Application of a Modified Roll Technique to Ridge Augmentation Before Implant Surgery: A Case Report

Transcription

1 Copyright CASE REPORTS Appliction of Modified Roll Technique to Ridge Augmenttion Before Implnt Surgery: A Cse Report Luiz Gustvo Nscimento de Melo, José Sérgio Mi Neto, Wendel Teixeir, Frederico Ciporkin, Cio Márcio Figueiredo Implnt-supported prosthetic rehilittion of nterior edentulous spces is chllenge to the dentist performing the implnt surgery. Proper positioning of the implnt nd its hrmonious reltionship with the hrd nd soft tissues re fundmentl, since the re requires high esthetic demnd. This cse report suggests vrition in the roll technique for correction of defect on the mxillry nterior ridge efore plcement of dentl implnt. Key words: soft tissue, implnt, ridge ugmenttion INTRODUCTION AND LITERATURE REVIEW Prosthetic rehilittion of n isolted edentulous spce t the premxill is criticl, considering the high esthetic demnd (Lewis, 1995). Aspects s the shpe nd mount of remining one, quntity nd qulity of the mucos, reltionship with the neighoring teeth nd opponent rch, smile line, orthodontic spects, periodontl prolems, esides the size of the implnt to e employed should e strictly nlysed. For chievement of predictle esthetic outcome, detiled previous plnning is required (Askry, 2001; Mthews, 2000). According to Sdoun et l (1994), desirle esthetic outcome my not e chieved if there is impirment in the hrmony etween prosthesis nd soft tissues, even though the ppernce nd shpe of the prosthetic crown re cceptle. Therefore, surgicl correction of the one nd/or mucogingivl ltertions in edentulous res or peri-implnt regions tht will e rehilitted with prostheses is essentil (Askry, 2001; Hürzeler nd Weng, 1999; Andrienssens et l, 1999; Potshnick, 1998). A loclised defect on the residul lveolr ridge is chrcterised regionl deficit of one nd/or gingivl tissue. These types of defect my e cused locl trum, tooth extrction, periodontl lesions, tumors or congenitl developmentl disturnces (Gsprini, 2004; Schrf nd Trnow, 1992; Sdoun et l, 1994). According to Schrf nd Trnow (1992) nd Gsprini (2004), nterior res presenting such defects present difficult prosthetic rehilittion, especilly due to the esthetic involvement, in ddition to speech, feeding nd orl hygiene disturnces. Seiert (1983) clssified the lveolr ridge defects s follows:. Clss I: loss of tissue volume in uccolingul direction, with norml conditions of height in picl-coronl dimension. Clss II: tissue loss in picl-coronl direction, with no chnge in volume in the uccolingul dimension c. Clss III: decresed volume oth in uccolingul nd picl-coronl dimensions. Perio 2006; Vol 3, Issue 1:

