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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Combined soft and hard tissue augmentation for a localized alveolar ridge defect</title><author><name sortKey="Rana, Ritu" sort="Rana, Ritu" uniqKey="Rana R" first="Ritu" last="Rana">Ritu Rana</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Ramachandra, Srinivas Sulugodu" sort="Ramachandra, Srinivas Sulugodu" uniqKey="Ramachandra S" first="Srinivas Sulugodu" last="Ramachandra">Srinivas Sulugodu Ramachandra</name><affiliation><nlm:aff id="aff3"><italic>Faculty of Dentistry, SEGi University, Malaysia</italic></nlm:aff></affiliation></author><author><name sortKey="Lahori, Manesh" sort="Lahori, Manesh" uniqKey="Lahori M" first="Manesh" last="Lahori">Manesh Lahori</name><affiliation><nlm:aff id="aff2"><italic>Department of Prosthodontics, Kanti Devi Dental College and Hospital, Mathura, Uttar Pradesh, India</italic></nlm:aff></affiliation></author><author><name sortKey="Singhal, Reetika" sort="Singhal, Reetika" uniqKey="Singhal R" first="Reetika" last="Singhal">Reetika Singhal</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Jithendra, K D" sort="Jithendra, K D" uniqKey="Jithendra K" first="K D" last="Jithendra">K D Jithendra</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24403810</idno><idno type="pmc">3883345</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883345</idno><idno type="RBID">PMC:3883345</idno><idno type="doi">10.4103/0976-237X.123090</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">000141</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000141</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Combined soft and hard tissue augmentation for a localized alveolar ridge defect</title><author><name sortKey="Rana, Ritu" sort="Rana, Ritu" uniqKey="Rana R" first="Ritu" last="Rana">Ritu Rana</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Ramachandra, Srinivas Sulugodu" sort="Ramachandra, Srinivas Sulugodu" uniqKey="Ramachandra S" first="Srinivas Sulugodu" last="Ramachandra">Srinivas Sulugodu Ramachandra</name><affiliation><nlm:aff id="aff3"><italic>Faculty of Dentistry, SEGi University, Malaysia</italic></nlm:aff></affiliation></author><author><name sortKey="Lahori, Manesh" sort="Lahori, Manesh" uniqKey="Lahori M" first="Manesh" last="Lahori">Manesh Lahori</name><affiliation><nlm:aff id="aff2"><italic>Department of Prosthodontics, Kanti Devi Dental College and Hospital, Mathura, Uttar Pradesh, India</italic></nlm:aff></affiliation></author><author><name sortKey="Singhal, Reetika" sort="Singhal, Reetika" uniqKey="Singhal R" first="Reetika" last="Singhal">Reetika Singhal</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Jithendra, K D" sort="Jithendra, K D" uniqKey="Jithendra K" first="K D" last="Jithendra">K D Jithendra</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></analytic><series><title level="j">Contemporary Clinical Dentistry</title><idno type="ISSN">0976-237X</idno><idno type="eISSN">0976-2361</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Ideal alveolar ridge width and height allows placement of a natural appearing pontic, which provides maintenance of a plaque-free environment. The contour of a partially edentulous ridge should be thoroughly evaluated before a fixed partial denture is undertaken. Localized alveolar ridge defect refers to a volumetric deficit of the limited extent of bone and soft-tissue within the alveolar process. These ridge defects can be corrected by hard tissue and/or soft-tissue augmentation. A 30-year-old male patient was referred to the Department of Periodontology for correction of Seibert's Class III ridge defect in the lower anterior region. Granulation tissue/connective tissue present at the base of the defect was removed after elevation of full thickness flap. MucoMatrixX, an animal derived, collagen based soft-tissue graft was sutured to the labial flap and bone graft was placed into the defect. If a soft-tissue graft material could be used to replace the palatal grafts, then all the possible complications associated with donor site would be eliminated and above all periodontal plastic surgery and ridge augmentation would be better accepted by patients.