Prevalence of (alveolar ridge defect) using Seibert s classification in fixed partial denture patient

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1 Research Article Prevalence of (alveolar ridge defect) using Seibert s classification in fixed partial denture patient Nor Syakirah Binti Shahroom 1, Ashish R. Jain * ABSTRACT Background: Alveolar ridge defect may occur due to injury, trauma, denture wears, and periodontitis. Based on Seibert s Classification, it can be classified into three classes: Class I (buccolingual loss of tissue), Class II (apicocoronal loss of tissue), and Class III (both loss of tissue). It is important to close the ridge defect by replacing the tooth loss and to achieve good esthetic, phonetic, and mastication. According to the classification, proper treatment plan and alternative can be determined for successful outcomes. Aim: The aim of this study is to assess the prevalence of alveolar ridge defect using Siebert s classification in fixed partial denture patient among Indian population. Materials and Method: This study was conducted in the Department of Prosthodontics, Saveetha Dental College. A total number of 55 of 60 patients with alveolar ridge defect are selected. Based on the Siebert s Classification (Class I, Class II, and Class III), the amount of destruction is analyzed to determine the alveolar ridge defect using this classification. Therefore, the statistical analysis is performed using Chi-squared test. Results: Based on the result, the prevalence of alveolar ridge defect due to trauma is 91.6% (55 of 60). According to Siebert s classification, the most common alveolar ridge destruction was Class III defect which is both buccolingual and apicocoronal loss of tissue of alveolar ridge, 4 (40.0%). This was followed by Class I defect which is buccolingual loss of tissue of alveolar ridge with 0 (33.3%) number of patients. Class II defect was the least with 11 (18.3%) which is apicocoronal loss of tissue of alveolar ridge. Conclusion: The prevalence of Siebert s classification helps in suggestion of various management techniques or treatment planning to the patient to ensure that the prognosis and treatment outcomes turn out to successful. KEY WORDS: Alveolar defect, Andrew s bridge, Fixed partial denture, Ridge augmentation, Seibert s classification INTRODUCTION In prosthetic dentistry, dentist may face challenges in treating patient with alveolar ridge defect in edentulous area. Localized alveolar ridge defect can be seen as a volumetric deficit of limited extent of soft tissue and bone within the alveolar process. [1] The edentulous area may be due to tooth loss either due to trauma during extraction or congenital defects which lead to alveolar bone loss. [] The alveolar bone defect causes the soft tissue to collapse into the bone during healing which creates contours. [3] These contours make it difficult to produce an esthetical prosthesis. Besides, it may also lead to food impaction and difficulty in speech due to percolation of saliva. [4] As a dentist who faces such cases, it is required for them to replace the 1 Graduate Student, Saveetha Institute of Medical and Technical Science, Saveetha University, Chennai, Tamil Nadu, India, Department of Prosthodontics, Saveetha Institute of Medical and Technical Science, Saveetha University, Chennai, Tamil Nadu, India Access this article online Website: jprsolutions.info ISSN: *Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Institute of Medical and Technical Science, Saveetha, University, 16, Poonamalle High Road, Chennai , Tamil Nadu, India. Phone: dr.ashishjain_r@yahoo.com Received on: ; Revised on: ; Accepted on: missing tooth and close the defect for the patient to achieve esthetic, phonetic, and mastication. [] Besides, it is important to assess the factors such as type and amount of destruction of the residual ridge, systemic condition, and economic status of the patient for better treatment planning, clinical outcome, and prognosis. [5] Furthermore, it is also essential for the selection of pontic for the patient and indication for the patient to undergo surgical intervention to reshape the ridge. [1] Seibert has classified residual ridges into three categories based on the amount of destruction as shown in Figure 1a-d. [6,7] Class I: Buccolingual loss of alveolar soft tissue with normal apicocoronal height. Class II: Apicocoronal loss of alveolar tissue with normal buccolingual width. Class III: Both buccolingual width and apicocoronal height loss of tissue. Management of ridge defect 753

