pontics will be identical to those to augment ridges with a predominantly vertical de- described above, but far more radical. formity. THE DE-EpITHELlALlZED CONNECTIVE TISSUE PEDI- The Deformed (Collapsed) Ridge CLE GRAFT (Roll Technique)- This procedure has been The deformed pontic area or collapsed ridge (Fig 4) described in detail in the literaturel (Fig SA). Basically, has long posed a severe problem to the esthetically it is a form of contiguous grafting (pedicle graft} which conscious restorative dentist. Due to the many factors utilizes as the donor site only the connective tissue of the involved in tooth loss, areas where teeth have been palate adjacent to the ridge. The epithelium over the extracted can resorb severely, resulting in bizarre pedicle is first removed. This is readily done, using a
  • 5. The Edenlulous Ridge in Fixed Proslhodonlics 215 Fig 2A- The normal ridge. Tissue more coronal than that of the Fig 2B-Reduction of excessive soft tissue with rotary diamond. adjacent teeth. Hemorrhage droplet due to needle probing An arcuate form of the adjacent teeth is first developed in the soft indicates level of osseous crest and 3 to 4 mm of soft tissue below tissue, and then a mild concavity for the base of the rounded this. pontic is developed at the height of this curvature, midway between the two abutments in both a buccolingual and a mesio- distal dimension. fig 2C-final esthetic result. Pontic appears to be "growing out" Fig 3A-Clinical appearance of a situation with tissue more of the gingivae with normal physiologic configuration. coronal than that of the adjacent teeth; i.e., a flat ridge without the normal degree of scallop or rise and fall of the adjacent teeth. Needle probing reveals the osseous form of this extraction site and a layer of only 1.5 mm of soft tissue above the osseous. Fig 3B-Mucoperiosteal"trapdoor" flap is raised from the palatal Fig 3C-osteoplasty of the ridge to develop rise and fall similar to aspect, providing access to the underlying flat osseous ridge. that of the adjacent teeth. Fig JD-Final result showing concave pontic recipient site with Fig 4-Clinical appearance of a typically deformed ridge following simulated interdental papillae. extraction of two maxillary lateral incisors.
  • 6. 2 !6 The Compendium of Continuing Education Fig 58- The rolr tech nique showing de-epithelialized palatal Fig SC-Contiguous graft sutured into position and showing contiguous graft about to be rolled into position and sutured. increase in vertical dimension of the soft tissue. Graft is easily recognized due to lack of pigmentation. Fig SD-Pontic of temporary restoration reduced, demonstrating Fig 6A-Clinical appearance of gross vertical loss in dimension of dramatic increase in vertical dimension of soft tissue prior to a deformed edentulous ridge. (Courtesy of Dr. Jay Seibert, Uni- recreating the concavities for the ovate pontic form. versity of Pennsylvania.) Fig 6B-Ridge graft sutured in position. Note that no definitive Fig 6C-Healing 2 weeks after wedge procedure. Note the dif- shaping procedures are undertaken at this stage. (Courtesy of Dr . ference in color between the normal tissue and the graft and the Jay Seibert, University of Pennsylvania.) reduced size of the central incisors and the upper left lateral incisor of the prosthesis to accommodate the increase in soft tissue dimension. (Courtesy of Dr. Jay Seibert, University of Pennsylvania.)
