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| CASE SERIES |
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| Year : 2015 | Volume
: 5
| Issue : 2 | Page : 106-112 |
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Palatal pedicle flap-varied applications
AB Tarun Kumar, PS Divya Gayatri, MG Triveni, DS Mehta
Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
| Date of Web Publication | 10-Mar-2016 |
Correspondence Address:
Dr. P S Divya Gayatri
Room No. 5, Department of Periodontics, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2231-6027.178505
Implant restorations, a boon to dentistry, often suffer from ridge and soft tissue deficiencies because of the postextraction tissue remodeling. This hindrance could be overcome through soft and hard tissue augmentation as future implant site development. A good pink carpet is one of the prerequisite for esthetics around implant restoration, which could be achieved adequately through hard and soft tissue grafting procedures. In this regard, many techniques have been advocated, wherein the pedicle grafts gained popularity owing to the ability to maintain intact vascularity. Palatal tissue is desirable graft of choice for its thick biotype. Thus a combination of palatal tissue with pedicle grafts are said to be novel in this application. In this article, we discussed the applications of different palatal pedicle grafts along with elaborating their varied applications in three patients. Keywords: Biotype, implant, palatal pedicle graft, peri-implant soft tissue, pink esthetics
How to cite this article:
Tarun Kumar A B, Divya Gayatri P S, Triveni M G, Mehta D S. Palatal pedicle flap-varied applications. Int J Oral Health Sci 2015;5:106-12 |
| Introduction | |  |
The soft tissue morphology plays a pivotal role in the achievement of esthetic success for prosthetic replacements. As a consequence, wound healing of the extraction sockets results not only in dimensional alterations of the underlying bone but also the surrounding soft tissue architecture. More than 51% of the dimensional changes occur within 2 weeks of postextraction healing, irrespective of the underlying bone phenotype.[1] These defects are to be given prime concern to regain the lost pink esthetics for implant supported restorations.
The long-term stability of soft tissue around dental implant prostheses has been strongly correlated with adequate peri-implant mucosa, that is, a thick peri-implant biotype.[2],[3] Deficiencies of soft tissue thickness like thin biotype might pose hindrance for esthetic smile with permeable exposure of implant metal surface because of the transparency effect or recession of peri-implant mucosa. This can be addressed by correcting the biotype and increasing the peri-implant mucosa by using grafts such as sub epithelial connective tissue (CT) or free gingival graft (FGG)[4],[5],[6] with also other techniques such as onlay-interpositional graft procedure,[7] rotated split palatal flap (RSPF),[8] palatal roll technique,[9] vascularized interpositional periosteal-CT (VIP-CT) flap,[10] and so on. The proven promising results from these lead to further modifications and its use in different approaches such as cleft tissue repair.[11],[12]
| Palatal Pedicle Flaps | | |
The roots of palatal pedicle grafts seem to be from RSPF. It was advocated by Nemcovsky in 1999 for the soft tissue coverage over extraction sites with immediate implant placement.[8] Several other techniques based on the palatal pedicle grafts include palatal advanced flap by Khoury and Happe in 2000,[13] rotated full palatal flap by Nemcovsky in 2000,[14] and palatal advanced flap by Goldstein et al. 2002,[15] VIP-CT flap by Sclar 2003[10] and modified VIP-CT by Kim et al. 2012.[12]
Owing to the shortcomings of the free grafts such as poor vascularity and color match RSPF graft contained palatal CT and periosteum as a pedicle graft with intact vascularity [Figure 1]. It was harvested simultaneously with hard tissue augmentation in the maxillary anteriors for implant restorations. In this, the palatal full-thickness flap was elevated and further divided into two flaps wherein outer flap consists of epithelium and superficial CT while lower consists of deep CT and periosteum. Another incision, parallel to the reunion of the two palatal split thickness flaps, was given only to the inner flap. This incision extended from one gingival margin to not <5 mm from the other. The deeper part of inner flap was then made into a pediculated and was advanced over the maxillary defect. Later in 2000,[14] when Nemkovsky was conducting a comparative study on different pedicle flaps that is split pedicle flap with and without membrane and full pedicle flap from palate, he concluded there is no statistically significant difference among the groups. Further, he stated that rotated full palatal flap differed from the former RSPF by lacking a split incision dividing the CT graft. | Figure 1: Rotated deep split thickness palatal graft. (Adapted from Nemkovsky CE et al.[8])
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Khoury and Happe in 2000[13] described a palatal subepithelial CT graft pedicled over the maxillary defect. The method of harvesting subepithelial CT grafts (SCTG) was similar to the conventional technique, but for the graft remained attached to the palatal gingiva in the anterior region which acts a highly vascular pedicle and then the graft (posterior detached part) is rotated over the defect area for augmentation. Goldstein et al. in 2002[15] advocated palatal advanced flap [Figure 2] based on the sliding flap proposed by Tinti and Parma-Benfenati 1995.[16] In this technique, Goldstein achieved coverage of the coronal gap over the immediate implant placed in the extraction socket. This was an advancing L-shaped flap with parallel incisions designed according to the mesiodistal and labiopalatal dimensions of the gap left over. The long “leg” of the L was toward the distal while the advancing short leg was made perpendicular to the extraction site. On the inner part of the L-shaped flap, a triangular area was marked where the base of the triangle (equivalent to labiopalatal dimension of the gap) was on short leg, and apex was pointed distally along the long “leg”. | Figure 2: Palatal advanced flap. (a) Flap outline. (b) Outline of triangle “a” should be similar to the distance “b”, which is the implant area. (c) Epithelium removed from sliding area. (d) Dissection and buccal sliding for complete coverage of implant area. (Adapted from Goldstein M et al.[15])
