A 22 year old male patient visited the Department of Prosthodontics with the complaint of missing tooth in upper front region of jaw since last 1 year. (Fig: 1 & 2) The clinical and radiographic examination revealed a Seibert class 1 edentulous defect with concavity on the facial aspect in the anterior region which was aesthetically unpleasing. The patient opted for a fixed partial denture and the consent was recorded.
Teeth 21 and 23 were prepared to receive all ceramic 3 unit prosthesis. Impressions were made using VPS impression material (3M ESPE) using two step impression technique. The casts were poured in Type III gypsum product. On the maxillary cast, the pontic region was sectioned to mimic the shape of E pontic.4 The depth of the pontic region was maintained as 2 mm with slope towards the palatal side & 900 angle towards labio-cervical aspect. After this, wax build up was done on the cast to mimic the natural contours of the teeth involved. Then fabrication of a temporary prosthesis using Self cure bis-GMA acrylic resin (PROTEMP Shade A2) was carried out on the cast. The temporary prosthesis was kept ready for post-surgical cementation.
The surgical procedure of preparing the recipient site to receive the graft from the donor site was carried out after pre-operative mouth rinse using 0.2% CHX.
The pouch was prepared by placing a horizontal incision on the palatal side of the defect and the dissection was carried out in an apical direction. The mesiodistal entrance incision for the edge of the pouch was made with a long bevel and was started well to the palatal side of the defect with the pouch formation at the buccal side of involved area. (Fig: 3).5
The connective tissue graft was harvested with a “trapdoor” technique from the palatal aspect of the maxillary premolars/first molar. A horizontal incision was placed 3 mm apical to the soft tissue margin perpendicular to the underlying bony surface. Two vertical releasing incisions were made at either end of the primary incision. An incision was then placed from the line of the first incision and directed apically to perform a split incision of the palatal mucosa (Fig:4). A periosteal elevator was used to release the connective tissue graft from the bone.6 After harvesting the connective tissue graft, the door was sutured back with 4 − 0 vicryl sutures.
The graft was then filled into the pouch (Fig:5) and after proper seating of the palatal graft into the pouch, recipient site was sutured with 5 − 0 vicryl sutures. Immediate temporary prosthesis was then fixed with temporary cement (Fig: 6).
Patient was recalled for follow-up and suture removal. At 6 weeks post-surgical appointment, final impressions were made using VPS material with two step technique. All ceramic three unit fixed partial denture was fabricated in the laboratory. At try in appointment, patient confirmed his esthetic and functional satisfaction with prosthesis and it was cemented using dual cure esthetic resin cement (3M ESPE RelyX U200) under isolation. (Fig. 7)
Patient was recalled at regular intervals to check for oral hygiene maintenance and plaque status. The gingival contour was satisfactory with balance to esthetic and functional needs of the patient. (Fig-11)