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Table of Contents
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 2  |  Page : 92-96

Management of dehiscence and fenestration alveolar defects around incisors using platelet-rich fibrin: Report of two cases


1 Department of Periodontology, Saraswati Dental College, Lucknow, Uttar Pradesh, India
2 Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Department of Periodontology, ITS Centre for Dental Studies and Research, Murad Nagar, Ghaziabad, Uttar Pradesh, India
4 Astha Dental Care, Sambalpur, Odisha, India
5 Department of Conservative Dentistry and Endodontics, Chandra Dental College and Hospital, Lucknow, Uttar Pradesh, India

Date of Web Publication5-Jan-2016

Correspondence Address:
Rhythm Bains
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.173222

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   Abstract 

Breach in the continuity of the cortical plate often leads to dehiscence and fenestration alveolar defects. These case reports discuss the regeneration of periodontal tissues in fenestration and dehiscence defects that had developed around traumatized incisors, using a novel, cost effective platelet.rich fibrin clot along with hydroxyapatite bone grafting material. These alveolar defects profoundly affect the prognosis of both periodontal and endodontic treatment outcomes; therefore, they should be carefully diagnosed and managed to increase the long-term prognosis of the tooth.
CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

  • Since diseases never confined themselves within the purlieu of a department; henceforth with an interdisciplinary approach, careful diagnosis followed by sequential treatment methodology is of paramount importance while management of a disease
  • In the present case reports, fenestration and dehiscence defects were successfully treated with combined endodontic-periodontal approach with no recurrence of periodontal disease at 1-year and 6. months follow-ups, respectively.

Keywords: Key words: Dehiscence, fenestration, platelet rich fibrin


How to cite this article:
Bains VK, Bains R, Gupta SJ, Mishra P, Loomba K. Management of dehiscence and fenestration alveolar defects around incisors using platelet-rich fibrin: Report of two cases. J Interdiscip Dentistry 2015;5:92-6

How to cite this URL:
Bains VK, Bains R, Gupta SJ, Mishra P, Loomba K. Management of dehiscence and fenestration alveolar defects around incisors using platelet-rich fibrin: Report of two cases. J Interdiscip Dentistry [serial online] 2015 [cited 2019 Sep 15];5:92-6. Available from: http://www.jidonline.com/text.asp?2015/5/2/92/173222


   Introduction Top


The alveolar process is an extension of the body of the maxilla or mandible and is characterized by its dependence on the presence of teeth, and its contour conforms to the prominence of the roots and vertical depressions located between them.[1] The periodontium is considered healthy when the crest of the interproximal bone is positioned within 2 mm apical to cementoenamel junction (CEJ).[2] Whenever there is a breach in the contour of cortical plate, anatomical defects such as a fenestration or dehiscence may result.

Fenestration is derived from Latin word fenestra, meaning “window. ” In simple words, fenestrations are described as secluded areas of denuded root where the surface is blanketed only by the periosteum and gingiva, but marginal bone is intact. When the facial bone overlying the root is very thin, this denudation extends through the marginal bone and the defect is called a dehiscence.[3] According to Davies et al.,[4] “alveolar bone defect is considered as dehiscence when there is the absence of at least 4 mm of cortical bone apical to the margin of interproximal bone while fenestration is an isolated defect leading to exposure of root surface without involving the marginal alveolar bone. ” Fenestration and dehiscence occur in both the maxilla and mandible and many studies have reported geographical variations with overall prevalence ranging from 0.99% to 53.62% for dehiscence and 0.23% to 69.57% for fenestration observed in the skulls.[2],[5]

Platelet-rich fibrin (PRF), a natural reservoir for growth factors, is a strong fibrin matrix useful in tissue regeneration.[6] Choukran's PRF clot is a second generation leukocyte and platelet concentrate that has found application as a scaffold for breeding periosteal cells and bone regeneration in situ ations, such as sinus lift procedures, treatment of osseous defects, and coverage of denuded roots.[7],[8] These case reports detailed below discuss the use of PRF as a regenerative biomaterial for the management of alveolar defects in fractured nonvital teeth.


