PMC5855274_01
Intraoral preoperative view showing Seibert's Class III defect
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F1
Allen's mild Type C, between maxillary right canine and maxillary left central incisor [Figure 1]. After thorough evaluation of the history, clinical condition, and radiological investigations, surgical correction of the defect area by VIP-CT graft, harvested from the palate, in combination with alloplastic (hydroxyapatite and beta tricalcium phosphate) bone graft was planned since hydroxyl appetite is a slow-resorbing alloplastic bone graft material; it will help in maintaining the volume of defect fill.
(a) A labial full-thickness flap was elevated; (b) Vascular interpositional connective tissue pedicled graft
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F2
Following a presurgical rinse with chlorhexidine and administration of local anesthesia (2% lidocaine with 1:100,000 epinephrine), a labial full-thickness flap was elevated by giving crestal incision extending from maxillary right canine to maxillary left central incisor followed by two vertical releasing incisions, and the ridge defect was exposed [Figure 2a]. A VIP-CT pedicled graft was harvested from the palate [Figure 2b].
Surgical outline for harvesting vascular interpositional connective tissue pedicled graft
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F3
The surgical outline for VIP-CT graft is given in Figure 3.
(a) Placement of bone graft in defect; (b) vascular interpositioned connective tissue graft was placed and sutured; (c) the flap was sutured back with 3-0 silk suture
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F4
After thorough debridement of the bony defect and removal of all the granulation tissue present, alloplastic bone graft (Sybograft-plus [Eucare Pharmaceuticals(p) Limited, Chennai, India]) (hydroxyapatite and beta tricalcium phosphate) was condensed into the defect using a graft carrier, thus increasing the width in the buccal palatal aspect [Figure 4a]. The VIP-CT graft which was harvested at the beginning of the procedure was then placed and sutured [Figure 4b] over the bone graft, to increase the width as well as the apicocoronal height of the ridge. The flap was sutured back with 3-0 silk suture [Figure 4c].
Postoperative view after 10 days
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F5
The sutures were removed after 10 days [Figure 5], and the patient was recalled for follow-up every month.
Immediate after porcelain fused to metal restoration with 13 12 11 21
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F6
The final fixed prosthesis was cemented after 6 months once adequate soft- and hard-tissue healing of the defect, leading to improved esthetics of the patient [Figure 6], was seen.
Postoperative view (a) after 3 months, (b) after 6 months
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F7
The patient was recalled after 3 months and 6 months for regular follow-ups [Figure 7a and b].