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   Table of Contents    
CASE REPORT
Year : 2017  |  Volume : 21  |  Issue : 4  |  Page : 333-336  

Applications of a modified palatal roll flap in peri-implant soft-tissue augmentation – A case series


1 Department of Periodontics, SDM College of Dental Sciences and Hospital, Dharwad, India
2 Department of Dentistry, Vivekanand General Hospital, Hubballi, Karnataka, India

Date of Submission20-Apr-2017
Date of Acceptance25-Oct-2017
Date of Web Publication29-Jan-2018

Correspondence Address:
Dr. Mihir Raghavendra Kulkarni
Department of Periodontics, SDM College of Dental Sciences and Hospital, Sattur, Dharwad - 580 009, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_87_17

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   Abstract 

Abrams's palatal roll technique has been used extensively to augment peri-implant soft tissues in the maxillary esthetic zone and has seen numerous modifications. An adaptation of the palatal roll technique is described here and its simplicity of application in three different scenarios is demonstrated. At second-stage implant surgery, a partial thickness initial incision followed by a palatal subepithelial dissection at the site of implant was done and a connective tissue graft with a buccal pedicle was obtained. The graft was rolled under the buccal flap and allowed to heal with the support of a healing abutment. The graft healed uneventfully and provided excellent contours of tissues around the implant. The procedure demonstrated good results for augmentation of a buccal ridge deficiency, for covering exposed and unsightly implant fixtures and was also done with a papilla preservation incision. In addition, a second surgical site to obtain the connective tissue graft was avoided.

Keywords: Alveolar ridge augmentation, connective tissue graft, dental implants, esthetics, gingival recession


How to cite this article:
Kulkarni MR, Bakshi PV, Kavlekar AS, Thakur SL. Applications of a modified palatal roll flap in peri-implant soft-tissue augmentation – A case series. J Indian Soc Periodontol 2017;21:333-6

How to cite this URL:
Kulkarni MR, Bakshi PV, Kavlekar AS, Thakur SL. Applications of a modified palatal roll flap in peri-implant soft-tissue augmentation – A case series. J Indian Soc Periodontol [serial online] 2017 [cited 2019 Jul 17];21:333-6. Available from: http://www.jisponline.com/text.asp?2017/21/4/333/223050


   Introduction Top


Long-term edentulism can cause deficiencies in both the soft tissue and the hard tissue configuration of the alveolar ridge. Prosthodontic strategies such as ridge lap pontics, gingiva colored porcelains, and acrylic flanges are commonly used to mask localized defects of the ridge. These techniques more often are a compromise as compared to more demanding methods such as native soft- and hard-tissue augmentation. Prato et al.,[1] suggested that expected esthetic outcomes of implant therapy may be enhanced by manipulating or augmenting peri-implant soft tissues using periodontal plastic surgery. This management of soft tissues includes techniques to increase the width of attached gingiva, soft-tissue augmentation around implants, reconstruction of peri-implant papillae, and maintenance of the soft-tissue stability around implants. Consideration also has to be given to possibly enhance the mucosal biotype as it can influence the long-term stability of an esthetic outcome.

A free gingival autograft is known to be a successful and predictable way of augmenting the gingivae around teeth or implants.[2] Soft-tissue grafting techniques are commonly used to improve esthetics in the anterior maxillary area and are especially valuable in masking the visibility of titanium fixtures through gingivae of a thin biotype. Soft-tissue grafts carry the notoriety of being associated with postoperative pain and hemorrhage, at the site from where the graft has been obtained.[3] Abrams,[4] introduced the palatal roll flap technique to augment the peri-implant soft-tissue volume. Noteworthy, modifications of this popular technique include the modified roll technique,[5] rotated split palatal flap,[6] the vascular interpositional graft,[7] and the pouch roll technique,[8] among others.

An attempt is made to modify this technique to allow primary closure without requiring a trapdoor approach and to demonstrate its adaptability in three different cases.


   Case Report Top


This case series describes three patients treated at a private practice setup. An informed consent was obtained from all the patients in accordance with the guidelines as per the Helsinki Declaration of 1975, revised in 2000. The first patient (34, female) presented with a buccal alveolar ridge deficiency. The second patient (19, female) presented with a missing tooth in the aesthetic zone. The third patient (21, male) presented with unsightly implant fixture display through thin labial tissues, as a consequence of faulty implant angulation during placement. All the three patients had received dental implants and were to be taken up for the second-stage surgery.

