PMC7396066_01
(a, b) Site of chief complaint revealing unsatisfactory aesthetic appearance.
CRID2020-3906468.001.jpg
PMC7396066_01_CRID2020-3906468.001.jpg
fig1
Due to the ridge defect and lack of soft-tissue quantity, the discrepancy in the location of the gingival margin was about 1 cm (Figure 1(a)).
Section from panoramic radiograph representing the site of chief complaint, prior to the attempted extraction of the left maxillary central incisor. Severe vertical bone defect around the left maxillary central incisor is evident.
CRID2020-3906468.002.jpg
PMC7396066_01_CRID2020-3906468.002.jpg
fig2
Flap is released (split-full-split) following coronally advanced flap design (as described by Zucchelli & De Sanctis).
CRID2020-3906468.003.jpg
PMC7396066_01_CRID2020-3906468.003.jpg
fig3
The flap design applied to manage this case is presented in Figure 3.
(a) Deepithelialized free gingival graft. (b) Connective tissue graft folded in two layers and then sutured, to gain soft-tissue thickness in the vertical direction.
CRID2020-3906468.004.jpg
PMC7396066_01_CRID2020-3906468.004.jpg
fig4
The first graft, harvested from the right palate, of about 20 mm in length (Figure 4(a)), was folded (Figure 4(b)), and then secured by two vertical mattress sutures, with 7/0 PGA sutures, to form a two-layered graft.
Folded connective tissue graft sutured at the defect site.
CRID2020-3906468.005.jpg
PMC7396066_01_CRID2020-3906468.005.jpg
fig5
The two-layered graft was sutured on the connective tissue of the occlusal side of the edentulous deepithelialized area, with a horizontal mattress suture and an interrupted suture, to secure the graft in place (Figure 5).
Second deepithelialized free gingival graft.
CRID2020-3906468.006.jpg
PMC7396066_01_CRID2020-3906468.006.jpg
fig6
Then, the second graft was harvested from the other side of the palate, which was of 20 mm length and 7 mm in width (Figure 6).
First part of the second deepithelialized free gingival graft sutured on the buccal side.
CRID2020-3906468.007.jpg
PMC7396066_01_CRID2020-3906468.007.jpg
fig7
This second graft was cut in two parts; the first part, which was about 13 mm in length, was sutured on the periosteum of the buccal side, with a horizontal mattress suture on the apical side and with a single interrupted suture on the first graft on the deepithelialized anatomical papillae (Figure 7).
Second part of the second deepithelialized free gingival graft.
CRID2020-3906468.008.jpg
PMC7396066_01_CRID2020-3906468.008.jpg
fig8
Sutured multilayered connective tissue graft (frontal view).
CRID2020-3906468.009.jpg
PMC7396066_01_CRID2020-3906468.009.jpg
fig9
Sutured multilayered connective tissue graft (occlusal view).
CRID2020-3906468.010.jpg
PMC7396066_01_CRID2020-3906468.010.jpg
fig10
Suturing of the flap.
CRID2020-3906468.011.jpg
PMC7396066_01_CRID2020-3906468.011.jpg
fig11
Single interrupted sutures, with 6/0 prolene, were performed to have a complete closure between the horizontal incisions of the edentulous area and the palatal island flap (Figure 11).
Healing after 6 months. Incomplete soft-tissue augmentation is evident.
CRID2020-3906468.012.jpg
PMC7396066_01_CRID2020-3906468.012.jpg
fig12
Due to incomplete soft-tissue augmentation, we performed a second mucogingival surgery, 6 months after the first one (Figure 12).
Probing depth after flap elevation.
CRID2020-3906468.013.jpg
PMC7396066_01_CRID2020-3906468.013.jpg
fig13
After split-thickness flap elevation, probing depth around the anterior maxillary teeth was 2 mm (Figures 13 and 14), which could mean that we might have a connective tissue attachment to the root surface of the right maxillary central incisor and the left maxillary lateral incisor.
The previous connective tissue graft augmentation is evident after flap elevation.
CRID2020-3906468.014.jpg
PMC7396066_01_CRID2020-3906468.014.jpg
fig14
After split-thickness flap elevation, probing depth around the anterior maxillary teeth was 2 mm (Figures 13 and 14), which could mean that we might have a connective tissue attachment to the root surface of the right maxillary central incisor and the left maxillary lateral incisor.
Sutured multilayered connective tissue graft (3 layers of occlusal connective tissue graft and one layer of buccal connective tissue graft).
CRID2020-3906468.015.jpg
PMC7396066_01_CRID2020-3906468.015.jpg
fig15
After the first part of the second graft was secured in place and was completely stable, the second part of the graft (which was about 7 mm length) was then sutured occlusally with two sling sutures around the right maxillary central incisor and the left maxillary lateral incisor (Figures 15 and 16).