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Rastogi, Pk" uniqKey="Rastogi P">PK Rastogi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Seibert, Js" uniqKey="Seibert J">JS Seibert</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Walter, C" uniqKey="Walter C">C Walter</name></author><author><name sortKey="Buttel, L" uniqKey="Buttel L">L Büttel</name></author><author><name sortKey="Weiger, R" uniqKey="Weiger R">R Weiger</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gita, Vb" uniqKey="Gita V">VB Gita</name></author><author><name sortKey="Chandrasekaran, Sc" uniqKey="Chandrasekaran S">SC Chandrasekaran</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thoma, Ds" uniqKey="Thoma D">DS Thoma</name></author><author><name sortKey="H Mmerle, Ch" uniqKey="H Mmerle C">CH Hämmerle</name></author><author><name sortKey="Cochran, Dl" uniqKey="Cochran D">DL Cochran</name></author><author><name sortKey="Jones, Aa" uniqKey="Jones A">AA Jones</name></author><author><name sortKey="Gorlach, C" uniqKey="Gorlach C">C Görlach</name></author><author><name sortKey="Uebersax, L" uniqKey="Uebersax L">L Uebersax</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mishra, N" uniqKey="Mishra N">N Mishra</name></author><author><name sortKey="Singh, Bp" uniqKey="Singh B">BP Singh</name></author><author><name sortKey="Rao, J" uniqKey="Rao J">J Rao</name></author><author><name sortKey="Rastogi, P" uniqKey="Rastogi P">P Rastogi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wagshall, E" uniqKey="Wagshall E">E Wagshall</name></author><author><name sortKey="Lewis, Z" uniqKey="Lewis Z">Z Lewis</name></author><author><name sortKey="Babich, Sb" uniqKey="Babich S">SB Babich</name></author><author><name sortKey="Sinensky, Mc" uniqKey="Sinensky M">MC Sinensky</name></author><author><name sortKey="Hochberg, M" uniqKey="Hochberg M">M Hochberg</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Contemp Clin Dent</journal-id><journal-id journal-id-type="iso-abbrev">Contemp Clin Dent</journal-id><journal-id journal-id-type="publisher-id">CCD</journal-id><journal-title-group><journal-title>Contemporary Clinical Dentistry</journal-title></journal-title-group><issn pub-type="ppub">0976-237X</issn><issn pub-type="epub">0976-2361</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24403810</article-id><article-id pub-id-type="pmc">3883345</article-id><article-id pub-id-type="publisher-id">CCD-4-556</article-id><article-id pub-id-type="doi">10.4103/0976-237X.123090</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Combined soft and hard tissue augmentation for a localized alveolar ridge defect</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Rana</surname><given-names>Ritu</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Ramachandra</surname><given-names>Srinivas Sulugodu</given-names></name><xref ref-type="aff" rid="aff3">2</xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Lahori</surname><given-names>Manesh</given-names></name><xref ref-type="aff" rid="aff2">1</xref></contrib><contrib contrib-type="author"><name><surname>Singhal</surname><given-names>Reetika</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Jithendra</surname><given-names>K D</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib></contrib-group><aff id="aff1"><italic>Department of Periodontology, Kanti Devi Dental College and Hospital, Mathura, Uttar Pradesh, India</italic></aff><aff id="aff2"><label>1</label><italic>Department of Prosthodontics, Kanti Devi Dental College and Hospital, Mathura, Uttar Pradesh, India</italic></aff><aff id="aff3"><label>2</label><italic>Faculty of Dentistry, SEGi University, Malaysia</italic></aff><author-notes><corresp id="cor1"><bold>Correspondence:</bold> Dr. Srinivas Sulugodu Ramachandra, Faculty of Dentistry, SEGi University, No. 9, Jalan Teknologi, Taman Sains, Selangor, Kota Damansara, PJU 5, 47810 Petaling Jaya, Selangor, Darul Ehsan, 00601115417228, Malaysia. E-mail: <email xlink:href="periosrinivas@gmail.com">periosrinivas@gmail.com</email></corresp><fn id="fn1"><p>This case was done and followed up in Kanti Devi Dental College and Hospital, Mathura, India, when Dr. Srinivas S R was working there</p></fn></author-notes><pub-date pub-type="ppub"><season>Oct-Dec</season><year>2013</year></pub-date><volume>4</volume><issue>4</issue><fpage>556</fpage><lpage>558</lpage><permissions><copyright-statement>Copyright: © Contemporary Clinical Dentistry</copyright-statement><copyright-year>2013</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>Ideal alveolar ridge width and height allows placement of a natural appearing pontic, which provides maintenance of a plaque-free environment. The contour of a partially edentulous ridge should be thoroughly evaluated before a fixed partial denture is undertaken. Localized alveolar ridge defect refers to a volumetric deficit of the limited extent of bone and soft-tissue within the alveolar process. These ridge defects can be corrected by hard tissue and/or soft-tissue augmentation. A 30-year-old male patient was referred to the Department of Periodontology for correction of Seibert's Class III ridge defect in the lower anterior region. Granulation tissue/connective tissue present at the base of the defect was removed after elevation of full thickness flap. MucoMatrixX, an animal derived, collagen based soft-tissue graft was sutured to the labial flap and bone graft was placed into the defect. If a soft-tissue graft material could be used to replace the palatal grafts, then all the possible complications associated with donor site would be eliminated and above all periodontal plastic surgery and ridge augmentation would be better accepted by patients.