A novel approach in root coverage - Coronally repositioned flap with GTR membrane and frenotomy.

This case report describes a guided tissue regeneration (GTR) based root coverage procedure over maxillary central incisor using coronally advanced flap with simultaneously performed frenotomy. The patient was a 32-year-old female with chief complaint of gingival enlargement in relation to 11. Based on overall findings it was diagnosed as a case of inflammatory gingival enlargement. Vertical osseous defect along with Millers class I gingival recession was seen after initial therapy. GTR-based root coverage procedure using coronally advanced flap with simultaneously performed frenotomy was planned. Complete root coverage was achieved over the maxillary central incisor that initially presented with Miller's class I gingival recession along with radiographic bone fill of the osseous defect. This case report shows the possibility of applying GTR-based root coverage procedure using coronally advanced flap combined with frenotomy to treat Millers class I gingival recession.

INTRODUCTION

Gingival recession is defined as the displacement of gingival margin apical to Cemento-enamel junction.[1] The common causes of gingival recession include: Traumatic tooth brushing technique,[2] friction from soft tissue ablation,[3] high muscle attachment and frenal pull,[4] tooth position, alveolar bone dehiscence,[5] iatrogenic factors, and post-surgical gingival recession.[6] Dentinal hypersensitivity and compromised esthetics are the most common sequel associated with gingival recession.

A variety of periodontal plastic surgical procedures have been developed with promising results for root coverage.[78] GTR-based root coverage procedures have emerged as an attractive treatment because it may not only achieve similar results to those of traditional techniques, but also demonstrate histologically new attachment formation.[9] Both resorbable and non-resorbable membranes have been used with variable results for root coverage. Advantages provided with GTR-based root coverage are healing by new connective tissue attachment accompanied by regeneration of new cementum and bone. Piniprato et al.[10] showed more gain of keratinized gingiva in GTR if longer healing period was allowed and the results obtained were constant as comparable to other techniques.

So the case presented in the present report was assigned for GTR-based root coverage.

CASE REPORT

A 32-year-old female patient presented to Department of Periodontics, HKES's S. Nijalingappa Institute of Dental Sciences and Research with the chief complaint of swelling of gums in the upper front tooth region which bleeds profusely. Patient gave the history of the presence of the lesion since 1 month. Medical history of the patient was non-contributory. Extra-oral examination did not reveal any facial asymmetry but the sub maxillary lymph nodes were palpable and non-tender. Intraoral clinical examination revealed the presence of exophytic lesions which were located buccal to 11, 21, and 22 involving all parts of the gingiva, i.e., marginal, interdental, and attached gingiva [Figure 1]. The lesion was bright red in color, soft in consistency, and showed profuse bleeding upon slight provocation. A probing depth of 10 mm was seen in relation to 11 and the tooth was grade II mobile. Intraoral periapical radiograph of the region showed a vertical bone loss in relation to 11 [Figure 2].

Figure 1

First visit

Figure 2

Pre-op radiograph showing vertical defect in relation to 11

Based on the overall clinical findings it was diagnosed as a case of inflammatory gingival enlargement with an infrabony pocket in relation to 11. Routine blood investigations were advised and it showed normal results. Etiotropic phase of treatment included thorough scaling and root planning followed by oral hygiene instructions.

At the time of reevaluation after 3 weeks of scaling and root planning gingiva appeared healthy, but the probing depth was still persisting. There was a millers class I gingival recession in relation to 11 [Figure 3]. Patient was informed about the treatment plan and a GTR-based root coverage procedure using coronally advanced flap along with frenotomy was planned. An informed consent was obtained from the patient.