   Case Reports Top


Case 1

A 20-year-old, healthy, nonsmoker patient reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of pus discharge and fractured right upper front tooth. The patient gave a history of trauma approximately 10 years ago. Clinical examination identified a labially placed, discolored, and fractured maxillary right central incisor (11) [Figure 1]a. Tooth 11 was sensitive to vertical percussion, and thorough examination revealed pus discharge from its buccal sulcus. Sequential periodontal probing revealed an average probing depth of 3 mm around tooth 11. Radiographic examination showed a wide canal, reduced radicular dentin thickness, and an immature apex with a mid-root radiolucency [Figure 1]b. Tooth responded negatively to thermal and electric pulp (Parkell Electronic Division, New York, USA) sensitivity tests. The periodontal consultation that included bone sounding (transgingival probing) under local anesthetic infiltration gave rise to the suspicion of a fenestration defect on the radicular surface of tooth 11. The condition was diagnosed as symptomatic apical periodontitis with fenestration defect.
Figure 1:(a) Preoperative view 11. (b) Preoperative intraoral periapical 11 showing mid-root radiolucency. (c) Platelet-rich fibrin obtained from patient's blood sample. (d) Alveolar defect in relation to 11 after full thickness flap reflection. (e) Graft mixed with exudate from Platelet-rich fibrin. (f) Graft filled in the defect. (g) Platelet-rich fibrin placed over graft-filled defect. (h) Postoperative view. (i) Postobturation radiograph. (j) Follow-up photograph. (k) One year follow-up radiograph

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The treatment plan consisted of root canal treatment followed by a periapical surgery and retrograde filling of the root and PRF for regeneration of lost periodontal tissue. The entire procedure was explained to the patient, and an informed consent was obtained. Following rubber dam isolation and local anesthesia administration, access was gained into the tooth, and the canal was instrumented circumferentially. Chlorhexidine was used as an irrigant as use of sodium hypochlorite carried the risk of extrusion into the periapical region through the open foramen. Nonsetting calcium hydroxide-iodoform paste (Metapex) was used as an intracanal medicament. At the subsequent visit after 7 days, the patient was asymptomatic. The canal was obturated rolling two 80 number gutta-percha cones and endomethasone sealer. Rest of canal was laterally condensed using accessory cones, and the access cavity was sealed with noneugenol temporary cement (Cavit, 3M ESPE).

Prior to initiating the surgical procedure, 10 ml of patient's own blood sample was taken without anticoagulant in 10 ml tubes and immediately centrifuged at 3000 rpm for 12 min in tabletop centrifuge machine (REMI Laboratories, India). The resultant product consisted of following three layers namely, the supernatant at the top, the middle layer, and the red blood cells (RBC) layer at the bottom.[7] The supernatant was removed, and PRF was isolated by collecting the upper layer after cutting below the junction between the middle and RBC layers [Figure 1]c. Local anesthesia was administered using 2% lignocaine hydrochloride with 1:80,000 adrenaline. A crevicular incision was given to raise a full thickness mucoperiosteal flap from distal margin of 11 extending up to distal margin of 21. Complete debridement of the surgical site indicated a fenestration defect in relation to 11 [Figure 1]d. As the apexogenesis was incomplete, the osteotomy site was extended apically to expose the root end. The gutta-percha at the root end was sheared off with a heated excavator, and the root end was prepared with an inverted cone bur on a slow speed handpiece to receive mineral trioxide aggregate (MTA) (ProRoot MTA, Dentsply). The PRF obtained was squeezed to obtain the exudates. The hydroxyapatite graft (G-bone, modified hydroxyapatite granules; average particle size 0.4–0.9 mm; SURGIWEAR) was mixed with the exudate and filled in the osseous defect [Figure 1]e and [Figure 1]f. Thereafter, the PRF was positioned as a membrane over the surgical site, and the reflected tissue was readapted and sutured [Figure 1]g. Coepak (GC America Inc., Alsip, IL, USA) was applied on the operative area. Written postoperative instructions were given to the patient and analgesic (ibuprofen 400 mg thrice daily) was prescribed for 3 days. The patient was instructed to use 0.2% of chlorhexidine mouth rinse for a week from the 2nd day after periodontal surgery, as it interferes with healing by gingival fibroblast when used in fresh periapical wounds. Pack and sutures were removed 7 days after the surgical procedure [Figure 1]h and [Figure 1]i. Tooth 11 was restored with composite [Figure 1]j. Oral hygiene instructions were reinforced, and the patient was regularly evaluated until 1 year after the surgical procedure, and follow-up radiographs indicated a significant reduction in the apical radiolucency [Figure 1]k. The patient was advised a full ceramic or metal-ceramic crown to improve the esthetics.