[Figure 1] shows a localized ridge deficiency on the buccal aspect of the ridge at the site of implant placement. [Figure 2] shows a line diagram for the planned incisions.
Figure 1: Site of implant placement showing a buccal ridge deficiency

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Figure 2: Line diagram showing the planned incisions

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A partial thickness incision was given at the implant site with a number 15 blade (Incision A). Sharp dissection was done on the palatal aspect to separate the epithelium with a thin layer of connective tissue from the underlying connective tissue bed [Figure 3]. Full-thickness sulcular incisions were then placed on the adjacent teeth, and a full-thickness incision was placed on the apical-most extent of the previously prepared pouch – using a technique similar to the single incision technique by Hürzeler and Weng (Incision B).[9] Vertical full-thickness incisions were then placed on the mesial and distal aspects of incision B, to establish continuity with the sulcular incisions.
Figure 3: Partial thickness palatal flap raised to uncover the connective tissue bed

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A periosteal elevator was used to separate the graft from the underlying bone [Figure 4]. The connective tissue graft was then inverted and tucked into the buccal aspect of the exposed implant [Figure 5]. A healing abutment was placed and tissues were approximated with simple interrupted sutures (3-0, braided silk) [Figure 6]. At 1-month follow-up, the prosthesis was removed to visually examine the tissue contours around the implant [Figure 7]. A 1-year follow-up photograph showed good soft-tissue contours around the implant prostheses. The labio-palatal tissue gain was maintained reasonably well, and the interdental papillae were completely filling the embrasures [Figure 8].
Figure 4: Pedicled connective tissue graft raised with a periosteal elevator

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Figure 5: Connective tissue graft displaced to the buccal aspect of the implant

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Figure 6: Primary closure obtained using braided silk sutures with a healing abutment in place

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Figure 7: Healing of the site as seen 1 month after the procedure

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Figure 8: (a) Tissue contours as seen 1 year after the procedure (b) Occlusal view of ridge contour 1 year after the procedure

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The technique was used with a papilla preservation incision in the second patient [Figure 9]. In the third patient, the technique was used on two adjacent teeth to augment buccal soft tissue and to mask the implant fixture visibility through thin mucosa [Figure 10].
Figure 9: (a) Buccal soft-tissue deficiency at implant site; (b) Papilla preserving incision used and palatal connective tissue pedicle graft obtained; (c) Occlusal view of augmented soft tissue around the healing abutment; (d) Final prosthesis with an augmented zone of keratinized mucosa and maintained papillae

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Figure 10: (a) Implant fixtures visible through thin alveolar mucosa; (b) Modified palatal roll technique used to obtain soft-tissue augmentation; (c) 1-month recall picture showing augmented labial tissue and the implant fixtures are no longer visible; (d) One-year recall photograph

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In the first patient, the buccal ridge deficiency could be corrected using the modified roll flap technique [Figure 8]. In the second patient, the use of papilla preservation incisions helped to prevent papillary recession and resulted in an esthetic outcome [Figure 9]d, and in the third patient, the display of implant fixtures through the soft tissue was masked by firm, keratinized soft tissue, created using the technique at the 1-year recall visit [Figure 10]d.


   Discussion Top


Palatal soft-tissue grafts are known for their high rate of clinical success, excellent predictability, and long-term stability.[10] Grafts with a vascular pedicle have the benefit of a better blood supply that can ultimately result in faster healing, lesser graft shrinkage, and heightened chances of graft uptake. Abrams's palatal roll flap technique was one of the first techniques to employ the palatal connective tissue pedicle.[4]

The techniques for the use of the palatal tissue have been revisited, reintroduced, and revised by many authors.[5],[6],[7],[8] Scharf and Tarnow [5] gave the most obvious modification of Abrams's technique using a trap-door approach to obtain the connective tissue pedicle. This allowed closure of the palatal soft-tissue donor site, thereby reducing the morbidity associated with the original technique. Nemcovsky and Artzi [6] used a similar to cover immediately placed implants. In their technique, a partial thickness flap was raised palatal to the implant site via a sulcular incision and the connective tissue bed was split to obtain a pedicle. The pedicle was rotated over the immediately placed implant to augment the soft-tissue contour.[6] Sclar [7] employed a “tunnel” to access and reposition a palatal connective tissue pedicle and called the technique “Vascularized interpositional periosteal-connective tissue flap.”[7] Park and Wang [8] described a “pouch roll” technique for augmenting soft tissue around single or multiple implants. The authors used a very conservative surgical approach and did not use sutures.[8]