  • 7. The EdentulousRidge in Fixed Prosthodontics217 The donor site from which the flap was rolled will initially heal as an epithelial-covered depression, which will slowly granulate in and fill. The pontic is reduced (Fig 5D), and the area is dressed and allowed to heal for 10 days, when the sutures are removed. The area is then redressed for I week, when a B plasty is done to prepare a concave pontic recipient site A for an ovate pontic. There are occasions when an ovate pontic can be placed at the time of the initial surgery and the tissue allowed to heal and form around it. Such situations usually require less gingivoplasty at a later date. This type of procedure is excellent if the loss of dimension is predominantly vertical. It also allows the mucogingival junction to be repositioned by the ex- tension of two vertical incisions out to the buccal surface c of the involved area. The procedure should not be used when there is inadequate thickness of palatal tissue available or when the edentulous ridge area is knifelike, with scant under- lying bone and soft tissue. That is, there must be a scaffold of underlying bone to support the graft; other- wise, excessive shrinkage could result. These situations can be assessed utilizing needle probing under anesthesia prior to surgery. THE A UTOGENOUS COMBINED EPITHELIAL AND CONNECTIVE TISSUE FREE GRAFT (Wedge Tech- u nique)-This procedure is most useful in knifelikeeden- tulous ridge areas or when there is insufficient palatal Fig SA-Diagrammatic representation of the complete roll pro- tissue available in the ridge area for use of the roll cedure. (Courtesy of Dr. Leonard Abrams, University of Pennsyl- technique. It is also particularly useful when a large vania.J amount of gingiva must be added in a vertical dimension (Fig 6A). This technique, in contrast to that using the non-epinephrine bearing anesthetic, by sharp dissection pedicle graft, described above, requires the utilization of or by use of a rotary diamond instrument. Free bleed- a donor site distant from the ridge to be augmented. An ing, permitted by the non-epinephrine anesthetic, is excellent site, which invariably yields the required ade- evidence of complete epithelial removal. The tissue is quate thickness of donor tissue, is the tuberosity area then infiltrated with an anesthetic containing a distal to the maxillary molars. hemostatic agent, and a connective tissue pedicle flap is The recipient site is prepared first by a partial outlined through to the osseous, and then elevated from thickness dissection which removes the epithelium and a the palate within the de-epithelialized zone (Fig 58). In nominal portion of the underlying connective tissue, this procedure, it is important that the proximal resulting in a free bleeding surface. The amount of marginal tissue of the adjacent abutment teeth is not required tissue is then outlined on the tuberosity area involved. This will ensure stability of the crown margin- according to the measurements taken from the recipient to-tissue relationship. site, and a large wedge of both epitheliwn and connective A zone of tissue is de.epithelialized corresponding to tissue is removed. This wedge, the undersurface of which the amount of augmentation required, and the pedicle is shaped to conform to the ridge to be augmented, is may even be rolled in upon itself twice before being sutured in position (Fig 6B). It is essential to expedite placed on the apex of the residual osseous ridge. Next, a this stage of the procedure, allowing for rapid coapta- pouch on the labial aspect of the ridge is created by tion of the free graft and the development of adequate blunt dissection and the flap is inverted upon itself and nutrient circulation. placed into it. Sutures are removed at 12 days (Fig 6C). At this stage, A specific suturing technique is used to maintain the resulting tissue may not blend in perfectly with the stability of the pedicle graft. The needle is initially tissues above and lateral to it. A gingivectomy or inserted from the buccal surface through the rolled gingivoplasty invariably is required to blend in the pedicle to the palatal side and then back through the donor tissue and to develop the concave form of the pedicle and the pouch, through to the buccal surface pontic recipient site. It should be emphasized that these once again, where the suture is tied off (Fig 5C). plasty procedures should not be done at the time of
  • 8. 2/8 The Compendium of Continuing Education surgery but only at a subsequent visit, following the this donor tissue is placed on saline-soaked gauze. Next, "take" of the graft. the initial envelope flap is sutured back.in position and Loss of Dimension of a Horizontal Nature (Fig 7)- held in close apposition with the underlying bone for 6 The subepithelial connective tissue graft generally is or 7 minutes. This covers the denuded bone, facilitating used to augment ridges with a predominantly horizontal healing with only a mild depression that will fill to its deformity. Depending upon the anatomy of the de- normal level over a period of time, at the same time formity, two types of surgical plastic procedures are decreasing both the amount of pain associated with the available to the