JICDRO is a UGC approved journal (Journal no. 63927)

   Table of Contents      
CASE REPORT
Year : 2010  |  Volume : 2  |  Issue : 2  |  Page : 98-102

Overcoming esthetic challenges in the smile zone using the "roll flap procedure"


1 Department of Conservative, Endodontic and Aesthetic Dentistry, Rural Dental College, Loni. Ex Faculty Goa Dental College and Hospital, Bambolim, India
2 Department of Periodontics, A. J Institute of Dental Sciences, Kuntikana, Mangalore, Karnataka, India
3 Department of Conservative, Endodontic and Aesthetic Dentistry, Goa Dental College and Hospital, Bambolim, India

Date of Web Publication20-Apr-2012

Correspondence Address:
Rajdeep S Pavaskar
Department of Conservative, Endodontic and Aesthetic Dentistry, Goa Dental College and Hospital, Bambolim - 403 202
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.95277

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   Abstract 

Hard and soft tissue alveolar ridge deformities occur following the extraction of teeth, creating functional and esthetic tooth replacement challenges, especially in the esthetic zone. A surgical technique using a roll flap technique for ridge augmentation is discussed which when combined with conventional fixed partial dentures for tooth replacement creates a template of the labial and interproximal sulcus at the edentulous site, allowing for the molding of an ovate pontic resulting in greatly improved esthetics in an esthetically compromised case. This results in vastly improved restorative emergence profiles with minimal or no change in the height of the labial gingival margin and the form and height of the interproximal papillae with adjacent teeth. This technique enhances soft tissue contours adjacent to the definitive restoration that vary little from those of the original natural tooth.

Keywords: Gingival esthetic line, roll flap, zenith points


How to cite this article:
Wagle RG, Shanbhag C, Pavaskar RS. Overcoming esthetic challenges in the smile zone using the "roll flap procedure". J Int Clin Dent Res Organ 2010;2:98-102

How to cite this URL:
Wagle RG, Shanbhag C, Pavaskar RS. Overcoming esthetic challenges in the smile zone using the "roll flap procedure". J Int Clin Dent Res Organ [serial online] 2010 [cited 2019 Jun 24];2:98-102. Available from: http://www.jicdro.org/text.asp?2010/2/2/98/95277


   Introduction Top


In the adult patient, tooth loss in the maxillary anterior zone can occur secondary to facial trauma, failing root canal therapy, root fracture, internal or external tooth resorption, or decay. In the normal process of healing and repair following tooth extraction, the maxillary alveolar ridge adjacent to the involved tooth will resorb, leaving a deformity in the shape and form of both the hard and soft tissues. [1],[2]

The alveolar ridge width decreases by 50% in the first year after a tooth is extracted. [3] As the extraction sites heal, the largest change occurs on the labial and coronal aspects of the alveolar ridge, bringing with it a loss in both horizontal and vertical ridge dimensions. Any change in the alveolar hard and soft tissue ridge profile is undesirable as it results in compromised esthetics or failure of fixed restorative therapy. [4]

The surgical procedure for esthetic ridge preservation in the anterior maxilla requires successful completion of several interdependent coordinated steps to preserve the bony hard tissue ridge architecture and to preserve and maintain the ridge soft tissue profile. The first step in this process is the atraumatic extraction of the involved tooth. If possible, the reflection of a mucogingival flap on the labial aspect of the extraction site should be avoided. In addition to complicating the soft tissue procedures to preserve the interdental papillae of the extraction site with the adjacent teeth, the reflection of a full-thickness flap removes the periosteum from the underlying labial plate of bone, thus affecting the supply of nutrients that this soft tissue provides the thin cortical bone on the labial aspect overlying the maxillary anterior teeth. After the tooth is removed, a bony socket defect is present in the confines of the maxillary alveolar ridge. Overlying the bony socket at the extraction site are the soft tissue elements that comprise the connective tissue fiber apparatus, epithelial attachment, and gingival sulcus adjacent to the extracted tooth root. [5],[6] Interproximally, these soft tissue elements combine in height to form the interdental papillae with the neighboring teeth. On the labial aspect of the extraction site, the soft tissue is thin and drapes apically, as defined by the gingival margin and the gingival soft tissue profile of the ridge. Maintenance of this soft tissue architecture on the labial and interproximal aspects of the ridge adjacent to the extraction site is critical for the esthetics of the eventual replacement tooth.