2 includes ridge augmentation which was proposed by Langer, Kaldhal et al., and Calanga. [8,9] It can be categorized under the soft tissue augmentation and hard tissue augmentation procedure. [1] Soft tissue augmentation procedure includes the roll technique for Class I defects, interproximal graft technique for Class II and III defects, and free gingival graft. [10] Ridge augmentation is preferably done for Class I ridge defects. Besides, for Class II and Class III ridge defect, bone augmentation technique by inlay and outlay grafting with either autogenous grafts, allografts, or xenografts is preferred. [11] Other procedures include removable partial denture, fixed partial dentures with pink ceramic, and Andrew s bridge. [10] The ideal ridge width and height allow placement of natural appearance pontic and thus help in the maintenance of plaque-free environment. [1,1] Anterior ridge defect is the most difficult to treat well esthetically. In such cases, the conventional option of fixed partial denture or implant-supported fixed partial denture is not enough to achieve esthetic results. [10] Therefore, as an alternative, Andrew s bridge is a good option. It was introduced by Dr. James Andrews of Amite, Louisiana in [13] Andrew s bridge consists of two fixed retainer attached to their abutments and connected by a rectangular bar that follows the curve of the ridge under it. [14] The advantages of Andrew s bridge are that it has a flexibility and stabilizing qualities of the fixed prosthesis. [1] It is indicated in cases such as excessive residual ridge defect, jaw defect, cleft palate, and patient with periodontal problems. [15] Few studies have done on the prevalence of alveolar ridge defect using Siebert s classification on fixed partial denture patient. Many studies have presented the case reports on various treatments of ridge defect patient. Therefore, the purpose of this study is to assess the prevalence of Siebert s Classification among fixed partial denture patient in Indian populations to achieve a good treatment outcome for the most prevalence ridge defect. MATERIALS AND METHODS Sample Collection This study was approved by the Research Committee of Saveetha Dental College, Saveetha University, Chennai, India. This study was done in the Department of Prosthodontics, Saveetha Dental College. Patients who are completely edentulous were excluded from this study. Meanwhile, single partially edentulous site, multiple partial edentulous site, excessive ridge defect, and anterior or posterior ridge defect were included in this study. The alveolar ridge of the patient was observed clinically based on the Siebert s Classification as shown in Figure 1: (a) Normal apicocoronal alveolar ridge, (b) buccolingual loss of alveolar ridge, (c) apicocoronal loss of alveolar ridge, (d) normal buccolingual alveoral ridge Figure : (a) Clinical image of alveolar ridge defect with Class I Siebert s, (b) clinical image of alveolar ridge defect with Class II Siebert s, (c) clinical image of alveolar ridge defect with Class III Siebert s Figure a-c. Therefore, the amount of destruction of the alveolar ridge was analyzed to determine the classification. Sample Size The sample size was determined using calculator developed by Naing et al. [16] which can be downloaded freely from resources.htm. At least 3 patients with alveolar ridge defect were required to determine the prevalence of Siebert s classification. Samples size was calculated using 95% level of confidence (Z), prevalence of 91% (P), and the precision (d) of 0.05 with normal approximation assumption. Sample size Z P(1- P) n = d Which n=sample size Z=Z statistic of level confidence P=Expected prevalence of proportion d=precision. 754

3 Sample size ( ) n = = Statistical Analysis The data were collected, and statistical analysis was performed using Microsoft Excel. The descriptive statistic was computed. Mean and Chi-square test were done. The Chi-square test was used to compare the data and checked for the distributions at 0.05 level of significance for effect statistical significance. RESULT A total of 60 patients with partially edentulous site were selected in this study. However, 55 of the patients met the inclusion criteria which are single or multiple partial edentulous site and defect in the alveolar ridge. The remaining five patients were excluded from this study due to the clinically normal alveolar ridge. Therefore, this study population composed of 55 partially edentulous patients with alveolar ridge defect of whom 30 (54.5%) were males and 5 (45.5%) were females as shown in Figure 3. Based on the participants age, 3 (5.5%) were in the range of 0 9 years old, 15 (7.3%) were in the range of years old, 8 (50.9%) were in the range of 40 to 49 years old, 7 (1.7%) were in the range of years old, and (3.6%) were in the range of years old as shown in Figure 4. All the patients (100%) came with the complaints of trauma including tooth loss or decayed tooth. Based on the result, the prevalence of alveolar ridge defect due to trauma is 91.6% (55 of 60). According to Siebert s Classification, the most common alveolar ridge destruction was Class III defect which is both buccolingual and apicocoronal loss of tissue of alveolar ridge, 4 (40.0%). This was followed by Class I defect which is buccolingual loss of tissue of alveolar ridge with 0 (33.3%) number of patients. Class II defect was the least with 11 (18.3%) which is apicocoronal loss of tissue of alveolar ridge as shown in Figure 5. However, the results do not show any correlation of age and the type of destruction of alveolar ridge based on Siebert s classification. DISCUSSION This study shows that the prevalence of alveolar ridge defect according to Siebert s Classification is high with 91.6%. According to Siebert, he classified the alveolar ridge defect according to the presence of deficiencies in form, function, and esthetics. [6,7] In these studies, Class III defects had the most number of incidence which was 40.0% followed by Class I with 33.3% and Figure 3: The bar graph of patient with alveolar ridge defect depends on gender Figure 4: The bar graph of the varying age of patients with alveolar ridge defect Figure 5: The prevalence of alveolar ridge defect using Siebert s classification Class I with 18.3%. According to these studies also, male gender has high prevalence in having alveolar ridge deformities with 54.5% and also patients in the age within years old have a high incidence of alveolar ridge defect with 50.9%. However, no study has done on the correlation of alveolar ridge defect with age and gender. According to this classification, the quantification of the magnitude of ridge deficiencies was not included by Siebert. Therefore, modification of Siebert s classification was introduced by Allen et al. [17] in the year 1985 which include the magnitude of the ridge 755

4 defect. This classification was meant to aid in the treatment planning and prognosis of the patient with alveolar ridge defect. The main problem occurs with the incidence of anterior tooth loss with alveolar ridge defect which is very difficult to treat properly due to esthetic factor. [10] Besides, other problems might also be encountered such as lack of emergence profile, lack of root eminence, lack of marginal gingiva, and presence of black triangles in interdental papillae area which is esthetic disturbance. [18] Black triangle can be described as dark appearance of alveolar tissue above the pontic in comparison to the adjacent gingival tissue. [19] The main reason of alveolar ridge deformities is due to trauma to the alveolar process during extraction. After extraction, the process of healing of the bone and soft tissue took place. However, due to the trauma, the soft tissue will collapse into the bone defects which create contours which make esthetic functional prosthesis would be difficult. [3] Therefore, the management of alveolar ridge defect can be classified into hard tissue augmentation and soft tissue augmentation. [1] There are various treatment options to treat alveolar ridge defect such as the roll technique for Class I defect and interproximal graft technique for Class II and Class III defect, free gingival graft, bone grafting using both inlay and onlay grating technique either autogenous grafts, allografts, or xenografts, ridge augmentation using bone graft followed by implant placement, removal partial denture, fixed partial denture with pink ceramic, and Andrew s bridge. [10] To achieve an esthetically successful pontic, all criteria including replication of the form, contours, incisal edge, gingival and incisal embrasures, and color of adjacent teeth should be met. [19] Besides, the study of prevalence in Siebert s classification was intended to give a clear image on the treatment choices and alternatives to achieve a successful outcomes. As the primary goal of closing, the defect and replacing the tooth are to restore the loss of function, esthetic, and natural appearance, but the goal can only be achieved if the final prosthesis is modified according to the prevalent situation. [19] In a study done by Abrams et al., [0] they reported that the prevalence of anterior ridge deformities of partially edentulous patient was 91% similar to the current study which is 91.6%. Class III defects were the highest with 55.8% followed by Class I defects with 3.8% and Class II defects with.9%. In a study done by John et al., [1] bone defects in posterior mandibular tooth region show a maximum defect with 33.8% followed by maxillary posterior with 19.9%. Since the prevalence of Class III defect is the highest compared to Class I and Class II, many articles have described the treatment outcome for Class III defects patients in their case report article. [,5,10,] In Class III defect, Andrew s bridge is the best option due to the challenging situation with esthetics and severe alveolar ridge defect. Andrew s bridge was introduced by Dr. James Andrew of Amite Louisiana in the year [13] It is a combination of a fixed dental prosthesis and a removable dental prosthesis and commonly used for anterior edentulous area. [] It replaced the teeth within the bar area which incorporated with the fixed dental prosthesis. The removable dental prosthesis received retention from the vertical wall of the