clinician: the flap or the pouch (single or exposed bone and the problems associated with dressing double). the area. The basis of all these procedures is the placement of a The connective tissue graft can now be placed in a graft of only connective tissue from a remote site, prepared recipient site and sutured in position. subepithelially, in the area of the ridge requiring REClPIENT SITE PREPARATION--Preparation of the augmentation. recipient site for both the flap and pouch procedures will Dhe-decision about which type of procedure to use in be discussed. any given case depends upon whether there is an I. F/ap procedure. This is the most useful procedure alteration in the mucogingival junction line of the ridge for correcting deformities in the horizontal dimension relative to the adjacent teeth, and on the number of teeth when the mucogingival junction has moved coronally, involved, that is, the lateral dimension of the graft. leaving insufficient masticatory mucosa for pontic re- The flap procedure (Fig 8) is indicated only if the ception directly over the ridge. mucogingival junction in the deformed area is to be A split thickness flap is first elevated on the buccal repositioned. This type of situation arises from prob- aspect of the deformed ridge, leaving the periosteum and lems associated with tooth extraction and the ultimate a portion of the connective tissue overlying the alveolar healing of the mucogingival junction at a level more ridge (Fig SA). The vertical incisions extend in an coronal than that of the adjacent teeth. However, if it is oblique fashion on either side of the deformed ridge and in line with the mucogingival junction of the adjacent into the labial fold as high as is necessary to reposition teeth, one of the pouch procedures is more suitable. the mucogingival junction. The horizontal incision is The double pouch procedure (Fig 9) generally is used made on the pa/ata/ aspect of the ridge so as to increase only when the deformity crosses the midline or is of too the zone of masticatory mucosa available for reposition- great a dimension to allow all the donor tissue to be ing. The connective tissue from the donor site is placed placed in through a unilateral incision. on this somewhat concave base and, if necessary, In all of these procedures, the removal of the connec- sutured in position with resorbable gut (Fig SB). The tive tissue graft from the donor site is similar; the only elevated split thickness flap is then sutured down over differences are in recipient site preparation, as will be the connective tissue to immobilize it in the desired demonstrated below. position and realign the mucogingivaljunction (Fig SC). DONOR SITE PREPARATION-The most readily avail- This overlying flap, together with the underlying con- able sources of donor tissue are found in the lateral nective tissue base, should provide an adequate source aspects of the palate and in the tuberosity region. The of nutrients for the connective tissue graft. tissue for the graft may be removed from these areas The sutures are removed at 10 days and the area either as part of a maxillary periodontal surgical pro- redressed with a periodontal pack. Next, the required cedure (secondary flap) or as an individual procedure pontic recipient concavities are created in the ( envelopeflap ). In the first case, the tissue for the graft is augmented ridge, and the pontics of the provisional removed either as part of the wedge and ledge procedure restoration relined with acrylic and adapted to these or in the thinning out of the primary palatal flap. After concavities. the secondary flap is removed, it is de-epithelialized of 2. Pouch procedures. The pouch procedure is used in marginal gingiva and inflamed sulcular tissue. those situations in which the dimensional loss of the In the case of the envelope flap, a rectangular form is ridge is predominantly horizontal (Fig 10A), and the first outlined in the posterior aspect of the palate. The mucogingival junction is essentially in line with that of base of the flap is towards the midline of the palate and the adjacent teeth. There are two approaches to place- the most coronal aspect approaches within 2 to 3 mm of ment of the initial incision: a vertica/ ob/ique incision or the free gingival margin, but does not encroach upon it. a horizonta/ incision. The lateral dimension of the flap depends upon the In the first approach, preparation of the recipient site recipient site deformity and the amount of tissue needed. is initiated by a vertical oblique incision extending from The split thickness envelope flap is then raised: by a the ridge apex, just mesial to one of the abutment teeth, procedure similar to that used for taking a free epithelial and up towards the vestibular fornix (Fig 10B). The graft for mucogingival procedures. The epithelium and integrity of the interproximal marginal tissue should not connective tissue are not removed, however, but are left be disturbed, in order to maintain the crown margin-to- attached along the midline. The underlying connective tissue relationship. Through this initial incision, a split tissue is then removed down to the palatal osseous, and dissection of the tissue overlying the ridge is performed.