2 de Melo et l Appliction of modified Roll Technique to Ridge Augmenttion Before Implnt Surgery Copyright In 1985, Allen et l clssified the ridges s to the depth of the deformity in reltion to the djcent lveolr level, s:. Mild: depth less thn 3 mm. Moderte: rnging from 3 6 mm c. Severe: more thn 6 mm These deformities were corrected with prosthetic mterils, in n ttempt to reestlish the nturl rch contour. This led to suspended teeth, s pontics tht usully were longer thn the djcent nturl teeth, or utilistion of flnks to simulte the gingiv over the pontic. Such types of prostheses were cceptle from functionl stndpoint, yet ll of them frequently cted s res for ccumultion of deris nd were not esthetic (Seiert, 1991). Periodontl or peri-implnt plstic surgery procedures hve een successfully performed in Implntology (Louise nd Borghetti, 2002; Adriessens et l, 1999; Isrelson nd Plemons, 1993) to restore the shpe nd dimensions of soft nd hrd tissues on the lveolr ridge efore, during or fter plcement of implnts. These include the pproches for ridge ugmenttion with soft tissues. The epithelil-connective free grfts (Meltzer, 1979), only grfts (Seiert, 1983), suepithelil connective tissue grfts (Lnger nd Clgn, 1980), nd roll pedicled grft techniques (Arms, 1980; Schrf nd Trnow, 1992; Brone et l, 1999; Gsprini, 2004) re the most employed pproches. Meltzer (1979) ws one of the first uthors to indicte the utiliztion of free epithelil-connective grfts for correction of lveolr ridge defects t the mxillry nterior region. The predictility of free gingivl grfts for correction of ridge defects ws confirmed lter Seiert (1983). However, this uthor suggested the ccomplishment of thicker grfts, such s only grfts, with complete removl of epithelium nd connective tissue from the plte, mking use of its entire thickness, for correction of Clss II nd III defects, considered s moderte nd severe, respectively. Developed Lnger nd Clgn (1980), the suepithelil connective tissue technique is indicted for esthetic res, since it llows chievement of resonle increse in the volume of the re nd does not led to ltertions in color t the grfted re. This comprises preprtion of the receptor site, rising uccl flp with two verticl relesing incisions, not including the ppille. The free connective tissue grft is plced under the flp, dpted nd sutured. The roll technique, descried Arms in 1980, comprises de-epithelistion of pltl flp. The length of the pedicle should e comptile with the height of the defect on the uccl spect nd similr to the crest in mesiodistl direction. This pedicle is rolled under the uccl mucos to increse the uccolingul dimension of the edentulous ridge for lter friction of fixed prosthesis. The flp is relesed two verticl incisions extended eyond the mucogingivl junction. This technique my e employed for correction of moderte defects, Seiert s Clss I. Lter, the first modifiction to this technique ws proposed (Schrf nd Trnow, 1992), in which the epithelium over the pltl connective tissue is rised nd preserved, 'trp-door' pproch. Two full thickness relesing incisions re performed on the top of the lveolr ridge crest towrds the plte, extending in uccl direction, preserving the ppille of the djcent teeth. These incisions re joined superficil incision on the lveolr ridge crest, followed division of the pltl epithelium nd its reflection under the uccl flp. This sme epithelium will e used to cover the exposed donor site, fter relese of the underlying connective tissue, which should e rolled under the uccl flp. Heling of the donor site first intention represents n evolution of the technique, reducing the heling period nd discomfort to the ptient. Moreover, some uthors suggest tht the mount of connective tissue tht my e rolled under the uccl flp is incresed. Brone (1999) modified the technique suggested Arms, dpting it to the second-stge implnt surgery, nd presented intrsulculr incisions forming full thickness 'envelope' on the uccl spect insted of the two uccl relesing incisions, which would serve to ccommodte the roll of connective tissue, dopting the technique of de-epithelistion of the donor site tht ws restricted to the portion of tissue over the cover screw. This pper ims t proposing modifiction of the roll technique for correction of Seiert s Clss I defects to improve the tissue contour efore the implnt surgery. CASE REPORT The ptient E.T.S.A., ged 23 yers, white nd presenting good generl helth sttus, ttended the implntology sector t the Hospitl for Rehilittion of 50 Perio 2006; Vol 3, Issue 1: 49 56

3 Copyright de Melo et l Appliction of modified Roll Technique to Ridge Augmenttion Before Implnt Surgery Fig 1 Ptient presenting genesis of the right nd left mxillry lterl incisors. Fig 2 Seiert s clss I lveolr ridge defect: norml conditions of height in picl-coronl dimension. Fig 3 Seiert s clss I lveolr ridge defect: loss of tissue volume in uccolingul direction. Crniofcil Anomlies of the University of São Pulo, presenting genesis of the right nd left mxillry lterl incisors (Fig 1), mild Seiert s clss I tissue loss (Figs 2, 3) nd mild Seiert s Clss III loss t the edentulous spces of the right nd left mxillry lterl incisors, respectively. Intervention ws initited on the re of the right mxillry lterl incisor, ecuse this region only required soft tissue grft for lter plcement of n osseointegrted implnt, different thn the left mxillry lterl incisor, plnned for future intervention, due to the need for one grfting. After locl nesthesi with three tues of 1.8 ml of 0.5% upivcine with epinephrine 1:100,000, intrsulculr incisions were initilly performed with lde n. 15C round the right mxillry centrl incisor nd cnine. A simple incision, of prtil thickness, ws relised in mesiodistl direction from the mesil spect of the right mxillry cnine to the distl spect of the right mxillry centrl incisor, over the prtil edentulous ridge, on the pltl side, joining intrsulculr incisions (Figs 4, 5). The ngle of the lde ws 90 degrees to the one. Following this incision, the lde ws plced t n ngle of pproximtely 135 degrees nd n undermining preprtion towrd the center strted within the incision of the plte. At ech new movement of the lde long the incision line, the ngle ws further flttened until the lde reched nerly prllel position to the one surfce. The prtilthickness preprtion should e oserved from the outside without trying to elevte the tissue while cutting with the lde. The position of the lde just elow the soft tissue should e crefully controlled to prevent flp perfortion. The movement with the lde continued until n dequte size for the grft Perio 2006; Vol 3, Issue 1:

4 de Melo et l Appliction of modified Roll Technique to Ridge Augmenttion Before Implnt Surgery Copyright Fig 4 Intrsulculr incisions round right mxillry centrl incisor nd cnine, joined superficil liner incision ccomplished pltlly to the ridge. Fig 5 Superficil liner incision ccomplished pltlly to the ridge. ws chieved. The underlying connective tissue grft ws seprted from the surrounding connective tissue mking incisions in the mesil, distl nd picl prts of the grft, directing towrds the one (Fig 6). No extr incision esides the initil incision ws relized in the epithelium, preserving mximum lood supply to the donor re, reducing suture size nd llowing first-intention heling, thus providing etter post-opertive condition for the ptient. A periostel elevtor removed, delictely, the insertion of the grft to the one nd therefter dislocted it in uccl direction, preserving the remining pedicle t the top of the lveolr ridge (Fig 7). This flp ws 'folded' nd the pedicle ws emedded inside the 'envelope'-like receptor site creted on the uccl spect. This tissue set ws then sutured with simple resorle suture (Vycril 5.0 Ethicon) (Fig 8). Prescription comprised 35 drops of sodium dipyrone every six hours (500mg/ml) to pin control, mouthrinsing with 0.12% chlorhexidine digluconte for one minute twice dy, eginning t 48 hours fter surgery, nd locl ppliction of ice for 15 minutes, with 30-minute intervls, for 48 hours following the surgery. The ptient returned fter 60 dys for post-opertive control (Fig 9). DISCUSSION Loclised lveolr ridge defects my e corrected two different pproches: one grfts or guided one regenertion (Buser et l, 1996), or soft tissue mngement (Arms, 1980) if the mount of remining one tissue llows the plcement of n implnt with fvorle conditions; however, the locl 52 Perio 2006; Vol 3, Issue 1: 49 56

5 Copyright de Melo et l Appliction of modified Roll Technique to Ridge Augmenttion Before Implnt Surgery c Fig 6 c The underlying connective tissue grft ws seprted from the surrounding connective tissue mking incisions in the mesil, distl nd picl prts of the grft, directing towrds the one. c Fig 7 c Connective tissue incised nd rised with Molt elevtor up to the top of the lveolr ridge crest. Perio 2006; Vol 3, Issue 1:

6 de Melo et l Appliction of modified Roll Technique to Ridge Augmenttion Before Implnt Surgery Copyright Fig 9 Sixty dys post-opertive control. c Fig 8 c Flps sutured with horizontl mttress nd simple sutures. gingivl contour would impir the finl esthetic outcome. The free gingivl grft techniques, oth of epithelil nd connective tissue (Meltzer, 1979) nd suepithelil connective tissue (Lnger nd Clgn, 1980) re recognised nd predictle techniques. However, oth techniques present disdvntges. The free gingivl grft technique my not e pplied on esthetic res, due to the difference in color etween the grft nd the receptor site, esides the need of two distinct surgicl sites. Since it is free grft, its supply depends on the underlying periosteum, incresing the risk of necrosis if comined to its thickness. Moreover, there is possiility of hemorrhge t the donor site nd postopertive discomfort due to heling second intention. The suepithelil connective tissue grft requires second surgicl site nd does not mintin its originl vsculristion, with possiility of necrosis, esides lrger shrinkge of the grft. Concerning the roll technique proposed Arms in 1980, the risk of grft necrosis, need for second surgicl site, nd pin due to heling second intention t the donor site, represent some of the disdvntges of this pproch. The modified roll technique, proposed Schrf nd Trnow (1992), involves horizontl incision close to the lveolr ridge crest nd two prllel verticl incisions on the plte for removl of connective tissue trp-door pproch. This type of pproch, with rising of prtil thickness flp, usully llows good visiility nd proper ccess to the underlying connective tissue. However, in the trp-door pproch, with ccomplishment of three incisions, there is possiility of impirment of the lood supply to the flp. The higher the numer of incisions performed, the smller will e the supply 54 Perio 2006; Vol 3, Issue 1: 49 56

