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Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 69-75

Pontic site development by modified vascularized interpositional periosteal-connective tissue graft: A case series

1 Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
2 Department of Periodontics and Head, Bapuji Implant Centre, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Date of Submission02-Dec-2021
Date of Acceptance27-Feb-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. Arifa Areej Farooqui
Department of Periodontics, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdi.jdi_31_21

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Ridge resorption is unavoidable sequelae of tooth extraction, which leads to soft and hard tissue deficiencies and formation of black triangles. Pedicled grafts inherently have advantage of intact vascular supply over free conventional grafts. A vascularized interpositional periosteal-connective tissue (VIP-CT) graft comprises pedicled connective tissue which is rotated anteriorly to the recipient site. It maintains intact vascular supply thus minimizes chances of graft necrosis and the amount of graft shrinkage. The objective of this case series was to achieve stable, esthetically pleasing pontic site using VIP-CT graft in the anterior maxillary region. In the present case series, the pontic site was developed successfully in three patients having ridge deficiency using a modified approach of VIP-CT. After soft-tissue augmentation, the site was altered by placing a cantilevered provisional ovate pontic. Once the emergence profile had achieved by molding the grafted area, permanent restoration using the adjacent implant as an abutment was delivered to patient. Esthetically pleasing anterior restorations, satisfying the patient's esthetic demands were obtained, and results were found stable up to a period of 9–24 months and thus can be concluded that modified VIP-CT is a predictable approach in anterior esthetic areas to enhance the emergence profile.

Keywords: Dental implants, emergence profile, ovate pontic, pontic site, vascularized interpositional periosteal-connective tissue grafts

How to cite this article:
Farooqui AA, Tarun Kumar A B, Triveni M G, Shah R. Pontic site development by modified vascularized interpositional periosteal-connective tissue graft: A case series. J Dent Implant 2022;12:69-75

How to cite this URL:
Farooqui AA, Tarun Kumar A B, Triveni M G, Shah R. Pontic site development by modified vascularized interpositional periosteal-connective tissue graft: A case series. J Dent Implant [serial online] 2022 [cited 2023 May 31];12:69-75. Available from:

   Introduction Top

Ridge resorption is inevitable sequelae of tooth loss.[1] Alveolar ridge defects are one of the most commonly encountered challenges while planning an esthetically pleasing anterior restoration in a prosthetically correct position. The form and function of a pontic should have an ideal emergence profile in harmony with the surrounding soft and hard tissues to achieve optimal esthetics in the anterior maxillary region. Dr. Harvard Payne has stated, “Set the teeth where they grew.”[2] The planning for implant site development or augmentation of soft or/hard tissue becomes essential to obtain an esthetically pleasing and functionally stable restoration in cases of ridge defects.[2]

Various periodontal plastic surgical procedures have been used to correct ridge defects in soft tissues. Free soft-tissue autografts are considered the gold standard for soft-tissue augmentation.[3] However, their use is limited by factors including the requirement of two surgical sites and risk of necrosis due to poor vascular supply as their survival exclusively depends on the blood supply of the recipient bed. Free gingival graft gives the most predictable outcomes but has a disadvantage of poor color matching and thereby inferior esthetics.[4] The use of connective tissue autografts is limited to smaller ridge defects due to the limited donor site availability. To overcome these limitations, a new pedicled connective tissue technique, that is., vascularized interpositional periosteal-connective tissue (VIP-CT) graft, has been proposed for soft-tissue augmentation.[5] This retains the advantages of superior esthetics of connective tissue grafts and overcomes the vascular limitations of a free graft due to its pedicled nature. The aim of this case series is to present the rehabilitation of anterior maxillary ridge defects for esthetic pontic site development using palatal pedicled grafts [Nemcovsky et al.] also known as VIP-CT graft.[5],[6]

   Methodology Top

This case series included three cases presenting with ridge deficiency in the maxillary anterior region. After initial clinical and radiographic examination, the pattern and severity of bone loss were determined, and accordingly, cases were selected for grafting by the modified VIP-CT technique. Phase-I therapy was completed, and the surgical intervention was initiated only after achieving adequate plaque control. The benefits and risks associated with the surgical procedure were explained in detail to the patients, and written consent was obtained from them before the surgery.

