The Pediculated Connective Tissue Graft: A Novel Approach for the “Blown-Out” Site in the Esthetic Zone
David P. Mathews, DDS
Management of the soft tissue framework around an implant is key to achieving ideal esthetics in the maxillary anterior esthetic zone. When a patient has a tooth with advanced bone loss and recession in the esthetic zone, removing that tooth and replacing it with an implant often requires multiple surgical procedures to restore the lost hard and soft tissue. This article will discuss a novel approach to this dilemma. A case treated with a 1-stage surgical procedure using the pediculated connective tissue graft will be presented. The extraction of an anterior tooth with advanced bone loss, placement of an immediate implant, and reconstruction of the hard and soft tissue with one surgery will be demonstrated. The 2-year follow-up of the final prosthetic restoration that shows the stability of the soft tissue also will be presented.
Clinicians often are faced with the dilemma of how to handle a tooth with advanced bone loss and recession when it is planned for extraction and implant replacement. Reconstruction of the hard and soft tissue is imperative if an esthetic result is to be achieved. This is especially challenging if the tooth is in the maxillary esthetic zone and the patient has a high smile line.
There are many ways to treat a site that presents with advanced bone loss and recession. One way is to extract the tooth, consider a ridge preservation procedure, and let the site heal for a few months. When there is a vertical deficiency, further bone grafting with autogenous blocks or membranes often is required.1-3 After approximately 6 months the implant can be placed. Further soft tissue augmentation of the site can be done at placement or any time during the healing or provisionalization stage if needed. Another method of treatment is to extract the tooth and place the fixture immediately with concomitant bone grafting.4-9 The deficient soft tissue can be reconstructed with connective tissue at a later time.10-14 Many other permutations of techniques can achieve similar results. However, the case with advanced hard and soft tissue loss often requires multiple surgeries to achieve an esthetic result.
This case will demonstrate a novel approach to this dilemma. The pediculated connective tissue graft15-20 will be used in a 1-stage surgical procedure to treat the “blown-out” site during immediate implant placement, concomitant bone grafting, and soft tissue augmentation.
A 45-year-old woman presented with advanced bone loss and gingival recession in and around tooth No. 9 (Figure 1 View Figure View Figure). The tooth exhibited class 3 mobility and probed to 8 mm on the labial and mesial aspects with suppuration. The patient had a very high smile line that showed considerable gingival tissue above the already receded gingival margin. She also had a triangular tooth form that would further complicate the esthetic restoration of the affected tooth.21
The tooth was extracted using the periotome (Ace Surgical, Brockton, MA) and gentle removal with forceps to preserve the already deficient hard and soft tissue. The site was debrided with curettes and rinsed with a saturated solution of tetracycline. The labial plate was present at the apical one fifth only. A surgical stent was used to direct the implant angle slightly lingual to the incisal edge. The osteotomy site was initiated at the palatal wall with the use of special lateral cutting burs (Ace Surgical). The inner labial aspect of the osteotomy site was dehisced approximately 5 mm (Figure 2 View Figure). This area was basted with a mixture of autogenous bone from the osteotomy site, Bio-Oss (Osteohealth Co, Shirley, NY), freeze-dried cortical bone (Lifenet, Virginia Beach, VA), calcium sulfate, and tetracycline. A firm putty-like mix was made and basted into the deficient site before the implant was placed.
A 3.75-mm x 15-mm Osseotite external hex implant (Implant Innovations Inc, West Palm Beach, FL) was placed (Figure 3 View Figure). Despite the deficient gingival margin, utmost care must be used in placing the platform at the proper location, 3 mm to 4 mm apical to the ideal gingival margin of the final restoration.22-25 A split-thickness dissection was made on the labial of the site to make a pouch for the soft tissue graft. A 2-mm healing abutment was placed on the implant to serve as a “tent pole” for the pediculated graft26 (Figure 3 View Figure). To augment the soft tissue deficiency, a large, pediculated connective tissue graft was harvested from the left palate.19 An outer split-thickness dissection was made on the palate starting at the mesial of the first molar and extending to the palatal sulcus of the extraction site. The pedicle was scribed to bone with a sharp blade on the distal, coronal, and apical areas. The mesial was left intact at the base of the extraction site. The graft should be at least 8 mm wide to cover the mesial-distal width of the extraction site. The pediculated graft was elevated from the bone with a Pritchard elevator (Hu-Friedy, Chicago, IL) with care taken to keep the base of the graft intact. The graft must be released adequately so that the end of the pedicle can be positioned, tension free, 3 mm to 4 mm apical to the platform of the fixture. The pedicle was then “flipped” over the implant site and tucked into the labial pouch (Figure 4 View Figure View Figure). Two 5-0 gut (Surgical Specialties Corp, Reading, PA) purse-string sutures were used to position the end of the graft 3 mm to 4 mm apical to the platform of the implant. The site can be closed with the same suture. Occasionally, it is possible to release the labial tissue enough so that complete closure is possible with a horizontal mattress suture.