7 Copyright de Melo et l Appliction of modified Roll Technique to Ridge Augmenttion Before Implnt Surgery to the pltl flp. Moreover, in cses in which the flp length is igger thn its se, the lood supply to the flp is seriously impired. Moreover, higher numer of incisions usully require higher numer of sutures, once the relesing verticl incisions, inherent to the trp-door pproch, my e copted with simple suture (Hürzeler nd Weng, 1999). These forementioned disdvntges, when considered in comintion, represent risk fctors tht my led to necrosis of the pltl flp, with consequent heling of the donor site second intention nd unnecessry discomfort to the ptient. Thus, modifiction of the pproch for removl of connective tissue descried in the present cse report, with ccomplishment of only one incision insted of two prllel verticl incisions, represents concern of the uthors for mintennce of integrity of the donor site. Also, doption of the principles of single incision presents severl dvntges: it requires only one horizontl incision for ccess nd relese of the underlying connective tissue, there is mintennce of proper lood supply to the pltl grft, reduced numer of sutures, no need for stents or hemosttic gents t the pltl region, nd heling first intention t the donor site, which provides more comfort to the ptient in the postopertive stge (Hürzeler nd Weng, 1999). In the present study, the modified roll technique ws performed efore plcement of the implnts. Louise nd Borghetti (2002) ssure tht the est time for relistion of peri-implnt plstic surgery would e in second surgicl intervention, during the second-stge implnt surgery, for reducing the numer of interventions. However, we elieve tht n dequte mount of connective tissue over the lveolr crest is necessry to perform the roll technique. The spce occupied the cover screw in the lveolr crest usully fills the spce tht could e occupied connective tissue during the heling period. Hence, in these cses, the connective tissue over the lveolr crest would e thinner, which would difficult or even void relistion of the roll technique. CONCLUSIONS REFERENCES The procedure descried in this cse report is indicted for correction of moderte Seiert clss I defects. Such procedure, when relised previously to implnt instlltion, provides etter control of tissue heling nd greter predictility of the dimensionl stility of peri-implnt tissues fter the mturtion period of the soft tissue grft. Arms L. Augmenttion of the deformed residul edentulous ridge for fixed prosthesis. Compend Contin Educ Dent 1980;1:3, Allen EP, Ginz CS, Frthing GG, Newold DA. Improved technique for loclized ridge ugmenttion. A report of 21 cses. J Periodontol 1985;56:4, Andrienssens P, Hermns M, Inger A, Prestipino V, Delemns P, Mlevez C. Pltl sliding strip flp: soft tissue mngement to restore mxillry nterior esthetics t stge 2 surgery: clinicl report. Int J Periodontics Rest Dent 1999;14: Askry AS. Multifceted spects of implnts esthetics: the nterior mxill. Implnt Dent 2001;10:3, Brone R, Cluser C, Prto GP. Loclized soft tissue ridge ugmenttion t phse 2 implnt surgery: cse report. Int J Periodontics Restortive Dent 1999;19:2, Buser D, Dul K, Lng NP, Nymn S. Long-term stility of osseointegrted implnts in one regenerted with the memrne technique. 5-yer results of prospective study with 12 implnts. Clin Orl Implnts Res 1996;7: 2, Gsprini DO. Doule-fold connective tissue pedicle grft: novel pproch for ridge ugmenttion. Int J Periodontics Restortive Dent 2004;24:3, Hürzeler M, Weng D. Functionl nd esthetic outcome enhcement of periodontl surgery ppliction of plstic surgery principles. Int J Periodontics Rest Dent 1999;1: 1, Isrelson H, Plemons JM. Dentl implnts, regenertive techniques, nd periodontl plstic surgery to restore mxillry nterior esthetics. Int J Orl Mxillofc Implnts 1993;8: 5, Lnger B, Clgn L. The suepithelil connective tissue grft. J Prosthet Dent 1980;44:4, Lewis S. Anterior single-tooth implnt restortions. Int J Periodontics Restortive Dent 1995;15:1, Louise F, Borghetti A. Cirurgi plástic peri-implntr. In: Lim LB (ed). Cirurgi Plástic Periodontl Porto Alegre: Artmed Editor S.A., 2002; Mthews DP. Soft tissue mngement round implnts in the esthetic zone. Int J Periodontics Restortive Dent 2000; 20:2, Perio 2006; Vol 3, Issue 1:

8 de Melo et l Appliction of modified Roll Technique to Ridge Augmenttion Before Implnt Surgery Copyright Meltzer JA. Edentulous re tissue grft correction of n esthetic defect. A cse report. J Periodontol 1979;50:6, Potshnick SR. Soft tissue modeling for the esthetic single-tooth implnt restortion. J Esthet Dent 1998;10:3, Sdoun AP, Sullivn DY, Krischek M, Le Gll M. Single tooth implnt--mngement for success. Prct Periodontics Aesthet Dent 1994;6:3, Schrf DR, Trnow DP. Modified roll technique for loclized lveolr ridge ugmenttion. Int J Periodontics Restortive Dent 1992;12:5, Seiert JS. Reconstruction of deformed, prtilly edentulous ridges, using full thickness only grfts. Prt II. Prosthetic/ periodontl interreltionships. Compend Contin Educ Dent 1983;4:6, Seiert JS. Ridge ugmenttion to enhnce esthetics in fixed prosthetic tretment. Compendium 1991;12:8,548, 550, 552 pssim. Reprint requests: Luiz Gustvo Nscimento de Melo Telephone: Ru João Poletti 3-13 pto. 28 Vil Guedes de Azevedo CEP: Buru, SP, Brzil E-mil: luiznsc@terr.com.r 56 Perio 2006; Vol 3, Issue 1: 49 56