   Case Reports Top

Case report-1

A 19-year-old, periodontally healthy nonsmoking patient reported with the chief complaint of missing front tooth. The patient gave a history of road traffic accident 2 years ago. On clinical and radiographic examination, residual root stump in relation to #10 and a root fracture in relation to #9 were observed [Figure 1] and [Figure 2]. Hence, extraction of #9, #10 with immediate implant placement in relation to #9 followed by pontic site development of #10 was planned. After obtaining adequate anesthesia with 2% lidocaine HCl, socket-shield procedure was carried out to prevent buccal bone collapse in relation to #9 followed by immediate implant placement [Figure 3]. The patient was recalled after 4 months for second-stage implant surgery followed by soft-tissue augmentation in relation to #10 by a modified VIP-CT approach.
Figure 1: Preoperative view with clinically missing #10 and grade I mobility in relation to #9

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Figure 2: IOPA showing horizontal root fracture and root stump in relation to #10

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Figure 3: Extraction of #9 done followed by socket shield procedure to prevent buccal plate collapse with subsequent implant placement

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Surgical procedure for vascularized interpositional periosteal-connective tissue

Following administration of adequate local anesthesia (2% lidocaine HCl with 1:80,000 adrenaline), surgical procedure for the recipient site preparation was started by giving a mid crestal incision in the area of interest using a number 15c blade. This was followed by the creation of a deep supraperiosteal soft-tissue pouch by sharp dissection extending up to the mucogingival junction apically.

For donor site preparation, a full-thickness incision was placed 2 mm away from the gingival margin starting from the mesial half of the maxillary first molar extending up to the recipient site. A full-thickness palatal flap was raised, which was further dissected into two halves; the inner or deeper half of the flap containing periosteum and the deeper part of connective tissue, whereas the outer or superficial half contained epithelium and the superficial part of the connective tissue [Figure 4]. This deeper flap was raised from the rest of the palate and transformed into a pedicled flap. This was done by freeing it completely from the adjacent tissues in the distal aspect and leaving the mesial tissue attachment intact [Figure 5]. This deeper pedicled flap was then rotated anteriorly, tucked into the recipient pouch, and sutured [Figure 6]. The superficial flap of the palate was also repositioned back and sutured [Figure 7].{Figure 3}
Figure 4: Diagrammatic representation of splitting the full-thickness palatal flap (depicted by dotted lines) into two halves – Superficial half containing epithelium and superficial part of connective tissue and deeper half containing deeper half of connective tissue and periosteum

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Figure 5: Diagrammatic representation of rotation of deeper half of the palatal flap which was elevated from the rest of the palate and transformed into a pedicled graft

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Figure 6: (a) Clinical picture of rotation of pedicled flap anteriorly. (b) Pedicle was tucked into the prepared recipient supraperiosteal pouch and was immobilized with the help of suture

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Postoperative antibiotic therapy (amoxicillin-500 mg TDS for 5 days) with an analgesic (ibuprofen-400 mg TDS) was prescribed. The patient was asked to refrain from brushing in the surgical area, and 0.2% chlorhexidine mouth rinse was prescribed for 2 weeks. After 2 weeks, the patient was recalled for suture removal and provisionalization using the adjacent implant as an abutment to mold the augmented soft tissue was done [Figure 8]. Care was taken not to put excessive pressure while the placement of ovate pontic on the augmented area to prevent any local ischemia and necrosis. After 6 weeks, optimal soft-tissue healing with an emergence profile was observed [Figure 9]. The temporary restoration was removed to make the final impression.
Figure 8: Provisionalization was carried out after 2 weeks by ovate pontic using the adjacent implant as an abutment to mold the augmented soft tissue

