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Case Series Pedicle Connective Tissue Graft With Novel Palatal Tunneling Introduction: Implant esthetics can be compromised

with a lack of hard and/or so ft tissue in the anterior maxilla. Softtissue augmentation is often a crucial step in optimizing esthetic outcomes. Palatal pe dicle soft-tissue grafts present a versatile option and have a high survival potential. This case series presents a pedicle c onnective tissue graft technique with novel palatal tunneling as an additional tool for implant site development. It has mul tiple indications, including complete socket closure, augmentation of soft-tissue volume, enhancement of gingival papillae, and treatm ent of peri-implant defects. Case Series: In the first case, the pedicle graft was performed to achieve softtissue closure over a socket preservation site that was fully dehisced on the facial aspect. This procedure allowed for pr otecting the bone graft and developing the soft tissue for implant placement 4 months later. The second case was more chall enging because of an ankylosed maxillary central incisor presenting with a severe gingival discrepancy. After tooth extra ction and hard-tissue reconstruction, a pedicle graft was used at the time of implant placement to augment the soft tissue over the facial dehiscence of the implant in combination with a bone graft. Conclusions: The novel palatal tunneling in this technique improved the position ing of the pedicle graft at the recipient site. It also preserved the integrity of the mucosa palatal to the defect site b y minimizing the protuberance that resulted at the site of pedicle rotation. Soft-tissue height and volume were found to be inc reased. Clin Adv Periodontics 2013;3:191198. Key Words: Dental implants; esthetics, dental; maxilla; pedicle flap; tissue gra fts. Background Hard- and soft-tissue reconstruction of the anterior maxilla has gained particular interest with the progression of implant dentistry. To prevent or cor rect the inevitable ridge reduction that takes place after tooth extraction,1,2 hard-tissue augmentation techniques have been proposed to reconstruct the integr ity and shape of the deficient ridge.3,4 Simultaneously, various mucogingival pr ocedures have been described to address the soft-tissue deficiencies and the increased es thetic concerns. Enhancement of periimplant soft tissue can be performed at mult iple treatment stages: 1) socket preservation; 2) immediate or conventional impl ant placement; 3) second-stage implant surgery; 4) after delivery of implant-sup ported restoration; and 5) treatment of peri-implant disease. Numerous technique s addressing these indications mainly through autogenous soft-tissue options hav e been advocated in the literature.5-18 At the time of socket preservation or im mediate implant placement, several treatment options are available to achieve so cket closure and augment the soft-tissue volume and contour. Free gingival graft s (FGGs) have been described as a viable therapy to achieve soft-tissue closure of extraction sockets after immediate implant placement or socket grafting proce dures.8,11,16 These grafts are harvested from the palate to fit the custom size of the socket orifice. FGGs were found to integrate at the recipient sites in 7 4% to 92.3% of cases.11,16 Similarly, free connective tissue grafts (FCTGs) are obtained from the palate and used to seal socket defects. Their main differences with FGGs include tucking the graft under the facial and palatal soft-tissue ma rgins and expecting donor site wound healing by primary intention. However, heal ing of FCTGs at the recipient site is similar to that of FGGs, relying completel