bar. The advantages of Andrew s bridge system are the advantages of fixed and removable partial dentures with better esthetics, hygiene along with better adaptability, and phonetics. [10] Besides, it is economical and comfortable for the patient. Other advantages of this technique process are the flexibility and stabilizing quantities of the prosthesis. [10] In a study done by Snehal and Amberkar [7] the clinical case report suggests that soft tissue augmentation with subepithelial connective tissue graft is a promising treatment in a condition with Class I defect. The study was done by harvesting the connective tissue graft from the palate along with metal ceramic restoration. The advantages of this technique are maintenance of adequate blood supply, and the use of stents or hemostatic agent can be avoided and healing by first intention which provides greatest comfort to the patient postoperatively. [7] Apart from that, the disadvantages of this technique are the limited volume of graft which depends on the size of the graft and increases prone to necrosis in case of large grafts. [3] In a study done by Tanaka et al., [4] a segmental osteotomy procedure with an interpositional graft is done on a patient with Class II alveolar ridge defect. Most of the studies shown that this technique is practical and a predictable procedure with low incidence of complications and a high probability of successful treatment outcomes. [5-8] Apart from that, alveolar osteotomy associated with interpositional grafting is another alternative in increasing vertical bone height. It is known as sandwich bone graft because of the interposing bone graft between osteotomized bony segments, which acts as a sandwich. [5-8] The advantage of this technique is that it offers good vasculature to the segment and graft which helps in reducing bone resorption. Lack of alveolar bone height (apicocoronally) condition can be overcome using various vertical guide bone regeneration procedures, alveolar distraction osteogenesis, titanium mesh, or only bone graft. [9-31] There is a possibility of increase in ridge height depending on the material used. However, in such cases with excessive alveolar ridge defect, implant placement is totally avoided as it is difficult and impossible for support due to lack of bone. Several studies show that short implants can be an alternative to avoid problems associated with vertical augmentation. [3-34] Besides, this placement demonstrated high success rate and predictable 756

5 clinical outcomes. In another study done by Parikh et al., [18] roll flap technique is suggested to be the most predictable and simplest method for the management in patient with alveolar ridge defect. This technique was introduced by Abrams. [35] The advantages of this technique are utilization of pedicle flap, increase probability of success, lesser chance of tissue loss and shrinkage, simple technique, easy to perform, stabilize the graft, maintenance of the color and texture, and single surgical wound. [18,36,37] The disadvantages include it depends on the thickness of the adjacent palatal tissue, moderate volume gain, and very difficult for adjusting addition mucogingival problems simultaneously. [18] Besides, as designed by Abrams, the ovate pontics was selected for fixed prosthesis. [35] This type of pontic automatically created interdental papilla which fills in the embrasure and removes the unesthetic black interdental triangles. [18] CONCLUSION It is important to assess the alveolar ridge deficiencies among patient who came to the hospital with a complaint of trauma or tooth loss. According to the amount of destruction, it can be classified into three classes based on Siebert s classification. Through this, various management techniques or treatment planning can be suggested to the patient to ensure that the prognosis and treatment outcomes turn out to successful. In summary, the suggestive treatment for Class I is soft tissue augmentation, Class II is alveolar osteotomy with interpositional grafting, and Class III is Andrew s bridge. REFERENCES 1. Rastogi PK. Aesthetic enhancement with periodontal plastic procedure in a class 3 alveolar ridge defect. BMJ Case Rep 01;1-3.. Jain VH, Janani T. Rehabilitation of sieberts class III defect using fixed removable prosthesis (andrew s bridge). J Pharm Sci Res 016;8: Herbert T, Shillingburg SH, Lowell D. Whitsett Fundamentals of Fixed Prosthodontics. 