Figure 3

Pre-operative view of Millers Class I gingival recession in relation to 11

At the time of surgery, the denuded root surface of 11 intended for root coverage was thoroughly root planed. A full thickness trapezoidal flap was prepared by giving a horizontal incision extending from the distal surface of 12 to the distal surface of 21, at the level of CEJ. Two vertical releasing incisions were given along the distal line angle of 12 and mesial line angle of 21. Crevicular incision was given to connect the horizontal and vertical releasing incisions. Full thickness flap was elevated 3-4 mm apical to the crest of osseous dehiscence; partial thickness flap was prepared thereafter [Figure 4]. Epithelial tissue in the interdental papillary area was debrided. Root planning was repeated and an odontoplastic procedure was performed in which the root was made concave to ensure regeneration space. The surgical site was degranulated and bioactive osseous graft was placed in relation to 11. GTR membrane was bent in a tent like fashion with a suture [Figure 5] and placed over the denuded root surface. A sling suture was used to stabilize the membrane against the root surface [Figure 6]. Before advancing the flap in a coronal direction, frenotomy was performed using no 15 blade to eliminate positive frenal pull [Figures 7 and 8]. The flap was displaced coronally until the flap covered the membrane completely, so as to avoid the exposure of the membrane and sutured using a sling suture [Figure 9].

Figure 4

Flap reflection

Figure 5

GTR membrane bent in a tent like fashion

Figure 6

Stabilization of GTR

Figure 7

Positive frenal pull while adopting the flap

Figure 8

Frenotomy performed to stabilize the flap

Figure 9

After suturing

The patient was instructed to apply cold compression on the face over the surgical area during the first few hours post operatively. The following medications were provided: Amoxicillin (500 mg TID for 5 days) and ibuprofen (400 mg BD for 3 days). The patient was instructed not to use any mechanical plaque control device at the surgical site for 1 week and to rinse twice daily with chlorhexidine mouthwash.

After 10 days of healing, the flap appeared to be stable, erythematous, and well perfused. The frenotomy was determined to be healing within normal limits [Figure 10]. The patient was re-evaluated at 2, 4, and 6 months postoperatively, and no recession was observed on the treated tooth [Figures 11 and 12].

Figure 10

Post-op view after 10 days

Figure 11

After 6 months

Figure 12

Radiograph after 6 months

DISCUSSION

Root coverage using GTR-based technique is a type of mucogingival plastic surgery. The maintenance of gained attachment is influenced by post-operative inflammation, hence the result of GTR is more affected by oral hygiene than the surgical procedure.[11] The role of patient in maintaining proper oral hygiene and to follow the instructions given by the dentist is critical. Patient must be made aware of the importance of the oral hygiene and brushing technique to avoid the chances of post-operative recession.

The simultaneous performance of a frenotomy with the coronally advanced flap technique is clinically advantageous compared to two-stage techniques.[12] The described one-stage combination technique for root coverage is not time consuming and is cost-effective. Combining frenotomy with the coronally advanced flap yields a pedicle graft with no clinically discernable tension when it is compared with coronally advanced flap alone.

The reason for selecting GTR-based root coverage procedure in the present case is that the membrane prevents the migration of fast growing epithelial and connective tissue cells into the defect area.[13] Use of membrane enhances the predictability of new attachment gain in deep vertical osseous defects. Other advantages are the esthetic results with good color harmony with the surrounding tissue and the donor site is not necessary.

The results of coronally repositioned flap alone can be compromised by the existence of frenal pull in the apical direction. The predictability of the results can be improved by removing this potential etiology prior to coronally repositioning the tissue using frenotomy/frenectomy.

The present case could have been treated with other surgical procedures such as free soft tissue grafts along with coronally repositioned flap or using the tunnel technique to achieve esthetic results, but it would involve a palatal donor site. In the present case report, the coronally repositioned flap combined with a frenotomy avoided an additional surgical phase, donor site, and also provided tension free flap to adapt.

CONCLUSION

The results of this case report show the possibility of applying a combined coronally repositioned flap with a frenotomy along with GTR therapy in Millers class I gingival recession with vertical bone defect. Further controlled investigations are needed to define the efficacy of this surgical technique.