y on a socket vascularization source.7 Conversely, pedicle palatal soft-tissue g rafts have been described as advantageous alternatives to free grafts in the clo sure of socket grafting and immediate implant sites.12,13,15,17 Rotated split- a nd full-thickness palatal flaps were found to achieve predictable bone formation around peri-implant dehiscence defects.12 Meanwhile, the palatal subepithelial connective tissue (CT) flap technique was presented with minimal partial flap ne crosis. The technique involved elevating a full-thickness palatal flap after a p aramarginal straight incision from the molar area to the extraction site, dissec ting a CT graft from the coronal, apical, and distal aspects, and rotating it ov er the socket toward the facial aspect.13 A modification of this method consiste d of flipping the pedicle graft over the defect instead of rotating it.17 Although both techniques showed improved clinical outc omes, they also resulted in a soft-tissue protuberance palatal to the defect sit e, corresponding to the site of pedicle rotation or flipping. This case series p resents a pedicle CT graft technique with novel palatal tunneling as an alternative trea tment modality to enhance soft-tissue volume and coverage of socket grafting and implant sites. Clinical Presentation, Management, and Outcomes Patients 1 and 2 presented to a private practice limited to periodontics and imp lant dentistry in Beirut, Lebanon (AHR). Their treatment extended from 2007 to 2 011. Both patients provided written informed consent before treatment began. Case 1 The patient was a healthy 47-year-old male who presented with a fractured tooth #7. During an apicoectomy attempt, a root fracture was noted and the patient was referred to the periodontist (AHR) for tooth extraction and implant placement. At the timeof periodontal evaluation, the patient presented with moderate edema and erythema of the alveolar mucosa on the facial aspect of tooth #7 and a mucos al tear over tooth #6 with residual silk sutures (Fig. 1a). A periapical radiograph revealed adequate bone height on the adjacent teeth (Fig. 1b). After local anesthesia and a minimally invasive extraction of tooth #7, the socket was curetted and inspected. A complete facial bony dehiscence was enc ountered, whereas the other socket walls were intact. The dimensions of the sock et orifice were measured and considered for pedicle graft preparation in the fol lowing steps. A single palatal incision design19 was placed from the mesial aspe ct of tooth #3 to the midpalatal aspect of tooth #6. Care was taken to stop the incision one tooth distal to the defect site (tooth #7). The length of this inci sion was calculated to achieve complete closure of the palato-facial size of the socket and to extend at least 3 mm under the facial tissue. Similar to a subepi thelial CT graft, the pedicle graft was dissected at the coronal, distal, and ap ical aspects, leaving the mesial side attached (Fig. 2a). The width of the graft was calculated to match the mesio-distal size of the socket. Using an Orban periodontal knife,x a tunnel was created under the palatal mucosa , connecting the donor site to the socket orifice. A polyglactin 910 5-0 suture w as used at the distal end of the pedicle graft to aid in sliding it under the cr eated tunnel and into the socket space (Figs. 2a and 2b). A collagen membrane wa s trimmed to cover the facial dehiscence, and a freeze-dried bone allograft was placed in the socket (Figs. 2c through 2e). The pedicle was then adapted over th e grafting materials and fitted under the facial mucosa. Using a polyglactin 910 5-0 suture, horizontal mattress and simple interrupted sutures were placed over the pedicle at the socket orifice and for primary closure at the donor site (Fi g. 2f). Healing was uneventful in the immediate postoperative period (Fig. 3). S ite reentry was performed at 4 months postoperatively for implant placement and immediate temporization (Figs. 4a through 4c). Adequate bone and soft tissue qua ntity and quality were noted. A dental implant was placed in an optimal position and immediately temporized (Figs. 4d through 4f). A permanent restoration was p laced 6 months later. Evaluation of results up to 2 years postoperatively reveal s high gingival esthetic outcomes at site #7 (Fig. 5).

