Frenectomy with semilunar coronally repositioned flap: A single stage approach - simple solution for complex problem.

Gingival recession is defined as the displacement of gingival margin apical to cementoenamel junction. Aberrant frenum attachment can contribute to the progression of recession by generating tension on the marginal tissues. Treating such defects is a two stage procedure-frenectomy and recession coverage procedure. New techniques are developed to increase the predictability, reduce patient discomfort and number of surgical sites. Also, these techniques try to satisfy patients esthetic demands, which include the final colour and tissue blend of the covered area. In this case report, we present a method for coronally repositioning gingiva for root coverage over the maxillary central incisors while simultaneously performing a frenectomy, thus being clinically advantageous compared to two-stage technique.

INTRODUCTION

Gingival recessions and aberrant frenal attachments are routinely encountered in day to day practice, and different surgical techniques are available to correct these deformities. However, infrequently some cases present with simultaneous aberrant frenal attachment with maxillary anterior recessions. Routine treatment protocol followed for such deformities are usually two stage procedures: Frenectomy followed by root coverage procedures.

The term “periodontal plastic surgery” was first suggested by Miller, 1988. It is defined as “surgical procedures performed to prevent or correct anatomical, development, traumatic or plaque disease-induced defects of the gingiva, alveolar mucosa, or bone” (The American Academy of Periodontology 1996).[1] These procedures are performed to maintain an adequate mucogingival complex, with emphasis on the amount of attached gingiva.

A frenum is a mucous membrane fold which contains muscle and connective tissue fibres that attach the lip and the cheek to the alveolar mucosa, the gingiva and the underlying periosteum.[2] Maxillary frenum can present as a thick, broad fibrous attachment that interferes with oral hygiene and the normal function of the upper lip. The frena may also jeopardize the gingival health by causing a gingival recession when they are attached too closely to the gingival margin, either because of an interference with the proper placement of a toothbrush or through the opening of the gingival crevice because of muscle pull, leading to increased accumulation of plaque.[2] It can also lead to diastema persistence as well as compromised esthetics. Frenectomy is the complete removal of the frenum, including its attachment to the underlying bone, while frenotomy is the incision and the relocation of the frenal attachment.[3]

Gingival recession is the displacement of gingival margin apical to cementoenamel junction (CEJ).[4] The recession of the gingiva results in attachment loss and root surface exposure, which causes esthetic concerns and root hypersensitivity. Also, gingival recession increases the risk of root caries and cervical abrasion. Several surgical procedures have been suggested for treatment of Miller's Class I gingival recessions. Tarnow, 1986, proposed semilunar coronally repositioned flap technique as a technique for root coverage of such defects.[5] The technique involves a semilunar incision made parallel to the free gingival margin of the facial tissue and coronally placing the semilunar pedicle over the denuded root. The semilunar flap design does not involve the complete undermining of adjacent papilla and thus, avoids the vascular disadvantages of the traditional coronally repositioned flap[6] when combined with frenectomy.

In this case report, we attempted a method for coronally positioning gingival tissue for root coverage over maxillary central incisors using the semilunar coronally repositioned flap technique while simultaneously performing frenectomy, as described by Sorrentino and Tarnow, 2009.[7]

CASE REPORT

A 46-year-old male patient reported to the Department of Periodontology, Rishiraj College of Dental Sciences and Research Centre, Bhopal, with the chief complaint of sensitivity to cold food in upper front region of jaw. The patient was in good health with noncontributory medical history and had a fair oral hygiene. On clinical examination, there was gingival recession involving both maxillary central incisors with Miller's Class I mucogingival defect. Gingival biotype was thick with adequate width of keratinized gingiva. Depth of maxillary labial vestibule was adequate. However, a broad frenum was seen extending beyond the mucogingival junction into the esthetic zone, terminating on patient's midline [Figure 1].

Figure 1

Preoperative intraoral view

A semilunar coronally positioned flap with frenectomy was planned and patient was informed about the treatment plan. An informed consent was obtained from the patient. Full mouth scaling and root planing was done 2 weeks before the root-coverage procedure. Probing depths of the maxillary central incisors were < 2 mm in all sites. Both maxillary central incisors exhibited 2 mm of gingival recession on facial surfaces and 4 mm of keratinized gingiva.

Following the markings with an indelible pencil [Figure 2], a continuous semilunar incision was made apically following the curvature of the gingival margins of the teeth, using a scalpel with a 15c blade. The incisions involving the central incisors coalesced 2 mm below the coronal extent of the maxillary labial frenum. Incisions were extended into the alveolar mucosa so that apical portion of the flap could rest over periosteum for better blood supply. All interproximal portions of the semilunar incisions remained ± 2 mm from the tips of the papillae and free gingival margins to permit optimal perfusion of blood to the repositioned tissue [Figure 3]. After semilunar incision, a new 15c blade was used to perform the frenectomy while the keratinized tissue was still bound and immobile. The frenectomy was initiated where the semilunar incisions coalesced between the central incisors and extended at a 45° angle in an apical direction to the cortical bone. Another incision was made from 2 mm beyond the apical portion of the frenum at a 45 angle in the coronal direction. The V-shaped frenum was removed at this point [Figure 4].