If a fixed partial denture is used for tooth replacement, replacing the lost periodontal tissue profile requires filling the site with metal, porcelain, or plastic restorative materials. In practical terms, this means that the pontic replacement tooth will be longer than the adjacent natural teeth. Some authors have reported that the minimum horizontal change in the gingival margin height that will occur on the labial aspect of an extraction site is 2 mm. [7],[8] In addition; the interdental papillae will be altered and reduced in height, impacting the periodontal soft tissue esthetic profile for the replacement tooth in the definitive fixed prosthesis. [9]

Zenith points are the most apical points of the clinical crowns, which are the height of contour. Their positions are dictated by the root form anatomy, cementoenamel junction (CEJ), and the osseous crest, where the gingiva is scalloped the most. The zenith points are generally located just distal to a line drawn vertically through the middle of each anterior tooth. The lateral incisors are one exception to that rule, as their zenith points are placed more centrally or on the midline of the tooth margin.

This morphologic feature, produced by the correct position and arrangement of the anterior teeth, is especially evident in the maxillary central incisors, giving them a marked characterization because of the mirror imaging that distinguish them. [10]

One of the most significant features of gingival esthetics is contour progression from the incisors to canine. The gingival esthetic line (GAL) is a classification for creating pleasing gingival level transition between the maxillary anterior teeth. GAL is defined as a line joining the tangents of the zeniths of the free gingival margins of the central incisor and canine. The GAL angle is formed at the intersection of this line to the maxillary dental midline [Figure 1].
Figure 1: Gingival esthetic line

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Assuming a normal w/l ratio, anatomy, position, and alignment of the anterior dental segment, four classes of GAL are described:

  • Class I: The GAL angle is between 45° and 90° and the lateral incisor is touching or below (1-2 mm) the GAL [Figure 1].
  • Class II: The GAL angle is between 45° and 90° but the lateral incisor is above (1-2 mm) the GAL and its mesial part overlaps the distal aspect of the central incisor. This situation is often seen in Angle's class II or pseudo-class II conditions, and adds variety to the dental composition [Figure 1].
  • Class III: The GAL angle = 90°, and the canine, lateral, and central incisors all lie below the GAL [Figure 1].
  • Class IV: The gingival contour cannot be assigned to any of the above three classes. The GAL angle can be acute or obtuse. A myriad gingival asymmetries are apparent clinically including recession, passive, and altered passive eruption, eccentric eruption patterns, loss of interdental papillae, clefts, and high frenal insertions.





   Case Report Top


A 25-year-old male patient presented with an anterior fixed prosthesis which was esthetically unacceptable [Figure 2]. He had history of traumatic extraction of 11 resulting in loss of vertical height of the alveolar ridge. For which an acrylic (pink) obturator was placed over a period of 1 year this had become loose and mobile and was causing further gingival irritation [Figure 3].
Figure 2: Preoperative

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Figure 3: Old bridge removed