Long-term stability of the palatal roll flap grafting procedure is an important factor in the clinical decision-making process. Recently, Man et al.,[11] reported successful implementation of a similar technique in the management of peri-implant soft-tissue deficiency and reported stable results in a prospective study. The authors observed that the shrinkage of the graft and scarring on the labial side were reduced with the use of this technique.[11] A slight modification of this technique was also described by Man et al.,[12] for tissue augmentation around multiple contiguous implants. Good contours and complete filling of papillae were reported with a follow-up of 3–5 years.[11],[12]

With most techniques, the palatal tissue heals either with the secondary intention or involves a trap-door approach. This may lead to considerable postoperative discomfort as the trapdoor can sometimes undergo necrosis as well.[12] The technique described in the present case series overcomes this issue by allowing a primary closure of the surgical site and does not use a trapdoor approach. In addition, a healing abutment is used to support and dictate the contour of the healing tissue as described by Barone et al.[13]

The primary indication for this technique is the treatment of localized Seibert class 1 ridge deficiencies that can be masked by soft-tissue augmentation alone. Such a procedure is of considerable value in the maxillary esthetic region. This technique does not require a second surgical site, retains some blood supply to the obtained graft, and also allows the site to heal by primary intention. This simple technique is a very relevant and versatile tool and should be routinely employed to augment the soft tissues around an implant with minimal patient discomfort.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Prato GP, Clauser C, Cortellini P. Periodontal plastic and mucogingival surgery. Periodontol 2000 1995;9:90-105.  Back to cited text no. 1
    
2.
Evian CI, al-Maseeh J, Symeonides E. Soft tissue augmentation for implant dentistry. Compend Contin Educ Dent 2003;24:195-8, 200-2, 204-6.  Back to cited text no. 2
[PUBMED]    
3.
Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative complications following gingival augmentation procedures. J Periodontol 2006;77:2070-9.  Back to cited text no. 3
[PUBMED]    
4.
Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Gen Dent 1980;1:205-13.  Back to cited text no. 4
[PUBMED]    
5.
Scharf DR, Tarnow DP. Modified roll technique for localized alveolar ridge augmentation. Int J Periodontics Restorative Dent 1992;12:415-25.  Back to cited text no. 5
[PUBMED]    
6.
Nemcovsky CE, Artzi Z. Split palatal flap. I. A surgical approach for primary soft tissue healing in ridge augmentation procedures: Technique and clinical results. Int J Periodontics Restorative Dent 1999;19:175-81.  Back to cited text no. 6
    
7.
Sclar A. Vascularized interpositional periosteal-connective tissue (VIP-CT) flap. In: Sclar A, editor. Soft Tissue and Esthetic Considerations in Implant Dentistry. Chicago: Quintessence Publishing; 2003. p. 163-87.  Back to cited text no. 7
    
8.
Park SH, Wang HL. Pouch roll technique for implant soft tissue augmentation: A variation of the modified roll technique. Int J Periodontics Restorative Dent 2012;32:e116-21.  Back to cited text no. 8
[PUBMED]    
9.
Hürzeler MB, Weng D. A single-incision technique to harvest subepithelial connective tissue grafts from the palate. Int J Periodontics Restorative Dent 1999;19:279-87.  Back to cited text no. 9
    
10.
Harris RJ. Root coverage with connective tissue grafts: An evaluation of short- and long-term results. J Periodontol 2002;73:1054-9.  Back to cited text no. 10
[PUBMED]    
11.
Man Y, Wang Y, Qu Y, Wang P, Gong P. A palatal roll envelope technique for peri-implant mucosa reconstruction: A prospective case series study. Int J Oral Maxillofac Surg 2013;42:660-5.  Back to cited text no. 11
[PUBMED]    
12.
Man Y, Wu Q, Wang T, Gong P, Gong T, Qu Y,et al. Split pedicle roll envelope technique around implants and pontics: A prospective case series study. Int J Oral Maxillofac Surg 2015;44:1295-301.  Back to cited text no. 12
    
13.
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;19:141-5.  Back to cited text no. 13
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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