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In 2003, Sclar [10] in his book, “Soft Tissue and Esthetic Consideration in Implant Therapy” described a pedicle CT grafting technique namely VIP-CT flap. Exaggerated curvilinear cutback incisions, for tension releasing, were advised on the recipient site for flap elevation. On the palate, vertical releasing incisions were given mesial and distal aspects of the recipient site. The palatal incision on distal aspect was extended further parallel to gingival margin horizontally upto the distal aspect of second premolar via single incision technique and subepithelial CT graft including periosteum was reflected. The tissue was relieved in the distal aspect with a vertical incision made through the CT-periosteal layer. Coronal tension was generated using Adson's forceps, and a horizontal incision similar to vertical incision was given and distal aspect of the CT is harvested as a graft. The pedicle graft with an attachment in the anterior region is advanced coronally with a pivot over the incisive papilla region and grafted over the recipient site; wherein it was stabilized using external mattress sutures. Later, the donor and recipient flaps were secured with interrupted sutures for primary wound closure.
The technique VIP-CT successfully aids to reconstruct a large volume of esthetic ridge defects along with ease for allowing simultaneous hard and soft tissue implant site development. This technique was designed owing to the neurovascular supply of premaxilla and palate utilizing the pivotal help of incisive papilla for the interpositioning of the harvested graft. Several limitations of other techniques such as length of the graft, color matching, vascularity, postsurgical shrinkage of the graft, limited thickness, and increased operating time were overcome and well addressed with VIP-CT flap.[10]
Though Sclar primarily advocated this technique of VIP-CT for soft tissue augmentation in anterior esthetic zone, several innovations have been put forward to this incentive and became wider with its application including in alveolar cleft augmentation.[11] Kim et al. in 2012[12] proposed a modified VIP-CT graft including papilla preservation flap in the implant site in order to reduce the postoperative flap shrinkage to prevent papillary loss. Despite, the several advantages there are few limitations for VIP-CT flap, such as the inability to meet the other demands of mucogingival surgery like shallow vestibular depth in a single procedure.[17] However, limited literature is available on this technique to assess the long-term stability of the procedure. In this case series, we are presenting the palatal pedicle flap with varied applications in simultaneous hard and soft tisuue augmentations and its application in closure of oroantral fistula. Further, we also described a new modification of VIP-CT flap, with palatal tunneling [Figure 3] and [Figure 4]; Case 1] which minimizes tissue insult thus reduces postoperative shrinkage and maintains the intact vascularity of donor site even better. All the three patients were explained about the treatment protocols, and informed consent was obtained from them prior to the commencement of the procedure. | Figure 3: (a) Modified single incision given for connective tissue harvest, (b) reflection of periosteal pedicle sub-epithelial connective tissue graft, (c) palatal tunneling done near the recipient site for advancement of pedicle graft, (d) advancement of the pedicle graft through the tunnel over the extraction socket
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 | Figure 4: Case 1: (a) Root stump in relation to 11, (b) extraction socket, (c) immediate implant placed in the socket and vascularized interpositional periosteal-connective tissue harvested through modified single incision technique, (d) palatal tunneling done connecting donor and recipient sites, (e and f) advancement of graft into socket through tunnel, (g) pedicle graft in the extraction socket, (h) stabilizing the graft with external mattress sutures, (i) 3 months postoperative view of the grafted site with root mimicking pink esthetics
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| Case Series | | |
Case 1
A 30-year-old male patient with fractured tooth in the maxillary anterior region in relation to 11 has reported with a chief complaint of broken tooth in upper front teeth region [Figure 4]a. Patient wanted an implant supported restoration of the missing tooth. On examination, the root of the fractured tooth was intact and a thin gingival biotype was observed. Pretreatment records were taken with medical and dental history, photographs were taken, casts were made, routine blood investigations were done, and treatment plan was formulated. After achieving adequate local anesthesia, atraumatic extraction was done in relation to 11 [Figure 4]b followed by immediate implant placement using 4.0 mm × 13.0 mm CMI implant (Neobiotech ®, USA) [Figure 4]c. After ensuring the correct three-dimensional placement of the implant, the jumping distance between the implant and socket was grafted with Novabone Dental Putty ®. Further, soft tissue augmentation was planned over the implant site to achieve optimum pink esthetics with root form morphology. Modified VIP-CT [Figure 4]c graft was harvested with modified single incision technique [18] from the palate and the advancement was done through palatal tunneling procedure.