3rd ed. New Delhi: Quintessence Publishing; p Rosenstiel SF, Land MF, Fujimoto J, Lang SC. Contemporary Fixed Prosthodontics. St. Louis: Junhei Fujimoto Mosby Inc.; Rathee M, Sikka N, Jindal S, Kaushik A. Prosthetic rehabilitation of severe siebert s Class III defect with modified Andrews bridge system. Contemp Clin Dent 015;6: Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part II. Prosthetic/ periodontal interrelationships. Compend Contin Educ Dent 1983;4: Snehal C, Amberkar JV. Reconstruction of localized horizontal maxillary ridge defect with subepethelial connective tissue graft. JSM Oro Facial Surg 017;: Kaldahl WB, Tussing GJ, Wentz FM, Walker JA. Achieving an esthetic appearance with a fixed prosthesis by submucosal grafts. J Am Dent Assoc 198;104: Langer BC. Epithelialized connective tissue graft. A new method for amelioration of the anterior segment esthetic. Rev Int Parodont Dent Rest 198;: Jain AR. A prosthetic alternative treatment for severe anterior ridge defect using fixed removable partial denture Andrew s bar system. World 013;4: Van den Bergh J, Ten Bruggenkate C, Tuinzing D. Preimplant surgery of the bony tissues. J Prosthet Dent 1998;80: Rana R, Ramachandra SS, Lahori M, Singhal R, Jithendra K. Combined soft and hard tissue augmentation for a localized alveolar ridge defect. Contemp Clin Dent 013;4: Immekus JE, Aramany M. A fixed-removable partial denture for cleft-palate patients. J Prosthet Dent 1975;34: Taneja P, Anehosur GV, Lekha K. Prosthodontic rehabilitation of anterior alveolar defect: An esthetic challenge. Indian J Oral Sci 014;5: Nallaswamy VD. Textbook of Prosthodontics. nd ed. New Delhi: Jaypee Brothers Medical Publisher; Naing L, Winn T, Rusli B. Practical issues in calculating the sample size for prevalence studies. Arch Orofac Sci 006;1: Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation: A report of 1 cases. J Periodontol 1985;56: Parikh AK, Sheth T, Shah M. Esthetic adjustment of alveolar ridge defect using the roll flap technique. J Ahmedabad Dent Coll Hosp 011;1: Shrivastav SG. A simple surgical approach for correction of deficient alveolar ridge for prospective fixed partial denture patients: A clinical report. Dent J Adv Stud 014;: Abrams H, Kopczyk RA, Kaplan AL. Incidence of anterior ridge deformities in partially edentulous patients. J Prosthet Dent 1987;57: John A, Vrostos GD, Parashis AO, Smulow JB. Prevalence and distribution of bone defects in moderate and advanced adult periodontitis. J Clin Periodontol 1999;6: Rai R, Menaga V, Prabhu R, Geetha K, Suprabha R. A prosthodontic management of severely resorbed anterior ridge defect-a case report. J Clin Diag Res 014;8:ZD Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentation procedures for mucogingival defects in esthetic sites. Int J Oral Maxillofac Implants 014;9 Supp l: Tanaka K, Sailer I, Kataoka Y, Nogami S, Takahashi T. Sandwich bone graft for vertical augmentation of the posterior maxillary region: A case report with 9-year follow-up. Int J Implant Dent 017;3:0. 5. Schettler D, Holtermann W. Clinical and experimental results of a sandwich-technique for mandibular alveolar ridge augmentation. J Maxillofac Surg 1977;5: Stoelinga P, Tideman H, Berger J, De Koomen H. Interpositional bone graft augmentation of the atrophic mandible: A preliminary report. J Oral Surg (American Dental Association: 1965) 1978;36: Jensen OT. Alveolar segmental sandwich osteotomies for posterior edentulous mandibular sites for dental implants. J Oral Maxillofac Surg 006;64: Jensen OT, Kuhlke L, Bedard JF, White D. Alveolar segmental sandwich osteotomy for anterior maxillary vertical augmentation prior to implant placement. J Oral Maxillofac Surg 006;64: Simion M, Jovanovic SA, Tinti C, Benfenati SP. Long-term evaluation of osseointegrated implants inserted at the time or after vertical ridge augmentation. Clin Oral Implants Res 001;1: Chiapasco M, Consolo U, Bianchi A, Ronchi P. Alveolar distraction osteogenesis for the correction of vertically deficient edentulous ridges: A multicenter prospective study on humans. Int J Oral Maxillofac Implants 004;19: Roccuzzo M, Ramieri G, Spada MC, Bianchi SD, Berrone S. Vertical alveolar ridge augmentation by means of a titanium mesh and autogenous bone grafts. Clin Oral Implants Res 004;15:

6 3. Thoma D, Zeltner M, Hüsler J, Hämmerle C, Jung R. EAO supplement working group 4 EAO CC 015 short implants versus sinus lifting with longer implants to restore the posterior maxilla: A systematic review. Clin Oral Implants Res 015;6: Lee SA, Lee CT, Fu MM, Elmisalati W, Chuang SK. Systematic review and meta-analysis of randomized controlled trials for the management of limited vertical height in the posterior region: Short implants (5 to 8 mm) vs longer implants (> 8 mm) in vertically augmented sites. Int J Oral Maxillofac Implants 014;9: Nisand D, Picard N, Rocchietta I. Short implants compared to implants in vertically augmented bone: A systematic review. Clin Oral Implants Res 015;6: Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Gen Dent 1980;1: Naef R, Schärer P. Adjustment of localized alveolar ridge defects by soft tissue transplantation to improve mucogingival esthetics: A proposal for clinical classification and an evaluation of procedures. Quintessence Int 1997;8: Sullivan HC, Atkins JH. Free autogenous gingival grafts 3. Utilization of grafts in the treatment of gingival recession. Periodontics 1968;6: Source of support: Nil; Conflict of interest: None Declared 758