  • 9. The Edentulous Ridge in Fixed Prosthodontics 219 Fig 7-Clinical'appearance of typical horizontal loss in dimension Fig 8A-Surgical approach to flap procedure. Split thickness flap is of a deformed edentulous ridge, due to loss of buccal plate during raised to reposition mucogingival junction and to provide a base extraction of lateral incisors. on which to place the connective tissue graft. (Courtesy of Dr. E.S. Rosenberg, University of Pennsylvania.) ~ ~ [ ,c J 'f c c~ r l ./!n.~ Fig 8B-Diagrammatic representation of flap procedure. Connec- Fig 8C-Diagrammatic representation of elevated flap sutured tive tissue graft is sutured onto the periosteum of the deformity. back into position over the connective tissue graft in such a way as to realign the mucogingival junction. Fig 9-Diagrammatic representation of double pouch procedure extending across the midline. The lateral extent of the deformed ridge requires that grafts must be placed in position through a bilateral incision on either side of the midline. Fig lOA-The preoperative appearance of horizontal bone loss in Fig 10B-Clinical appearance of the vertical oblique incision. Note an edentulous ridge. that the marginal integrity is left undisturbed.
  • 10. 220 The Compendium of Continuing Education Fig 10C-Split thickness dissection of tissue over the entire Fig 10D-Connective deformity to develop a tissue graft being pouch into which con- slipped into the pouch nective tissue grafts and tried in position may be placed. prior to suturing. It extends through the masticatory mucosa and the pouch (Figs IOD and E). It may be necessary to try one mucogingival junction into alveolar mucosa. or more pieces of connective tissue to ascertain if the The tissue over the entire deformity and slightly amount of augmentation is adequate and of the correct beyond is elevated to create a pouch (Figs lOC and E). form. The tissue graft is sutured in position as described The fact that the deformity is concave permits the below (Figs IOF and G), dressed, and allowed to heal for elevation of the tissue towards the buccal aspect without 4 weeks when the pontic concavities are developed. The any tension being placed on it. temporary restoration is relined and recemented, and 13 The connective tissue from the donor site is cut into weeks is allowed to elapse before the augmented ridge the appropriate size and tried in position within the (Fig IOH) is ready for the final prosthesis. Fig 10F-Diagrammatic representation of suturing technique. Fig 10E-Cross-sectional diagrammatic representation of connec- Note that the connective tissue graft is not yet in position within tive tissue graft in position, subepithelially. the pouch. It will be pulled into the pouch utilizing the two loose ends of the suture and will be stabilized in a position which depends upon the initial entry of the "bite" of the first suture. Fig 10G-Diagrammatic representation of pouch closure with Fig 10H-Augmented ridge with depression created for ovate interrupted sutures, following insertion of connective tissue pontic. (Compare with Fig 10A.) grafts.
  • 11. The Edentulous Ridge in Fixed Prosthodontics 221 Fig 11A-Clinical appearance of horizontal incision at the crest of Fig 11B-Diagrammatic representation of horizontal incision. In. edentulous ridge. cisal view. " , ~ Fig 11C-Diagrammatic representation of horizontal incision with Fig llD-Clinical appearance of the small initial incision and pouch development. Dissection has been extended laterally and pouch. apically over the entire deformity via the initial incision. Fig 11E-Connective tissue being placed into the pouch Fig 11F-Connective tissue graft sutured into position. Fig 11G-Clinical view of preoperative ridge. Fig llH-Postoperative view of the same ridge following augmel tation. Note the dramatic increase in horizontal dimension.