The case with advanced hard and soft tissue loss often requires multiple surgeries to achieve an esthetic result.
It is paramount that the temporary tooth does not put pressure on the site or the palate. For that reason, an Essex appliance or a bonded tooth is necessary to relieve the temporary so that it does not encroach on the graft and also leaves room for subsequent swelling.19 Further adjustment is often needed at the 1-week postoperative appointment. The area is evaluated at 6 months to see if there is adequate soft tissue bulk in all dimensions (Figure 5 View Figure View Figure). Further soft tissue augmentation is rarely needed. The fixture can be uncovered 4 to 6 months after surgery using a punch technique or a pedicle flap initiated from the palate (Figure 6 View Figure).22-25 It is imperative that the site be overbuilt before uncovering and preserved at the uncovering.
A provisional restoration can be placed approximately 3 weeks after uncovering (Figure 7 View Figure). The contours are critical in molding the soft tissue that has been overbuilt. The site can be molded to an ideal gingival framework in a few months.22, 27 The final restoration should mimic the contour of the provisional to maintain this ideal molded framework (Figures 7 View Figure, 8 View Figure, 9 View Figure View Figure, and 10 View Figure).
The pediculated connective tissue graft can augment a large volume of soft tissue. It also may serve as a barrier membrane. There has been considerable discussion about the advisability of “rotating” the pedicle vs “flipping” the pedicle over the site to be augmented. When the pedicle is rotated, the periosteal side is against the bone and may have a greater barrier/osteoconductive effect, but there has been no research as of yet to validate this. When the pedicle is flipped over the site, it allows for greater vertical soft tissue augmentation. There are a few drawbacks to flipping the pedicle over the site. Primary closure is more difficult to achieve (Figure 4 View Figure View Figure), and the maturity of the graft may take more time. Secondly, the palatal aspect can be lumpy and may require thinning if it is bothersome to the patient (Figure 5B View Figure).
From a restorative standpoint, this patient had a triangular tooth form and restoration of the adjacent central incisor would enhance the esthetic result. If the adjacent tooth was not restored it would have been impossible to mimic its shape with the implant restoration without leaving a black space. In this case, the patient opted for some bonding of the mesial aspect (Figure 9B View Figure). A veneer or a full ceramic restoration would have resulted in a more esthetic result.
The pediculated connective tissue graft offers an alternative to multiple surgeries to correct sites with advanced hard and soft tissue loss.
The pediculated connective tissue graft offers an alternative to multiple surgeries to correct sites with advanced hard and soft tissue loss. It can be used at the time of immediate implant placement with concomitant bone grafting to achieve adequate soft tissue volume with one surgical intervention. The graft can be used in any area in the maxilla where soft tissue augmentation is required, and it can be used in conjunction with other grafts, membranes, and conventional connective tissue grafts.
The author would like to thank Dr. Connie Small of Tacoma, Washington, for the restorative treatment performed in this article.
1. Nevins M, Mellonig JT. Enhancement of the damaged edentulous ridge to receive dental implants: a combination of allograft and the GORE-TEX membrane. Int J Periodontics Restorative Dent. 1992;12(2):96-111.
2. Buser D, Dula K, Belser U, et al. Localized ridge augmentation using guided bone regeneration. 1. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent. 1993;13(1):29-45.
3. Jovanovic SA, Nevins M. Bone formation utilizing titanium-reinforced barrier membranes. Int J Periodontics Restorative Dent. 1995;15(1):57-69.