This is a modification of VIP-CT flap which differs from the conventional technique [10] by lacking the releasing incisions at donor site for advancing the pedicle over the recipient site. Instead in this proposed technique, the advancing was done through tunneling procedure [19] [Figure 4]d. An anteroposterior subperiosteal tunneling was done on the palate near implant site to create a passageway for pedicle graft connecting donor and recipient sites. Anterior extension of the tunnel was prepared beneath the margin of the extraction socket after atraumatic extraction before implant placement. The posterior end of the tunnel was prepared mesial to the single incision on the palate. The passageway of the tunnel thus prepared was further checked using an instrument. Then the flap was advanced over the jumping distance through the tunnel into the implant site [Figure 4]e,[Figure 4]f,[Figure 4]g. The pedicle graft was stabilized using external mattress sutures [Figure 4]h and the donor site by cross-mattress sutures with 5–0 Prolene ® suture. The patient was kept under regular antibiotic and analgesics. When recalled for prosthesis root mimicking prominence on the labial aspect with optimal pink esthetics was noticed [Figure 4]i. The advantage of this modification over the traditional approach was achieving optimum results with negligible tissue trauma.
Case 2
A 19-year-old female patient reported to the Department of Periodontics with a chief complaint of missing teeth for the past 6 months and wanted it to be replaced permanently without damaging the adjacent tooth. On clinical and radiographic examination, 11 appeared to be missing with loss of both horizontal and vertical components of alveolar bone and diagnosed as Siebert's Class-III defect [Figure 5]a and [Figure 5]b.[20] The soft tissue present over the edentulous site was of thin biotype. Pretreatment evaluation was done, and a treatment plan including simultaneous hard and soft tissue augmentation with implant placement was formulated. Initial preparation for the surgery was performed, and a 4.0 mm × 13.0 mm CMI implant (Neobiotech ®, South Korea) was placed [Figure 5]c. A dehiscence defect of 6–7 mm was observed on the labial aspect of the implant, which was further treated with autogeneous graft mixed with Novabone ® morsel (NB1805) for guided bone regeneration [Figure 5]d. Here, double layered closure of the graft site is opted to minimize the chances of exposure of neck of the implant and create a root mimicking morphology on labial aspect by using titanium mesh and pedicle flap from palate [Figure 5]e and [Figure 5]f. Primary flap closure was achieved using 4–0 Linex ® suture [Figure 5]g and the patient was kept under periodic observation for 3 months. Adequate hard and soft tissue components were observed during the second stage surgery [Figure 5]h and [Figure 5]i. | Figure 5: Case 2: (a) Partially edentulous in relation to 11, (b) Siebert's Class III defect, (c) implant placement done, (d) guided bone regeneration done in the labial aspect using autogenous graft admixed with novabone morsel, (e) titanium mesh placed over the bone graft, (f) soft tissue augmentation over the implant using vascularized interpositional periosteal-connective tissue flap, (g) primary closure achieved with polyamide 4–0 sutures, (h) appreciable amount of hard and soft tissue gain after 3 months, (i) emergence profile of the implant restoration with adequate tissue support
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Case 3
A 40-year-old female patient was referred for the treatment of sinus perforation in relation to 25 resulted as a consequence of extraction. On clinical examination, medium size sinus membrane perforation was observed [Figure 4]a. This was confirmed by using valsalva maneuver. A VIP-CT flap was raised from the posterior palate, and pedicled CT graft was harvested to repair the sinus perforation [Figure 4]b and [Figure 4]c and to prevent the formation of oroantral fistula. The graft was advanced over the extraction socket apically [Figure 4]d in order to seal the perforated membrane and stabilized using external mattress sutures with 4–0 Linex ® suture [Figure 4]e. Primary closure of the extraction socket and donor site of palate was achieved using 4–0 Vicryl ® suture [Figure 4]f. The patient was kept under regular post extraction observation with antibiotics and analgesics. Special postoperative instructions were given to the patient like do not blow through the nose, do not consume liquids through straw, sneeze with mouth wide open were given to the patient to enable proper healing of perforation repair.[21] Re-evaluation of the patient was done after 3 months and 4.2 × 11.5 implant (MIS Implant Technologies ® Inc., Israel) was placed uneventfully.