Figure 2

Incision markings with indelible pencil

Figure 3

Semilunar incision with 15C blade

Figure 4

Excision of V shaped frenum

Then, a partial thickness dissection was done, undermining the outline created by the initial semilunar incision. The passive pedicle graft obtained, was coronally positioned at the CEJ. Tissue was held against the teeth using moist gauze with slight pressure for 10 min, to allow for stabilization and for formation of uniform and thin clot [Figure 5]. The frenectomy site was sutured with two interrupted sutures (Ethicon 5-0, LNW 5080, Johnson and Johnson Pvt. Ltd., Himachal Pradesh, India) and periodontal dressing (Coe pack, GC America Inc., USA) was given.

Figure 5

Flap repositioned coronally

The patient was instructed not to brush in the surgical area for 2 weeks and no intrasulcular brushing for 8 weeks. After 2 weeks, brushing of the surgical area was asked to be performed gently using the roll technique in a coronal direction only. Chemical plaque control with chlorhexidine 0.2%, twice a day was instituted for 2 weeks along with nonsteroidal antiinflammatory analgesic (Diclofenac 50 mg, 3 times a day for 3 days) and antibiotic (Amoxicillin 500 mg, 3 times a day for 10 days).

After 10 days of healing, the flap appeared to be stable and erythematous [Figure 6]. The frenectomy site was determined to be healing within normal limits. Patient evaluation after 1, 3 and 6 months revealed adequate root coverage on both central incisors [Figure 7]. Mucogingival margins above both incisors showed small white scars which were well concealed under patient's smile line. The width of the residual frenum was reduced, and it was now attached to the alveolar mucosa, thus posing no esthetic concern. The patient was happy with the reduced sensitivity and the postoperative esthetics.

Figure 6

Postoperative view after 10 days

Figure 7

Postoperative view after 6 months

DISCUSSION

Depending on the number and type of recession defects, multiple techniques have been described in literature. These techniques have various advantages and disadvantages. There is variability in efficacy of the following procedures, that may depend on various factors-type of defect, location of defect, the mean initial depth and operator skills.

The current mucoperiosteal condition, can be treated by two approaches. The first approach is by a two stage technique that involves frenectomy as the first stage procedure and recession defect coverage by various techniques as second stage procedure. Another approach is by a single stage procedure that combines semilunar coronally positioned flap with frenectomy, which was described by Sorrentino and Tarnow.[7] In this technique, the blood supply to the graft is laterally derived from the adjacent papillae. Combining frenectomy with coronally positioned flap may compromise the blood supply to the flap that derives its vascularity from the apical base, thus semilunar coronally positioned flap is preferred. Also, this technique is advantageous as there is no clinically discernable tension to flap when it is coronally positioned and it is time-and cost-efficient for the clinician. Furthermore, there is no reduction in depth of maxillary vestibule. In fact, the depth of the vestibule may increase postoperatively, depending on the apical extent of the frenectomy. The proposed technique also spares the involved tissues the trauma that results from even atraumatic suturing because sutures are not needed to hold the passively repositioned tissue in place.

Small white scar formation occured postoperatively with semilunar coronally repositioned flap surgery. Thus, the use of this technique should be limited to patients with a high smile line, so that it does not compromise the esthetic results.

The recession defects in this case report can also be treated using other root coverage procedures to achieve similar esthetic results and reduced sensitivity. Frenectomy can also be combined with tunnel technique,[8] vista technique[9] or pinhole surgical technique.[10] Such techniques will not compromise the blood supply, but would involve a second surgical site, use of special instruments or special materials. Also, guided tissue regeneration based root coverage procedure over maxillary central incisor using coronally advanced flap with simultaneously performed frenotomy has been described recently by Patil and Patil.[11]

Successful outcome of this clinical procedure is dependent on various factors. One of the most important one being postoperative patient compliance. Healing of surgically treated site is a delicate process. Good oral hygiene should therefore be maintained and postoperative instruction should be followed meticulously during the healing phase, thus reducing the chances of postoperative recession.

CONCLUSION

Semilunar coronally repositioned flap combined with a frenectomy had following advantages-avoidance of additional surgical phase, donor site, and a reduction in vestibular depth; elimination of the aberrant frenum from the esthetic zone and tension due to frenal pull in surgically treated area. In addition, the technique is advantageous because it can be performed quickly and is cost effective.