4. Simion M, Misitano U, Gionso L, et al. Treatment of dehiscences and fenestrations around dental implants using resorbable and nonresorbable membranes associated with bone autografts: a comparative clinical study. Int J Oral Maxillofac Implants. 1997;12(2):159-167.
5. Becker W, Hujoel P, Becker BE. Effect of barrier membranes and autologous bone grafts on ridge width preservation around implants. Clin Implant Dent Relat Res. 2002;4(3):143-149.
6. Chen ST, Darby IB, Adams GG, et al. A prospective clinical study of bone augmentation techniques at immediate implants. Clin Oral Implants Res. 2005;16(2):176-184.
7. Cornelini R, Cangini F, Martuscelli G, et al. Deproteinized bovine bone and biodegradable barrier membranes to support healing following immediate placement of transmucosal implants: a short-term controlled clinical trial. Int J Periodontics Restorative Dent. 2004;24(6):555-563.
8. Hammerle CH, Lang NP. Single stage surgery combining transmucosal implant placement with guided bone regeneration and bioresorbable materials. Clin Oral Implants Res. 2001;12(1):9-18.
9. Chen ST, Wilson TG Jr, Hammerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. 2004;19(Suppl):12-25.
10. Langer B, Calanga L. The subepithelial connective tissue graft. J Prosthet Dent. 1980;44(4):363-367.
11. Edel A. The use of a connective tissue graft for closure over an immediate implant covered with occlusive membrane. Clin Oral Impl Res. 1995;6(1):60-65.
12. Bianchi AE, Sanfilippo F. Single-tooth replacement by immediate implant and connective tissue graft: a 1-9-year clinical evaluation. Clin Oral Implants Res. 2004;15(3):269-277.
13. Azzi R, Etienne D, Takei H, et al. Surgical thickening of the existing gingiva and reconstruction of interdental papillae around implant-supported restorations. Int J Periodontics Restorative Dent. 2002;22(1):71-77.
14. Grunder U. The inlay-graft technique to create papillae between implants. J Esthet Dent. 1997;9(4):165-168.
15. Wang PD, Pitman DP, Jans HH. Ridge augmentation using a subepithelial connective tissue pedicle graft. Pract Periodont Aesthet Dent. 1993;5(2):47-51.
16. Khoury F, Happe A. The palatal subepithelial connective tissue flap method for soft tissue management to cover maxillary defects: a clinical report. Int J Oral Maxillofac Implants. 2000;15(3):415-418.
17. Nemcovsky CE, Artzi Z, Moses O. Rotated split palatal flap for soft tissue primary coverage over extraction sites with immediate implant placement. Description of the surgical procedure and clinical results. J Periodontol. 1999;70(8):926-934.
18. Gasparini DO. Double-fold connective tissue pedicle graft: a novel approach for ridge augmentation. Int J Periodontics Restorative Dent. 2004;24(3):280-287.
19. Mathews DP. The pediculated connective tissue graft: a technique for improving unaesthetic implant restorations. Pract Proced Aesthet Dent. 2002;14(9):719-724.
20. Nemcovsky CE, Moses O, Artzi Z, et al. Clinical coverage of dehiscence defects in immediate implant procedures: Three surgical modalities to achieve primary soft tissue closure. Int J Oral Maxillofac Impl. 2000;15(6):843-852.
21. Weisgold A, Arnoux JP, Lu J. Single-tooth anterior implant: a word of caution. Part 1. J Esthet Dent. 1997;9(5):225-233.
22. Spear FM, Mathews DP, Kokich VG. Interdisciplinary management of single-tooth implants. Semin Orthod. 1997;3(1):45-72.
23. Mathews DP. Soft tissue management around implants in the esthetic zone. Int J Periodont Rest Dent. 2000;20(2):141-149.
24. Barone R, Clauser C, Prato GP. Localized soft tissue ridge augmentation at phase 2 implant surgery: a case report. Int J Periodontics Restorative Dent. 1999;19(2):141-145.
25. Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Dent. 1980;1(3):205-213.
26. Salama H, Salama M, Garber D, et al. Developing optimal peri-implant papillae within the esthetic zone: guided soft tissue augmentation. J Esthet Dent. 1995;7(3):125-129.
27. Potashnick SR. Soft tissue modeling for the esthetic single-tooth implant restoration. J Esthet Dent. 1998;10(3):121-131.