</p></abstract><kwd-group><kwd>Bone grafts</kwd><kwd>MucoMatrixX</kwd><kwd>ridge augmentation</kwd><kwd>ridge defects</kwd></kwd-group></article-meta></front><body><sec id="sec1-1"><title>Introduction</title><p>Localized alveolar ridge defect refers to a volumetric deficit of the limited extent of bone and soft- tissue within the alveolar process.[<xref ref-type="bibr" rid="ref1">1</xref>] The contour of a partially edentulous ridge should be thoroughly evaluated before starting the process of fabrication of a fixed partial denture. Siebert has classified residual ridge deformities into three categories: Class I defect: Facio-lingual loss of tissue width with normal ridge height, Class II defect: Loss of ridge height with normal ridge width, Class III defect: A combination of loss in both dimensions.[<xref ref-type="bibr" rid="ref2">2</xref>] The ideal ridge width and height allows placement of a natural appearing pontic, which provides maintenance of a plaque-free environment. Such type of ridge defects can be corrected by surgical ridge augmentation that can be accomplished by the addition of either soft or hard tissues.[<xref ref-type="bibr" rid="ref3">3</xref>]</p></sec><sec id="sec1-2"><title>Case Report</title><p>This was a case report of a 30-year-old male patient who was referred to the Department of Periodontology, Kanti Devi Dental College and Hospital, Mathura, India for correction of ridge defects in the lower anterior region. Patient gave a history of extraction of the mandibular right canine due to periodontal reasons around 6 months back. On intra-oral examination, loss of ridge height and loss of facio-lingual width was noticed. Hence, a diagnosis of Seibert's Class III alveolar ridge defect was made [<xref ref-type="fig" rid="F1">Figure 1</xref>]. Grade I recession was noticed on the mandibular right lateral incisor and canine. A treatment plan involving augmentation of the alveolar ridge defect with bone grafts and soft-tissue grafts was formulated, informed to the patient and consent was obtained.</p><p>After achieving adequate local anesthesia, vertical releasing incisions were placed on the distal line angle of lateral incisor and mesial line angle of first premolar. A full thickness flap was elevated until the muco-gingival junction and partial thickness flap was reflected beyond the muco-gingival junction [<xref ref-type="fig" rid="F2">Figure 2</xref>]. Granulation tissue/connective tissue present at the base of the defect was removed. A template was used to determine the size of the soft-tissue graft needed to augment the defect. MucoMatrixX, an animal derived, collagen based soft-tissue graft was sutured to the labial flap [<xref ref-type="fig" rid="F3">Figure 3</xref>]. Bone graft was placed into the defect. Labial flap was coronally advanced and interrupted sutures were placed to unite the labial and lingual flaps. Periodontal pack was placed and patient was recalled after 10 days for suture removal. Post-operative instructions were given and analgesics were prescribed for pain control. After 10 days, sutures were removed and remarkable improvement in ridge thickness and height was noticed. One month later, after evaluation of the ridge contour and dimensions, patient was referred to Department of Prosthodontics for placement of the prosthesis. All possible prosthetic options were discussed with the patient. Due to financial constraints, patient could not afford for implant supported prosthesis, instead patient choose for a fixed prosthesis. A porcelain fused to metal crown with mandibular left lateral incisor and mandibular left first premolar as abutment was delivered to the patient [<xref ref-type="fig" rid="F4">Figure 4</xref>]. Patient is being followed without any major complaints.</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Clinical image of Seibert's Class III alveolar ridge defect involving loss of both ridge width and height in relation to mandibular left anterior region</p></caption><graphic xlink:href="CCD-4-556-g001"></graphic></fig><fig id="F2" position="float"><label>Figure 2</label><caption><p>Crestal incision was placed on the alveolar ridge, vertical incisions were placed at the line angles of the adjacent teeth and full thickness flap was reflected till the mucogingival junction</p></caption><graphic xlink:href="CCD-4-556-g002"></graphic></fig><fig id="F3" position="float"><label>Figure 3</label><caption><p>The desired size of MucoMatrixX was procured, soaked in saline/patient's blood and placed in the ridge defect (inset shows the desired size of MucoMatrixX)</p></caption><graphic xlink:href="CCD-4-556-g003"></graphic></fig><fig id="F4" position="float"><label>Figure 4</label><caption><p>Clinical image 4 months after the surgical procedure with porcelain fused to metal crown being placed with the support of adjacent abutment teeth. Note the resolution of the alveolar ridge defects</p></caption><graphic xlink:href="CCD-4-556-g004"></graphic></fig></sec><sec sec-type="discussion" id="sec1-3"><title>Discussion</title><p>The structural loss of the residual alveolar ridge can occur as a result of congenital defects, periodontal disease, tooth extraction or surgical procedures.