case study _ periodontal surgery I to place a physiological crown. The edentulous ridge had a labial depression and an incisal edge that appeared concave (Figs. 3 & 4). The tissue had to be built up incisally and labially, and a harmonious flow of pink attached gingivally had to be maintained. Following a thorough evaluation, an autogenous connective tissue graft was placed sub-epithelially in one surgical procedure to achieve a symmetrical look. After anesthetising the patient, the flap outline and its reflection towards the labial were completed (Figs. 5 & 6). The connective tissue donor site could have been selected from various areas. In this particular case, the tuberosity area was used. The donor tissue was de-epithelialised, and the deformed edentulous area was sculpted to the desired shape. The original flap outline was designed to prevent recession on the adjacent teeth and provide a covering for the graft in order to avoid a keloid on the crest. During healing, a keloid would have been a different colour, which would have detracted from the goal of harmonious colour integration. The flap outline was then extended palatally to include more attached gingival, which avoided a keloid and retained the graft. Once the autogenous free connective tissue graft was in the desired location, the flap was repositioned and sutured for stability (Figs. 7 & 8). In this case, the patient had worn a flipper for years to replace a missing tooth. Following surgery, I reduced the existing flipper to allow space for the graft to heal. After an uneventful post-operative period, the patient healed and continued with good oral hygiene. The referring dentist had a choice of several restorative techniques. In this case, a fixed splint was fabricated with an acceptable pontic (Figs. 9a & b). In a one-stage procedure, we avoided creating a dark area of labial depression and/or an irregular, concave gingival crestal margin. A lengthy, unsightly pontic was replaced by a physiological, cosmetically acceptable, natural-looking pontic, and the patient was delighted. Fig. 14 that had been in the patient’s oral cavity for 20 years. This shows the longevity, as well as the aesthetic enhancement of the technique and its ability to enhance the prosthesis. The finished prosthesis, which is easily maintained by the patient, shows that the unaesthetic, unphysiological defects were successfully corrected (Figs. 13 & 14). Fig. 14_With final prosthesis in place. _Summary In these presentations, depressed concave ridges—one example in the anterior and the other in the posterior—were corrected using soft-tissue grafts. The results eliminated unaesthetic, dark, depressed food-gathering areas. This technique provides a pre-prosthetic treatment, thus avoiding large pontics, which as illustrated make the area difficult to keep plaque free or cosmetically pleasing. The restorative dentist will then have a positive background to create the aesthetic and physiologic prosthesis. There must be constant communication between the periodontist, restorative dentist and patient. Detailed techniques must be combined with artistic ideas and tempered with patience._ _Case 2 The second case demonstrates the use of the same technique in the posterior segment of a patient’s maxilla. An extreme buccal-incisal defect (Figs. 10 & 11) where an extraction was done is shown in a maxillary posterior area (Fig. 12). The soft-tissue ridge augmentation technique was used. A temporary provisional bridge shows the restored ridge enhancing the cleanliness and cosmetic appearance. The final prosthesis displays a prosthetic appliance _about the author cosmetic dentistry Dr David L.Hoexter is director of the International Academy for Dental Facial Esthetics,an organisation that combines physicians and dentists with other related fields in research and relates its finding to clinical practice.He lectures throughout the world and has published internationally.He has been awarded 11 fellowships including FACD,FICD and Pierre Fauchard.He maintains a practice in New York City,limited to periodontics,implantology and aesthetic surgery.He can be reached at drdavidlh@aol.com. cosmetic dentistry 4 _ 2009 I 09