  • 12. 222 The Compendium of Continuing Education In the second approach, a horizontal incision is made at the base of the edentulous ridge and extends apically through the entire length of the deformity (Figs IIA and B). The pouch is then developed by extending the split thickness incision laterally in order to elevate the tissue lying within the area of the deformity and slightly beyond (Fig II C). Next, the donor tissue is slipped through the primary horizontal incision into position in an inciso-apical direction (Figs IID, E, and F). Healing takes place as with the vertical incision, and Fig 12A-Cross-sectional diagrammatic representation of place- ment of horizontal incision on the palatal aspect of the ridge at a the augmented. ridge (Figs IIG and H) undergoes a more apical level, This facilitates a certain amount of drape to the gingivoplasty to develop the concave pontic recipient pouch, which is created by extending this incision horizontally site. toward the buccal aspect and then apically around the osseous crest Following placement of connective tissue within this pouch, If the deformity has an added vertical component as the augmentation will be in both a horizontal and a vertical well (Fig 12D), the placement of the horizontal incision dimension, Fig 12B-Clinical view of incision similar to that shown in Fig 12A Fig 12C -Clinical view showing connective tissue graft in position. It was slipped in through the initial palatal incision over the osseous crest and around onto the buccal aspect of the deformity, leaving the base of the graft overlying the actual crest of the osseous ridge. This will facilitate augmentation in a horizontal dimension as well as a vertical dimension. Note, however, that the initial incision cannot be closely coapted and should not be tightly tied off. This area must heal by secondary intention. Note the donor site on the right side of the palate. Fig 12D-Preoperative view with provisional restoration in place Fig 12E-Postoperative view of the same site following ridge and pink acrylic on the apical end of the provisional restoration. augmentation. Note the dramatic amount of vertical as well as horizontal ridge augmentation. Note, too, that the provisional restoration has been cut back on its apical end to allow for the increase in ridge dimension.
  • 13. The Edentu/ous Ridge in Fixed Prosthodontics 223 must be changed. It should now be made on the palatal incision is still easily closed (Fig lOO) despite the side of the edentulous ridge, at a more apical level, plumping, because elevation of the pouch from within corresponding to the crest of the underlying alveolus the concavity of the deformity results in an extra (Fig 12A). dimension of available tissue to bridge the gap:" The dissection is made horizontally from the palate The sutures are removed at 10 days and the area towards the buccal surface and then onward, around the redressed. After a further 2 weeks, the augmented alveolus in an apical direction (Fig 128). The tissue deformity can be shaped with a diamond stone to coronal to the primary incision will now drape some- develop the concave form for the pontic. The temporary what incisally, which will add vertical dimension to the pontic is relined with self-curing acrylic and placed while ridge. The dissection is completed by extending it later- still soft into this newly formed concave recipient site. ally over the complete area of the deformity. The donor The acrylic, once set, is trimmed, the ovate base graft is slid in through the incision around the alveolus polished, and the temporary bridge recemented in posi- and onto the buccal surface (Fig 12C). The base of the tion; The whole complex is allowed to heal a further 8 graft will remain on the crest of the alveolus, augment- weeks before final impressions for the prosthesis are ing it in both a vertical and horizontal dimension. The taken. initial incision should not be sutured back into close apposition or the net gain in a vertical dimension will be Summary lost. It should be allowed to heal by secondary intention The techniques described in this paper can be utilized or by placing a connective tissue graft with a small base to augment edentulous ridge concavities, irregularities, of epithelium, which will fill the void created by the and deformities in those cases in which esthetics is of drape of the pouch (Figs 12D and E). prime importance or in which the deformed ridge Ridge deformities may be bizarre, requiring augmen- interferes with the function of speech or the ability to tation in varying dimensions and planes; consequently, perform oral physiotherapy. The resulting soft tissue several separate incisions may be necessary, depending areas closely mimic normal gingival contours and form upon where the pouch is to be developed and where the a concave soft tissue pontic recipient site for the desired tissue is to be placed in the augmentation process. A convex pontic. These procedures are extremely useful deformity may require, therefore, the utilization of both adjuncts for correcting esthetic and functional problems vertical and horizontal