Case 2 A 19-year-old systemically and periodontally healthy male presented to the perio dontist (AHR) office with an ankylosed tooth #8 that was retained 4 mm apical to tooth #9 (Fig. 6a). At time of presentation, the patient was undergoing orthodontic treatment. Dental history revealed an avulsion of tooth #8 caused by an accident at age 12 years.mThe tooth was repositioned back into the socket af ter the accident. The tooth became ankylosed and preserved its initial position within the growingmaxilla.At age 19 years, two lateral cephalometric radiographs taken 6 months apart were superimposed and found to be identical, indicating th e end of growth. The patient was then referred for tooth extraction and implant placement. Severe gingival discrepancywas noted between the maxillary central in cisors; however, the interproximal bone height was adequate on the adjacent teet h. The apical position of the tooth imposed an esthetic challenge th at required multiple surgical therapies. FIGURE 1 Case 1. 1a Maxillary right lateral incisor (tooth #7) at initial presen tation after an aborted apicoectomy attempt. 1b Periapical radiograph showing ap ical lesion and normal crestal bone level. FIGURE 2 Case 1. 2a Pedicle graft dissected from the palate through a single inc ision design and channeled through the mucosal tunnel with a suture. 2b Facial v iew showing pedicle length. 2c Resorbable barrier shaped to cover the facial bon y dehiscence. 2d and 2e Placement of bone particulate graft into socket defect. 2f Pedicle positioned to cover the graft material and tucked under the facial gi ngival margin, achieving complete soft-tissue closure; suture placement at donor site and over the pedicle for stabilization. FIGURE 3 Case 1. 3a and 3b Uneventful healing at 2 days postoperatively. 3c and 3d Complete clinical healing at 3 weeks postoperatively. As a first phase of treatment, tooth #8 was extracted, leaving a severe localized horizontal and vertical ridge defect that was addressed using a ramus block graft (Figs. 6b through 6f). Four months later, the site was reentered for implant placement. After the elevation of a trapezoidal facial flap, the ridge revealed adequate horizontal gain and limited vertical gain, whereas adequate in terproximal bone height was still encountered on the adjacent teeth (Figs. 7a th rough 7c).ApedicleCTgraft was dissected from the midpalatal aspect of tooth #3 t o the distal aspect of tooth #7 and handled in a similar manner as in case 1 (Fi gs. 7d through 7f). A dental implant was placed in an optimal three-dimensional position, which created a 4-mm facial dehiscence (Fig. 8a). Autogenous bone chip s, deproteinized bovine bone mineral, and a resorbable barrier were selected to treat the peri-implant defect (Figs. 8b through 8d). The pedicle graft covered a ll the grafting materials, and primary flap closure was obtained at the recipien t and donor sites (Figs. 8e and 8f). FIGURE 4 Case 1. 4a through 4c Mature soft-tissue healing at 4 months postoperat ively showing adequate soft-tissue height and ridge contour. 4d Papilla preserva tion facial flap and implant placement in an optimal three-dimensional position. 4e Periapical radiograph at time of placement confirming proper implant positio ning. 4f Immediate implant temporization and flap repositioning with 5-0 polygla ctin 910 sutures. FIGURE 5 Case 1. 5a Final outcome at 1 year after implant placement with definit ive restoration in place. 5b Periapical radiograph showing stability of crestal bone 2 years after implant placement. 5c Soft-tissue esthetics maintained at 2 y ears after implant placement in the anterior maxilla. Augmenting the soft-tissue volume allowed for a resolution of the esthet ic discrepancy until the implant was uncovered at 6 months postoperatively (Fig. 9a). After another 3-month temporary phase (Fig. 9b), a permanent implant resto ration was placed. Although a 0.5-mm discrepancy of the gingival margins of the central incisors is noted, significant enhancement of gingival esthetics was ach

ieved in this challenging case using a combination of hard- and soft-tissue ridg e augmentations (Fig. 9c). Video 1 demonstrates harvesting and management of this novel pedicle CT graft technique in a patient whose informed written consent was obtained. Postoperative instructions were similar for both patients. Amoxicillin ( 500 mg) was prescribed three times a day for 1 week. Pain control was managed wi th nonsteroidal anti-inflammatory drugs. Chlorhexidine (0.12%) was also prescrib ed twice per day for 2 weeks postoperatively. The patients were seen at 1-, 2-, and 3-week followup visits, including removal of sutures and oral hygiene instru ctions. Wound healing at the recipient and donor sites was uneventful. Discussion Soft-tissue enhancement has numerous indications in implant therapy. It begins w ith developing the extraction site, continues at the time of implant placement a nd second-stage implant surgery, and proceeds after implant restoration in the t reatment of peri-implant disease. Various autogenous soft-tissue options have be en described for these purposes in the literature. Palatal pedicle grafts were s uccessfully used at time of socket preservation and/or implant placement. 