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The new treatment plan included soft tissue augmentation with the help of a roll flap procedure to bring back gingival esthetics and followed by a fixed partial denture with an ovate esthetic pontic. Following examination, the oversized teeth of the old FPD were shaped to get a satisfactory tooth size and a key or template was made with putty material. The bridge was removed and oral prophylaxis was done [Figure 3]. A temporary bridge with gingival extension made of pink composite was fabricated with tempress from the putty template (Tempress, Permoflo (pink), and Ultradent, [Figure 4]). The check-up after 1 week revealed good gingival health with class 2 gingival esthetic line [Figure 5]. Ridge augmentation using the roll flap procedure was carried out [Figure 5], using palatal mucosa as a host site [Figure 5]. A rectangular pedicle of connective tissue was prepared on the palatal side of the defect. The epithelium on the palatal surface of the donor site was first removed. Supraperiosteal connective tissue was raised from the palate using sharp dissection. A pouch was made in the supraperiosteal connective tissue at the facial (labial) surface of the ridge. The pedicle was tucked into the pouch and resorbable sutures were placed close to the mucobuccal fold so as to pull the pedicle to the apical portion of the pouch [Figure 5]. The interim fixed partial denture was then placed back and the pontic 11 was converted into ovate design so as to create esthetic emergence profile [Figure 6]. The recipient site was allowed to heal for 3 weeks showed good healing [Figure 6]. Impressions were made for a 3-unit porcelain fused to the metal (PFM) bridge. The temporaries were then placed back. The final 3-unit PFM bridge was then cemented with excellent esthetic results. The patient was recalled after 6 months [Figure 7].
Figure 4: Interim restoration

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Figure 5: The "roll fl ap procedure"

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Figure 6: Three weeks postsurgery

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Figure 7: Final restorations, a 6-month follow-up

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   Discussion Top


Numerous surgical graft and implant procedures attempting to reconstruct a partially edentulous ridge or ridge defect have been described in the literature over the years. The procedures may be grouped according to the means used for ridge augmentation as (1) soft tissue augmentation procedures and (2) hard tissue augmentation procedures. [11] The soft tissue augmentation procedure followed in this case facilitated a prompter recovery with acceptable results. The patient's expectations and clinical expertise are factors which govern the treatment outcome in such cases.

 
   References Top

1.Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prosthet Dent 1967;17:21-7.  Back to cited text no. 1
[PUBMED]    
2.Abrams H, Kopczyk RA, Kaplan AL. Incidence of anterior ridge deformities in partially edentulous patients. J Prosthet Dent 1987;57:191-4.  Back to cited text no. 2
[PUBMED]    
3.Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003;23:313-23.  Back to cited text no. 3
[PUBMED]    
4.Grunder U, Spielman HP, Gaberthüel T. Implant-supported single tooth replacement in the aesthetic region: A complex challenge. Pract Periodontics Aesthet Dent 1996;8:835-42.  Back to cited text no. 4
    
5.Gargiulo AW, Wentz FM, Orban B. Dimensions of the dentogingival junction in humans. J Periodontol 1961;32:261-7.  Back to cited text no. 5
    
6.Ingber JS, Rose LF, Coslet JG. The "biologic width" - A concept in Periodontics and restorative dentistry. Alpha Omegan 1977;70:62-5.  Back to cited text no. 6
[PUBMED]    
7.Kois JC. Esthetic extraction site development: The biologic variables. Contemp Esthet Restorative Pract 1998;2:10-5.  Back to cited text no. 7
    
8.Kois JC. Predictable single-tooth periimplant esthetics: Five diagnostic keys. Compend Contin Educ Dent 2004;25:895-6, 8.  Back to cited text no. 8
[PUBMED]    
9.Spear FM. Maintenance of the interdental papilla following anterior tooth removal. Pract Periodontics Aesthet Dent 1999;11:21-8.  Back to cited text no. 9
[PUBMED]    
10.Wheeler RC. Complete crown form and the periodontium. J Prosthet Dent 1961;11:722-34.  Back to cited text no. 10
    
11.Lindhe J, Lang NP, Karring T. Clinical Periodontology and Implant Dentistry. 5 th ed. Hoboken, New Jersey: Blackwell Publishing; 2008. p. 1011-3.  Back to cited text no. 11
    


    Figures

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



 

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