incisions, in both the palatal and in fixed prosthesis. buccal aspects. SUTURING TECHNIQUE-A suturing technique is re- quired which accurately localizes and stabilizes the The author would like to acknowledge Elissa Berardi for connective tissue grafts in the positions decided upon her work on the drawings in this article. during the try-in phase of the procedure. The needle is inserted from the labial surface at the point at which it is desired to anchor one of the connective tissue grafts. It then passes through the undersurface of the pouch and out through the initial REFERENCES incision. The needle is next passed through the donor connective tissue, back through the initial incision, into I. Abrams L: Augmentation of the deformed residual edentulous the pouch, and out onto the labial surface (Fig 1OF). ridge for fixed prosthesis. Compend Contin Educ Gen Dent 1(3):205-214, 19.80. The two ends of the suture are now gently pulled and the 2: Dilmmer PT , Gidden J: The upper anterior sectional denture. J connective tissue graft is eased through the primary Prosthet Dent 41: 146, 1979. incision into the pouch in the position determined by the 3. Eissman HJ, RadkeRA, Noble WH: Physiological design criteria for fixed dental restorations. Dent Clin North Am 15:3, 1971. placement of the initial insertion of the suture needle. 4. Goldstein RE: Esthetics in Dentistry. Philadelphia, JB Lippincott The suture is now tied off in the usual manner (Fig Co, 1976, pp 90-122. 5. Langer B, Calagna L: The subepithelial connective tissue graft. J 100). Prosthet Dent 44:363; 1980. It is important to the cosmetic success of the pro- 6. Nery EB, Lynch KL, Rooney GE: Alveolar ridge augmentation cedure that the donor tissue be immobilized accurately with tricalcium phosphate ceramic. J Prosthet Dent 40:668, 1978. in position and held there; The tissue can be im- 7. Risch JR, White JG, Swenson HM: The esthetic labial gingival prosthesis. Jlndiana Dent Assoc 56:15; 1977. mobilized in two or three different positions which will 8. Stein RS: Pontic-residual ridge relationships: A research report. J result in a specifically shaped pontic area. The initial Prosthet Dent 16:283, 1966.
  • 14. 224 The Compendium of Continuing Education ARTICLE #2 REVIEW QUESTIONS The article you have read qualifies for Ih hour of Continuing Education Credit from the University of Pennsylvania School of Dental Medicine. For your reference, record your answers on this page and then transfer them to the registration form inserted in The Compendium. I. The physical and anatomical form of the pontic recipient solutions to the problem of the deformed residual eden- site is influenced by tulous ridge? a. the state of the extracted tooth. a. blending of pontic to ridge area with poor axial b. the mode of tooth removal. angulation c. the patient's age. b. Andrew's bridge d. the healing potential of the body. c. ridge augmentation e. all of the above d. all of the above 2. The ovate (egg-shaped) pontic design can be used only if the pontic recipient site is first prepared by some form of 8. Which of the following pontic-residual ridge designs has been presented as the most desirable in the anterior part of surgical procedure. a. true the mouth? a. total ridge lap with concave pontic surface in contact b. false with convex ridge tissue 3. Horizontal ridge deformities can be corrected utilizing b. modified ridge lap with convex pontic surface in a. the flap procedure. contact with convex ridge tissue b. the single pouch procedure. c. ovate pontic surface in contact with concave ridge c. the double pouch procedure. tissue d. all of the above d. modified ridge lap with no tissue contact to allow for 4. The flap is the most useful procedure for correcting those self-cleaning e. none of the above horizontal ridge deformities in which the mucogingival junction needs to be elevated. 9. The roll technique is contraindicated when a. true a. there is inadequate osseous scaffolding. b. false b. there is very thin soft tissue covering the alveolar ridge. 5. The most readily available sources of donor tissue are c. the edentulous ridge is knifelike. found in the lateral aspects of the palate and in the d. the defect is predominantly horizontal. tuberosity region. e. all of the above a. true b. false 10. Which one of the following statements regarding the process of de-epithelialization for the roll technique is 6. The autogenous combined epithelial and connective tissue correct? free graft is most useful a. Epinephrine-bearing anesthetics are used to control a. in knifelike ridge areas. b. when there is insufficient palatal tissue available for a bleeding during de-epithelialization. b. Non-epinephrine bearing anesthetics are used to en- de-epithelialized connective tissue pedicle graft. c. when a large amount of gingiva must be added in a courage bleeding during de-epithelialization. c. The choice of anesthesia is unimportant in the de- vertical dimension. d. all of the above epithelialization process. d. Anesthetic injections are necessary to distend tissue 7. Which of the following methods have been offered as during de-epithelialization.