Modified Whale's tail technique for the management of bone-defect in anterior teeth.

The purpose of this case report is to describe the efficacy of a modified Whale's tail technique to achieve primary closure and thereby aid in regeneration of an interdental osseous defect between maxillary central incisors complicated by an aberrant frenal attachment. A healthy 32-year-old female patient reported with the complaint of spacing between her upper front teeth. Clinical examination revealed an aberrant frenum extending into the interdental papilla in relation to the central incisors. There was a 6 mm periodontal pocket in relation to the mesiopalatal aspect of maxillary left central incisor. Intraoral periapical radiograph showed vertical bone loss in relation to mesial aspect of maxillary left central incisor. A modified Whale's tail flap was employed to access the area. The defect was filled with an alloplastic graft. Six months postoperative review showed complete elimination of the pocket along with radiographic bone fill of the defect.

INTRODUCTION

Obtaining periodontal regeneration has always been a major challenge and several approaches have been used throughout years. The attempts involved use of various bone grafts with or without barrier membranes, root surface demineralization, enamel matrix derivatives, etc., It was found that porous bone graft material alone or in combination with a bilayer collagen membrane had the capacity to stimulate new bone and cementum formation.[1]

To ensure predictable results in periodontal regeneration, primary closure of the osseous defect is essential, or it may compromise clinical attachment gain. The flap design should be in such a way that maximum amount of gingival tissue is preserved to obtain complete coverage of the regenerative material placed in the osseous defect.[2345] Specific surgical approaches have been reported to obtain primary flap closure to preserve interdental tissue, the papilla-preservation technique,[2] modified papillae preservation,[3] simplified papillae preservation flap[4] etc.

Very recently, a new surgical technique to regenerate wide intrabony defects in esthetic zone was described-the “Whale's tail” technique.[5] The surgical procedure involved elevation of a large flap from the buccal to the palatal side to allow access and visualization of the intrabony defect and was created, especially to perform guided tissue regeneration while maintaining interdental tissues over grafting material.

The purpose of this case report is to describe the efficacy of a modified Whale's tail technique to achieve primary closure and thereby aid in regeneration of an interdental osseous defect between maxillary central incisors complicated by an aberrant frenal attachment.

CASE REPORT

A healthy 32-year-old female patient was referred from the Department of Orthodontics for periodontal evaluation. The patient initially reported with the complaint of spacing between her upper front teeth, which was noticed 6 months back and increasing since then. On clinical examination, a midline diastema about 4 mm was noticed. Periodontal probing revealed a six mm periodontal pocket in relation to mesiopalatal aspect of the maxillary left central incisor. The tooth exhibited Grade I mobility. Clinical signs of trauma from occlusion were not evident. An aberrant frenum was also noted, which demonstrated a positive pull on the interdental papilla [Figure 1]. The oral hygiene status of the patient was good and the remaining areas had no clinical attachment loss. Intraoral periapical radiograph showed vertical bone loss in relation to the mesial aspect of maxillary left central incisor [Figure 2]. The case was diagnosed as chronic localized periodontitis. After the initial phase of the therapy, it was decided to surgically access the area for the management of the osseous defect.

Figure 1

Clinical preoperative view of maxillary anterior teeth

Figure 2

Preoperative radiograph showing the vertical defect in relation to the maxillary left central incisor

After adequate anesthesia, two semilunar incisions were made on both sides of the frenum. The medial extensions of both the semilunar incisions excised only the base of the frenal attachment, preserving the continuity of the flap [Figure 3]. The distal extensions of the incision were continued as intrasulcular incisions on the buccal, interdental and palatal aspect of the central incisors, separating the flap from the buccal attached gingiva and allowing the separation of a thick, broad papilla-preserving flap. The flap was elevated from the buccal to the palatal aspect visualizing the intra-osseous defect [Figure 4]. The defect was thoroughly curetted and root planed. After root biomodification with tetracycline hydrochloride, the defect was filled with an alloplastic graft material containing porous hydroxyapatite and bioactive glass [Figure 5]. The flap was repositioned and sutured without tension. A frenotomy was also performed to relocate the aberrant frenal attachment [Figure 6]. The surgical area was covered with a periodontal dressing. Postoperative instructions along with suitable antimicrobials and analgesics were given. Sutures were removed 10 days after surgery [Figure 7]. Recall appointments were performed at 1-month interval to assess postoperative healing and plaque control by the patient. At the 6-month postoperative review, it was observed that the area was free of inflammation with complete elimination of the periodontal pocket without any gingival recession. This denoted a clinical attachment gain of 4 mm. A wider zone of attached gingiva was evident at the site [Figure 8]. Radiograph demonstrated complete fill of the defect [Figure 9]. The patient was referred to the Department Orthodontics for management of the midline diastema.

Figure 3

Initial two semilunar incisions

Figure 4

Intraoperative view of the defect

Figure 5

Alloplastic graft placed in the defect

Figure 6

Flap sutured

Figure 7

Clinical picture at suture removal

Figure 8

Six months postoperative view

Figure 9

Six months postoperative radiograph showing bone fill of the defect

DISCUSSION

Takei et al.[2] proposed a surgical approach called the papilla-preservation technique which retains the entire papillae covering the lesion, in order to preserve the interdental soft tissues for maximum soft tissue coverage following surgical intervention involving treatment of proximal osseous defects. For esthetic reasons, the papilla-preservation technique is often utilized in the surgical treatment of anterior teeth. Later, Cortellini et al.[3] described a modification of the flap design to be used in combination with regenerative procedures. The modified papillae preservation was developed in order to increase the space for regeneration, and in order to achieve and maintain a primary closure of the flap in interdental area. However, the papilla-preservation technique is indicated where there is adequate interdental space to allow the intact papillae to be reflected with the facial or lingual/palatal flap. When the interdental sites are narrower, this technique is difficult to perform and a conventional flap using crevicular incisions is employed.

Another surgical technique for interproximal tissues maintenance, the simplified papillae preservation flap, was explained by Murphy to provide surgical access to interproximal defect, while preserving interdental soft tissues, even in narrow interdental spaces and posterior teeth.[4]

In the original Whale's tail technique, two vertical full-thickness incisions were from the mucogingival line to distal margin of the tooth neighboring the defect on the buccal surface. A horizontal incision joined the apical margins of the first two incisions and the coronal margins of the vertical incisions were continued intrasulcularly on thebuccal, proximal and palatal aspects of the defect-associated tooth.[5]

In the proposed technique, two semilunar incisions below the mucogingival line on the buccal surface were used rather than using distinct horizontal and vertical incisions, which helped in better approximation of the flap margins. Soft tissue healing depend upon many factors such as incision technique, flap design, soft tissues management during surgery, root preparation, patient compliance etc.[5] The use of incision away from the osseous defect reduced the chance of flap dehiscence and thereby placement of sutures distant from the defect might have minimized the chance of bacterial colonization of the healing osseous defect. The flap design, which preserved the papillae helped to achieve good primary closure of the grafting material and allowed preservation of vascularization of the buccal flap. Once the flap is repositioned over the treated bone-defect, only perimeter sutures are required to stabilize the flap and no sutures are needed at papillae level,[5] which reduced the chances of “wicking effect” of suture materials. Root biomodification procedures helps in stabilization of clot and thus prevent epithelial migration, remove smear layer and improve their biocompatibility, helps to remove bacterial endotoxins from root surface.[67] Tetracycline stimulates fibroblast attachment and growth, while suppressing epithelial cell attachment.[8] Patient compliance and plaque control measures during postoperative period are also important in periodontal healing. The relocation of the frenum also reduced the chance of flap dehiscence during healing.