12,13, 15,17 These pedicle options have improved vascular supply and stability at the r ecipient sites when compared with free grafts. The subepithelial CT pedicle tech niques13,17 were shown to provide a greater amount of tissue, achieve soft-tissu e closure at donor and recipient sites, and cause minimal postoperative morbidit y. FIGURE 6 Case 2. 6a Ankylosed maxillary right central incisor (tooth #8) creatin g an esthetic discrepancy of 4 mm in height. 6b Trapezoidal facial flap and toot h extraction. 6c Residual bony defect lacking in ridge height and width at site #8. 6d Ramus block fixated at site #8 with two titanium miniscrews. 6e Autogenou s bone chips, deproteinized bovine bone mineral, and acellular dermal matrix all ograft placed over the ramus block. 6f Coronally advanced flap achieving primary closure at site #8. FIGURE 7 Case 2. 7a Improved clinical situation 4 months postoperatively. 7b Min imal exposure of ramus block at facial aspect of edentulous site. 7c Trapezoidal flap elevation and debridement of non-integrated part of the b lock graft. Horizontal bone gain was noted, interproximal bone height was mainta ined, and vertical bone gain was minimal. 7d Dissection of pedicle graft after a single palatal incision extending from the mesial aspect of the first molar to the distal aspect of the tooth distally adjacent (tooth #7) to the implant site (tooth #8). 7e Pedicle graft elevated from the donor site except for the mesial aspect. 7f Pedicle graft pulled through the created mucosal tunnel into the impl ant site. This case series presents a novel pedicle CT technique by incorporating a palatal tunnel through which the pedicle is channeled to the recipient site. M ore than 100 patients were successfully treated by the authors using this techni que. The clinical observation in the present case series reveals significant gai ns in soft-tissue height and volume of treated sites. Several advantages can be attributed to this novel modification. Although all existing palatal pedicle opt ions dissect the mucosa directly palatal to the defect site, the present techniq ue preserves the integrity of that mucosa by stopping the single incision one to oth distal to the defect site. This allows for the creation of a tunnel under th e mucosa palatal to the defect area. This tunnel contributes to the vascular su pply of the pedicle, whereas the overlying palatal mucosa stabilizes the graft in the desired position over t he defect site. Therefore, suturing the pedicle graft is not required for proper positioning, although sutures to approximate wound margins over the pedicle are usually placed. In addition, this novel tunnel modification significantly minim izes the formation of a soft-tissue protuberance at the site of pedicle rotation , which is normally encountered in other techniques that fully elevate the palat

al flap. Partial necrosis of the pedicle grafts was noted in only 4% of all trea ted cases. Nevertheless, the authors consider this treatment option more time co nsuming and technique sensitive than existing pedicle graft modalities FIGURE 8 Case 2. 8a Implant placement according to ideal three-dimensional posit ion leading to a coronal facial dehiscence. 8b Placement of autogenous bone chip s at the peri-implant defect. 8c Deproteinized bovine bone mineral particles use d as a contour bone graft. 8d Placement of a resorbable barrier secured with the implant cover screw. 8e Pedicle graft positioned over barrier at crestal and fa cial aspects. No sutures were required because of improved stabilization by the palatal tunnel. 8f Coronally advanced flap and prima ry soft-tissue closure. FIGURE 9 Case 2. 9a Patient smile line 6 months after implant placement. 9b Ging ival line symmetry restored between central incisors after implant temporization . 9c Two-year follow-up presentation demonstrating resolution of gingival margin discrepancy with final restoration in place. Summary Why are these cases new information? To the best of our knowledge, this is the first pedicle CT graft technique that d escribes a palatal tunneling. Multiple advantages can be attributed to this novel technique: 1) improved sta bility of pedicle graft; 2) no need to suture pedicle graft in position; 3) mini mal to no protuberance of the palatal mucosa at the site of pedicle rotation; an d 4) preservation of soft-tissue integrity and blood supply of palatal mucosa at the defect site. What are the keys to successful management of these cases? Refrain from extending the palatal single incision to the defect site. Prepare the pedicle graft longer and wider than the actual dimension of the defec t. Use caution when dissecting the pedicle at the curvature of the palate in the can ine region to avoid fenestration of the palatal mucosa. Use a suture to help in channeling the pedicle through the tunnel. What are the primary limitations to success in these cases? Minimal thickness of the palatal mucosa Multiple defect sites in the anterior maxilla Underestimating the graft dimensions required to cover the defect site