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Figure 9: Soft-tissue profile with well-formed interdental papilla was achieved 6 weeks after provisionalization

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An impression was made using a customized impression coping to transfer the soft-tissue contours to the master cast for the fabrication of final restoration.[7] A cantilevered ovate pontic using the adjacent implant as abutment was delivered to the patient. Clinical photographs of labial and occlusal views were evaluated for the prominence of gingival contour which showed a good emergence profile. Pink esthetic score was used to assess the soft-tissue esthetics which include analysis of seven parameters (mesial papilla, distal papilla, level of soft-tissue margin, soft-tissue contour, alveolar process deficiency, soft-tissue color, and texture).[8] The adjacent natural tooth was used as a reference. A total pink esthetic score (PES) was calculated to be 12 which was considered to be highly esthetically acceptable [Figure 10]. Patients were asked to rate their level of esthetic satisfaction on the final prosthetic outcome using visual analog scale ranging from 0 to 10 where 0 being very dissatisfied and 10 being highly satisfied.[9] Esthetic satisfaction score given by the patient was 9 at the most recent follow-up visits. The results were found to be stable on 18-month follow-up [Figure 11].
Figure 10: Pink esthetic score showing satisfactory esthetic outcomes

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Figure 11: Permanent prosthesis was placed, and results were found to be stable on 18-month follow-up

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Case report 2

A healthy 18-year-old male patient reported with the chief complaint of missing teeth in the upper front teeth region [Figure 12]. On clinical and radiographic examination, #7 is found to be missing and a residual root stump is present in relation to #8. Hence, treatment was planned as extraction of #8 followed by implant placement and pontic site development by soft-tissue augmentation in relation to #7. After implant placement, the second stage of implant surgery was carried out after 4 months along with the pontic site development by modified VIP-CT approach in a similar manner as described for case 1. After 2 weeks, soft-tissue molding was done by a provisional restoration of an ovate pontic using the adjacent implant as abutment. Once the emergence profile was achieved, permanent restoration was placed using the adjacent implant as an abutment. As per the patient's esthetic demand, veneering was done in relation to #6, #9, #10, and #11. An esthetically pleasant emergence profile with a PES of 13 and the patient esthetic satisfaction score of 9 was thus achieved. Results were found to be stable on 9-month follow-up [Figure 13].
Figure 12: Preoperative view with clinically missing #7 and root stump in relation to #8

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Figure 13: Postoperative view. Pontic site was developed by utilizing a modified vascularized interpositional periosteal-connective tissue approach. Veneers were placed in relation to #6, #9, #10, and #11. Good emergence profile was achieved and results were found to be stable on 9-month follow-up

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Case report 3

A healthy 25-year-old male patient reported with the chief complaint of missing upper front teeth, which were fractured in a road traffic accident and extracted 6 months back in a private clinic. On examination, #9 and #10 were found to be missing, and thus, the treatment plan included guided bone regeneration using block graft in relation to #9 to augment horizontal ridge width [Figure 14]. After 4 months, the site was reentered, and an implant was placed in relation to #9. At the time of the second stage of implant surgery, soft-tissue augmentation in relation to # 10 was carried out by a modified VIP-CT technique, as described above. Suture removal followed by provisionalization was done after 2 weeks to mold the obtained soft tissue. After 6 weeks, interdental areas demonstrated good soft-tissue fill, and thus, a permanent restoration was placed. An esthetically pleasing prosthesis having a PES of 13 with patient's esthetic satisfaction score of 9 was thus obtained, and results were found to be stable on 24-month follow-up [Figure 15].
Figure 14: Preoperative view with clinically missing #9 and #10

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Figure 15: Postoperative view: Pontic site development by modified vascularized interpositional periosteal-connective tissue approach. Esthetic emergence profile with good soft tissue fill in papillary areas was appreciated. Results were stable on 24-month follow-up

