Many times an edentulous area in the anterior region appears to be underdeveloped to create an ovate pontic. There is no cervical bulge because there is no root (Figs. 1 & 2). When esthetics is a driving concern and we have a high lip line, I would like to discuss an optional way for the general dentist to develop an ovate pontic site vs. connective tissue grafting.
CASE SELECTION
1. Proper underlying bone–determined by x-ray and sounding to bone. We don’t want to take a chance of raising a flap and find we have a bone defect that could cause us to loose tissue.
2. Ridge Type–We want a rounded to flat ridge where we don’t elevate the tissue more than 3mm from the bone (Figs. 3 & 4).
3. Tissue Type–The more thick and plump the better vs. a thin poorly vascularized area. Vertical height of the tissue being determined by the height of the interdental papilla next to the edentulous area (Fig. 2).
TECHNIQUE
Beginning with the end in mind, we want to create an ovate pontic site and create the illusion of a tooth growing out of a socket with a cervical bulge and interdental papilla (Fig. 5).
INCISION
Using a straight Bard Parker directed in the long axis of both abutment teeth. Begin your incision to the bone lingual to the interdental papilla and make a slight elliptical incision toward the buccal for gingival contour then back lingual to the interdental papilla of the adjacent teeth (Figs. 3 & 4).
ELEVATION
With a periosteal elevator, “gently” elevate the tissue away from the bone on the ridge and buccal plate. In essence, we are creating an extraction site (Fig. 4).
PONTIC CREATION
Prior to the procedure we can make a mock-up (Figs. 6 & 7) and then a study model for a suck down stint and a provisional shell. We can reline and begin adding and shaping the gingival of our pontic to be more root-like creating a matrix for the tissue (Fig. 8). If need be, we can even drill a hole in the provisional and place a suture to pull the tissue up and allow it to heal (Fig. 9).
The parameters for our pontic is to not get the pontic any closer than 2mm to the bone and not to push the buccal tissue any further away than 3mm from the bone. We can fully expect granulation and tissue formation in the voids (Fig.5). Note: This is the most important step of establishing the Esthetic Soft Tissue. Take your time and have some fun with this!
HOME CARE AND HEALING
We want the patient to realize we have intentionally created a wound and we want them to treat it with care and to always brush from the vestibule to the tooth–never up and down or cross ways.
We can irrigate with chlorahexadine but we’ll get staining. We can place EZ seat tetracycline and hydrocortisone in the wound prior to temporary placement.
Our prep appointment is just that–prep and provisional. We want the patient to leave with provisionals and looking reasonably well. We want them back in one week to work on incisal edge, function and guidance.
We are going to allow 6-12 weeks healing. This time period during healing is excellent for idealizing our incisal edge position, functional guidance, and esthetic parameters. We then remove our provisional, take master impressions and reseat provisional. Important: do not allow more than five minutes without supporting our pontic sight as it will collapse.
This exact information can then be passed on to the lab with exact incisal edge position, lingual guidance, shades, shapes, and tooth lengths.
Our goal is to have the same lengths for each lateral. 9.0mm was determined but we needed 2.5mm more to fill our pontic site. We have our lab make this in pink porcelain (Fig. 10). Therefore, if there ever is any shrinkage we still have a 9.0mm pontic from an arms length away.
Our new bridge is created and seated. Home care consists of modified bass-brushing the gums down over the teeth and pontic. Light oral irrigation and flossing.
SUMMARY
Our simplified EERSD allows the general dentist to be in control from start to finish when used within our parameters of thick tissue, proper elevation and using provisionals for a matrix. We can gain a cervical bulge horizontally and develop an ovate pontic that Mother Nature is proud of (Figs. 11 & 12).
Our patient came in thinking she wanted her 6 front teeth done, she left wanting 10. We both are better off (Figs. 13 & 14).
Acknowledgement
Special thanks to my Staff and Dental Mentors, Dr. John Kois, Dr. Peter Dawson and the Pankey Institute, Dr. Frank Spears, Dr. John Derango, Dr. Jack Turbyfill, and Dr. Bill Blatchford.
Dr. Elias is in private practice in Independence, MO. He is a past examiner for the AACD accreditation program.
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