[<xref ref-type="bibr" rid="ref4">4</xref><xref ref-type="bibr" rid="ref5">5</xref>] During healing, the overlying soft- tissue collapses into the bone defects, creating contours that make it difficult or impossible to make esthetic functional prostheses.[<xref ref-type="bibr" rid="ref4">4</xref>] In this case, Seibert's Class III defect was noticed because the mandibular right canine was extracted due to periodontal reasons resulting in loss of both tissue width and height.</p><p>Soft-tissue grafts (free gingival grafts, sub-epithelial connective tissue grafts) can be harvested from the patient's hard palate. However, these autogenous soft-tissue grafts have a disadvantage of a second surgical site. An acellular dermal matrix graft (Alloderm), which uses medically processed human skin tissue as source has been successfully used. Human skin is also considered to be a separate organ and stringent human organ transplantation rules apply for the use of processed human dermis as allograft. Due to these stringent human organs transplantation rules, which varies in different countries import of acellular dermal matrix (Alloderm) into many countries is prohibited.</p><p>MucoMatrixX is a collagen tissue matrix derived of animal dermis that passes through a multistep cleaning process, which removes all potential tissue rejection components from the dermis. This results into a three-dimensional stable matrix consisting of collagen and elastin. MucoMatrixX supports revascularization and fast soft-tissue integration and is a valid alternative for patients own connective tissue. After placement, the patient's blood infiltrates the MucoMatrixX graft through the three-dimensional soft-tissue network, bringing host cells to the soft-tissue graft surface and starting the revascularization process.</p><p>There are various other prosthetic and surgical options for improving esthetics in patient with ridge deformities.[<xref ref-type="bibr" rid="ref6">6</xref>] Long pontic design or gingival (pink) ceramic in the cervical region can enhance esthetics in such cases. Surgical procedures using soft-tissue autogenous graft, various alloplastic materials, autogenous bone graft and guided tissue regeneration can correct such type of ridge defects.[<xref ref-type="bibr" rid="ref6">6</xref>] In the present case, we have used a combination of bone grafts and soft-tissue xenograft for the purpose of hard and soft-tissue augmentation. Use of soft-tissue allografts and xenografts is a very useful alternative to harvesting soft-tissue graft from the palate. The prospect of a second surgical site and its inherent risks and complications, which may include pain, discomfort and bleeding, is especially undesirable.[<xref ref-type="bibr" rid="ref7">7</xref>] The requirement to harvest donor tissue necessitates the need for additional local anesthesia and surgical trauma to a site often distant from the area of concern. If a graft material could be used to replace the palatal grafts, then all the possible complications associated with donor site would be eliminated and above all periodontal plastic surgery and ridge augmentation would be better accepted by patients.[<xref ref-type="bibr" rid="ref7">7</xref>]</p></sec></body><back><ack><title>Acknowledgment</title><p>We would like to thank Mr. Matthias Matthes, MD, Dentegris International, Germany for providing with samples of MucoMatrixX.</p></ack><fn-group><fn fn-type="supported-by"><p><bold>Source of Support:</bold> Dr. Sulugodu Ramachandra Srinivas, Dr. Reetika Singhal and Dr. K.D. Jithendra have received a product grant from Dentegris International, the producers of MucoMatrixX soft tissue graft.</p></fn><fn fn-type="conflict"><p><bold>Conflict of Interest:</bold> None declared.</p></fn></fn-group><ref-list><title>References</title><ref id="ref1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Rastogi</surname><given-names>PK</given-names></name></person-group><article-title>Aesthetic enhancement with periodontal plastic procedure in a class 3 alveolar ridge defect</article-title><source>BMJ Case Rep</source><year>2012</year><volume>2012</volume></element-citation></ref><ref id="ref2"><label>2</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Seibert</surname><given-names>JS</given-names></name></person-group><article-title>Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. 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