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   Discussion Top

Loss of hard and soft tissue following tooth extraction complicates the placement of a prosthetically optimal esthetic restoration. The situation becomes more demanding when the replacement of two adjacent missing teeth on the unilateral side in the esthetic zone is required. Placement of two adjacent implants results in loss of interdental papilla, leads to the formation of unesthetic black triangles, and poor emergence profile, which disturbs the pink esthetic of the restoration.[10],[11] It also leads to unfavorable plaque control, which may further result in peri-implant mucositis or peri-implantitis. The most reliable method to prevent this black triangle formation is to cantilever an ovate pontic on the lateral incisor, which can be used to mold the augmented soft tissue.[10] Various soft-tissue augmentation techniques have been employed for preprosthetic site development. They include free subepithelial connective tissue grafts, onlay grafts, connective tissue pedicle grafts, and their modifications. Although free connective tissue grafts are widely used for soft-tissue augmentation, the significant shrinkage postoperatively poses an unpredictable outcome for the pontic site development. To overcome this disadvantage, Sclar in 2003 introduced pedicled connective tissue graft (VIP-CT) that comprises a pedicled palatal periosteal connective tissue. It is considered a predictable and viable technique for pontic site development having various advantages over conventional techniques.[5]

VIP-CT grafts maintain an intact vascular supply, which minimizes the occurrence of graft necrosis and also reduces the amount of graft shrinkage postoperatively. The donor site heals by primary intention and thereby reducing the patient's morbidity. Because the procedure requires only soft-tissue grafting, hence, the time required for total augmentation is much lower when compared to simultaneous hard and soft-tissue grafting for the pontic site development.[5],[11] Thus, it results in adequate soft-tissue volume gain; both horizontally and vertically, which can be further molded using ovate pontic. The alteration of augmented soft tissue results in the formation of interdental papilla, which restores the pink esthetic of the pontic by eliminating the adjacent black triangle, giving an illusion of tooth erupting from the band of the gingiva.[12],[13],[14]

In this case series, a VIP-CT graft technique was employed successfully to augment soft tissue in the anterior maxilla and obtained stable, esthetically pleasing pontic site emergence profile. However, certain modifications of the traditional technique were made in the presented cases to minimize the complications associated with the conventional VIP-CT technique.

Minimizing the surgical incisions not only reduces the surgical time but also minimizes the tissue trauma and potentiates the wound healing. In the present case series, the recipient site preparation was modified by not performing the curvilinear incisions of conventional VIP-CT; instead, a supraperiosteal pouch was made to receive the connective tissue graft. This resulted in less tissue trauma and also ensured additional blood supply to the pedicled connective tissue graft, which may further contribute to wound healing potential.

To obtain a pedicled connective tissue graft, it is important to predetermine the thickness of the palatal vault to eliminate any possible complications of palate perforations. In the presented case series, the palatal flap was split into two halves. For such splitting, the required thickness of the palatal tissue should be at least 4 mm to avoid potential complications.[6] Thus, the procedure is recommended in cases of a high and average palatal vault with thick periodontal biotype owing to the greater tissue availability. In shallow palates, the neurovascular bundle is located more proximally to the cementoenamel junction and thus providing a very narrow margin of safety.[15] Therefore, thorough knowledge and prior assessment of the palatal tissue is very important. The two main advantages of splitting the palatal flap are that it leaves a superficial layer of connective tissue underneath the epithelium and thereby reduces the chances of necrosis of the overlying epithelium. Second, the inclusion of periosteum, along with the connective tissue in the deeper half of the flap added the advantage of bone regeneration by the potential of cells that are lined in the periosteum.

The pontic site was successfully developed by modified VIP-CT in all the presented cases and showed stable results; however, some drawbacks of the current technique are that the surgical procedure is technique sensitive and requires a learning curve to obtain desired outcomes.