| Discussion | | |
The amount of implant/abutment surface soft tissue attachment is a significant contributor for the maintenance of peri-implant health and the overall aesthetics of the final restoration. The peri-implant mucosa has a higher fiber content than that of gingiva around teeth, and the collagen fibers were arranged parallel to the implant surface in contrast to that of the gingiva which are tended to be arranged perpendicular to the cementum surface of the tooth root. This permits a tight seal of mucosal tissue around the implant.[22]
In the early healing phase, following implant placement surgery peri-implant gingival tissue appears to shrink. The longitudinal arrangement of the major collagen fiber groups amplifies the process of collagen fibril contraction (as part of collagen maturation) in the vertical direction.[23] This discrepancy is even more pronounced in single-implant sites where a concavity forms between the edentulous site and the root prominences of the neighboring dentition. SCTG or FGGs can be employed in these cases to reconstruct the buccal dimensions of the site improving the tissue thickness. In addition, they create an illusion of root prominence and increase the width of the crestal peri-implant mucosa in order to provide an emergence profile for the restoration and enable the constructed site to closely resemble a natural tooth. Poor color match and insufficient vascular bed of the graft, when augmented with the hard tissue, stand out to be the limitations for SCTG and FGG. However, these were overcome in pedicle grafts by allowing large volume augmentations with rich vascular supply in a random pattern and excellent esthetic blending at the recipient site. The other advantages include minimizing the postsurgical shrinkage of the graft, facilitating primary closure of donor site, and reduction in treatment time.[10]
Palatal connective graft is one of the most opted treatment of choice for peri-implant plastic surgeries. Owing to the postextraction morphologic changes, often augmentation procedures are needed to support the implant restorations. In the regions of high esthetic demand like anterior maxilla where simultaneous guided bone regeneration with soft tissue correction is required pedicle flaps are desired. VIP-CT flap is one such graft being used. It protects underlying bone graft, nourishes it and simultaneously vertically augments the region. The periosteal surface of the flap is placed toward the bone while the CT of flap comes peripherally. This raw surface undergoes secondary healing with keratinized epithelium of color and consistency matching with adjacent mucosa.[24] In this case series, we have treated three patients with pedicle flap from palate where two were in the anterior and one in the posterior maxilla.
The advancement of the pedicle graft varied widely for all the three cases. In the first case [Figure 4], it was through the subperiosteal tunnel. Tunnel was preferred here to prevent the papillary loss around the immediate implant. Graft harvesting was similar to VIP-CT technique [10] except for the advancement. The grafting in the second case [Figure 5] includes double layered closure with pedicle flap where the graft harvested was similar to RSPF.[8] Special care was taken while harvesting because it was from the free tissue. In the third patient [Figure 6], where the treatment site was posterior maxilla the graft harvested was similar to VIP-CT flap but advanced posteriorly. | Figure 6: Case 3: (a) Extraction socket with oroantral communication, (b and c) advancing the vascularized interpositional periosteal-connective tissue flap over the extraction socket, (d and e) stabilizing the graft in socket with external mattress sutures, (f) implant placement in the socket done uneventfully
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| Conclusion | | |
Palatal pedicle grafts are effective in peri-implant mucosal development. They allow primary closure of implant site and reduce patient inconvenience.[10] Several factors such as the inability to use in mandibular defects, technique sensitivity, and expertize of clinician limit the usage of this flap widely. Literature states, high survival rates (97.2%) for this flap and considered a reliable treatment alternative in the reconstruction of maxillary soft tissue defects at the implant site. Donor site morbidity with palatal sloughing is observed in about 63% of the patients. If sloughing occurs, expected to heal rapidly and blends with adjacent palatal tissue in 2 months postoperatively.[25] These three cases were treated with no complications and were followed up for more than 1 year with stable results. This exemplifies the ability of palatal pedicle flap to augment the soft tissue with predictable simultaneous hard tissue maturation.[10] Hence, we conclude that palatal pedicle flap is a predictable treatment alternative in the maxillary soft tissue enhancement around implants for medium size defects.
| Clinical Significance | | |
The versatile nature of this flap availed its use in varying patterns for different clinical challenges. In future, more such incentives and literature is desirable on such imperative procedures in order to extend a helping hand for the clinician in day-to-day practice.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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