advanced coronally. The flap is sutured in place approximately 0.5 to 1 mm coronal to the cementoenamel junction. Interrupted sutures are used in the papilla regions and along the relieving incisions. Gentle pressure is applied for a few minutes, with a periodontal dressing applied as needed.
large recession defects and shallow sulcus depths. The gold standard for treatment is the use of the coronally advanced flap plus a subepithelial connective tissue graft.
Prognosis.—Gingival recession defects can be reduced and attachment levels improved through periodontal plastic surgery. Full root coverage after a single procedure can be difficult, with success often defined as a decrease in the amount of root exposed. Size of the initial recession defect also contributes to the final outcome. A higher percentage of complete and mean root coverage is noted for recession defects less than 4 mm. The laterally repositioned flap and double papilla flap achieve mean root coverage between 34% and 81% and complete root coverage between 40% and 50% of the time. Donor site recession risk is highest with laterally repositioned flaps of approximately 1 mm. For the single-stage coronally repositioned flap, the mean root coverage is between 55% and 99%, with complete root coverage achieved in 24% to 95% of the sites. To achieve 100% root coverage with a coronally repositioned flap, the flap should be overcompensated by 2 to 2.5 mm and sutured without tension. This is hard to obtain with
Clinical Significance.—Small Miller’s class I and II recession defects can be handled by pedicle flaps. The advantage of these flaps is their retention of blood supply to aid healing, but pedicle flaps are only useful when the gingival biotype is thick and the amount of keratinized tissue adjacent to the recession is sufficient. Thin gingival biotype cases or those with limited keratinized tissue are better managed using a free graft or a free graft along with the pedicle graft.
Patel M, Nixon PJ, Chan MFW-Y: Gingival recession: Part 2. Surgical management using pedicle grafts. Br Dent J 211:315-319, 2011 Reprints available from M Patel, Dept of Restorative Dentistry, Leeds Dental Inst, Clarendon Way, Leeds, LS2 9LU: e-mail: [email protected]
Implants Implant-retained removable partial denture Background.—The benefits of using dental implants to stabilize complete overdentures are well documented, but implants can also be used to stabilize removable partial dentures (RPDs). Oral anatomy and available teeth are vital components of an RPD stabilization plan. When the ridges are highly resorbed and there are too few suitable abutment teeth, stability is poor. In addition, RPDs with distal extensions, Kennedy class I and II, are usually less stable than those engaging distal abutment teeth. If only one distal abutment tooth is lost, the RPD becomes unstable. Several problems arise when clasps are used on anterior teeth, including unacceptable esthetics when the clasped tooth is visible during smiling, inadequate stability if there are no distal abutment teeth, and loss of anterior teeth should loads be excessive. A properly positioned implant permits the fabrication of a stable RPD. Use of an overdenture abutment also eliminates the need for unesthetic clasps. A clinical case was offered to demonstrate how the placement of a single implant allows one to establish a stable, esthetic unilateral distal extension removable partial overdenture. Case Report.—Woman, aged 47 years, who smoked had a chief complaint of a poorly fitting maxillary RPD with an unesthetic anterior clasp. She was missing teeth
numbers 1 to 7, 12, and 14 to 16, classified as a Kennedy class II partially edentulous arch. The original RPD had an I-bar metal clasp on the buccal surface of tooth number 8, but the patient did not always wear it because it was unstable and unesthetic. On clinical examination, the patient had severe resorption of the maxillary right residual alveolar ridge (Fig 2), with minimal bone between the crest of the alveolar ridge
Fig 2.—Preoperative clinical view showing severe maxillary right ridge resorption. (Courtesy of Mahn DH: Stabilizing and securing an RPD with a single implant. Dent Today, September 2011.)
Fig 4.—Closer view of Zest LOCATOR Abutment in site no 6. (Courtesy of Mahn DH: Stabilizing and securing an RPD with a single implant. Dent Today, September 2011.)
Fig 6.—Postoperative clinical view with RPD in place. (Courtesy of Mahn DH: Stabilizing and securing an RPD with a single implant. Dent Today, September 2011.)
and the floor of the maxillary sinus at the bicuspid to molar area. The patient’s options included sinus grafting, multiple implant placement, and fixed restorations. Financial concerns led her to choose fabrication of a maxillary RPD with a single implant overdenture abutment securing the right distal extension. The left side would be stabilized with a traditional clasp system.
resorbed, narrow maxillary right posterior residual ridge, and a maxillary right sinus floor close to the residual ridge crest in the bicuspid to molar range. Because fixed restorations were too expensive, the patient chose a complete overdenture retained by an implant on one side and a conventional clasp on the other. As a result, the RPD was highly stable and esthetic, giving the patient a sense of confidence in function and when smiling.
The dental implant placed in site number 6 had a regular diameter, measuring 4.0 10 mm2. The implant was allowed to osseointegrate, then an overdenture abutment was secured to it (Fig 4). The overdenture abutment supplied excellent retention for the right side. Tooth number 13 was engaged with a T-bar clasp and mesial-occlusal rest. The soft-tissue architecture was replicated by using pink acrylic. Appropriately sized teeth were used (Fig 6), with the final result being a stable, functional RPD that was highly esthetically pleasing to the patient.
Clinical Significance.—Patients who have implant-supported RPDs often report improved function, improved esthetics, and satisfaction with the cost of the restoration. Implantretained RPDs are highly cost-effective compared with fixed treatment options. Overdenture abutments also tolerate a range of divergence. This is highly beneficial when creating a path of draw for an implant-retained RPD.
Discussion.—Conventional RPDs can become unstable if a strategically placed tooth is lost. Distal extension RPDs, Kennedy class I and II, are less well retained than RPDs with distal abutment teeth. Conventional clasps are not only unesthetic but can produce excessive tooth loading and result in rapid loss of the tooth. The case involved a patient with a Kennedy class II partially edentulous arch, a highly
Mahn DH: Stabilizing and securing an RPD with a single implant. Dent Today, September 2011 Reprints available from DH Mahn: e-mail: [email protected]
Single implant-retained complete dentures Background.—Complete dentures are often associated with inadequate function and retention, mainly in the mandible. Patients with problematic dentures suffer reduced quality of life, social relationships, general health, and nutrition. In addition, some patients are unable to
adapt to conventional complete dentures in the mandible without any fixation. Studies have identified mandibular overdentures retained by two implants in the interforaminal area as the first-choice standard of care for edentulous patients. However, cost and other factors prevent many