The present case series demonstrated the use of modified VIP-CT with certain modifications as an esthetic alternative to the conventional treatment modalities to gain a sufficient amount of soft tissue in ridge defect areas. The alteration of gained soft-tissue volume by cantilevered ovate pontic gave a good emergence profile and harmonized the white and pink esthetics of the restoration. The patients showed stable results on 9–24-month follow-up and satisfied the patient's esthetic demand, which can be attributed to the superior vascular supply from the pedicled graft.

   Conclusion Top

Based on the results obtained in the current case series, it can be concluded that the modified VIP-CT technique is a predictable approach to augment soft tissues in anterior esthetic areas for pontic site development to enhance the emergence profile.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prosthet Dent 1967;17:21-7.  Back to cited text no. 1
Payne SH. Contouring and positioning. In: Moss SJ, editor. Esthetics. New York, NY: Medcom; 1973. p. 50-4.  Back to cited text no. 2
Langer B, Calagna LJ. The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent 1982;2:22-33.  Back to cited text no. 3
Bjorn H. Free transplantation of gingival propria. In: Symposium in periodontology in Malmo. Odontol Revy 1963;14:321-3.  Back to cited text no. 4
Sclar A, editor. Vascularized interpositional periosteal-connective tissue flap. In: Soft Tissue and Esthetic Considerations in Implant Dentistry. Chicago: Quintessence Publishing; 2003. p. 163.  Back to cited text no. 5
Nemcovsky CE, Artzi Z, Moses O. Rotated split palatal flap for soft tissue primary coverage over extraction sites with immediate implant placement. Description of the surgical procedure and clinical results. J Periodontol 1999;70:926-34.  Back to cited text no. 6
Paranhos KS, Oliveira R. An impression technique to accurately transfer soft tissue contours for implant-supported restorations: Three case reports. J Oral Implantol 2001;27:317-21.  Back to cited text no. 7
Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue around single-tooth implant crowns: The pink esthetic score. Clin Oral Implants Res 2005;16:639-44.  Back to cited text no. 8
Kim CS, Jang YJ, Choi SH, Cho KS. Long-term results from soft and hard tissue augmentation by a modified vascularized interpositional periosteal-connective tissue technique in the maxillary anterior region. J Oral Maxillofac Surg 2012;70:484-91.  Back to cited text no. 9
Spear FM, Kokich VG, Matthews DP. The esthetic management of a severe isolated periodontal defect in the maxillary anterior. Compend Contin Educ Dent 2008;29:280-2, 284-7.  Back to cited text no. 10
Tarnow DP, Cho SC, Chu SJ, Froum SJ. Esthetic complications with adjacent implant restorations. In: Froum SJ, editor. Dental Implant Complications: Etiology, Prevention and Treatment. 2nd ed. New Jersey: John Wiley & Sons, Inc.; 2016. p. 316-31.  Back to cited text no. 11
Agarwal C, Kumar AB, Triveni MG, Mehta DS. Vascularized interpositional connective tissue flap technique to correct soft tissue defect around maxillary anterior implant. Int J Oral Implantol Clin Res 2014;5:24-8.  Back to cited text no. 12
Akcalı A, Schneider D, Ünlü F, Bıcakcı N, Köse T, Hämmerle CH. Soft tissue augmentation of ridge defects in the maxillary anterior area using two different methods: A randomized controlled clinical trial. Clin Oral Implants Res 2015;26:688-95.  Back to cited text no. 13
Ferreira CF, de Magalhães Barreto E Junior, Zini B. Optimizing anterior implant esthetics with a vascularized interpositional periosteal connective tissue graft for ridge augmentation: A case report. J Oral Implantol 2018;44:267-76.  Back to cited text no. 14
Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial connective tissue graft palatal donor site: Anatomic considerations for surgeons. Int J Periodontics Restorative Dent 1996;16:130-7.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]


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