Case 2

A 17-year-old, nonsmoker male with noncontributory medical history reported to the Department of Conservative Dentistry and Endodontics for the treatment of fractured upper front teeth. Clinical examination revealed Elli's Class III fracture (According to Loomba et al.[9] type I/division 1/C) in the maxillary right central incisor (11), lateral incisor (12), and maxillary left central incisor (21) [Figure 2]a. Detailed history indicated that there had been a traumatic injury in relation to the maxillary anterior region about 5 years back, for which he had taken antibiotics and pain-killers at the time of injury but had not undergone any dental consultation. The teeth were fractured at cervical level with only 1 mm of clinical crown visible. Radiographic examination showed complete apexogenesis in all the affected teeth and a radiolucency in the middle third of the root of 21; there was no visible horizontal fracture in any part of the root [Figure 2]b. The patient had average oral hygiene, and sequential periodontal probing identified on average 3 mm probing depth in all teeth, except buccal aspect of 21, where 7 mm probing periodontal pocket was discovered. The periodontal consultation was obtained. Sounding under local anesthetic infiltration was performed to locate the extension of alveolar defect. A multidisciplinary approach involving endodontic and periodontal therapy was planned. The treatment procedure was explained to the patient, and an informed consent was obtained.
Figure 2:(a) Preoperative photograph of the fractured teeth. (b) Radiograph showing radiolucency in middle third of root of 21. (c) Radiograph after root canal therapy completion. (d) Photograph showing dehiscence defect after full thickness flap reflection. (e) Follow-up photograph after 4 weeks. (f) Photograph after core build-up. (g) Follow-up radiograph after 6 months

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Vitality of the involved teeth was performed using electric pulp tester (Parkell Electronics Division, New York, USA) which were found to be nonresponsive. An access cavity was prepared using an endoaccess bur (Dentsply, Maillefer, Switzerland) at the level of fracture, and the canal was negotiated with number 15 K-files. After working length determination using Root ZX apex locatar (Morita, Tokyo, Japan), the canals were enlarged up to ISO size 50 in all the teeth, under copious irrigation using 2.5% sodium hypochlorite gel and normal saline, and the access was temporarily sealed using intermediate restorative material. On the subsequent visit after 1 week, as the patient was asymptomatic, the canals were laterally condensed using gutta-percha and AH-plus sealer [Figure 2]c. The postspace was prepared by removing gutta-percha with heated pluggers and piezo reamers. An apical plug of 5 mm gutta-percha was left intact. A glass fiber post (Radix fiber post, Dentsply, Middle East and Africa) was cemented using dual cure resin cement (Smart Cem, Dentsply). The coronal portion was built-up with a nanocomposite (Z350, 3M ESPE).

Prior to starting the surgical procedure, PRF was obtained from 10 ml blood sample of the patient using the same procedure as in the above case report.[7] After obtaining the required blood sample, the surgical procedure was started under local anesthesia (2% lignocaine hydrochloride with 1:80,000 adrenaline) while PRF clot was being prepared. A crevicular incision was used to elevate a full thickness mucoperiosteal flap from distal margin of 12 extending up to distal margin of 22. Complete debridement of the surgical site indicated a dehiscence in relation to 22 [Figure 2]d. A regenerative procedure inclusive of hydroxyapatite graft material and PRF membrane as described in above case report was performed. Written postoperative instructions were given to the patient, and analgesic (ibuprofen 400 mg thrice daily) was prescribed for 3 days. Chlorhexidine 0.2% mouth rinse was instructed for 1 week, with caution to avoid it for first 24 h. Sutures were removed 7 days after the surgical procedure. The patient was instructed to maintain meticulous oral hygiene and was recalled after 4 weeks [Figure 2]e. The length of clinical crown was significantly increased after surgery, due to shrinkage of the soft tissue. Core build-up was completed using composite resin [Figure 2]f, and the patient was recalled for metalloceramic crown placement. However, patient was reluctant for further treatment due to financial constraints and reported asymptomatic at the 6 months follow-up appointment [Figure 2]g.


   Discussion Top


These 2 cases address the regenerative management of fenestration and dehiscence defects developed around traumatized incisors. The situation needs careful clinical examination to be detected as radiographs are not of much help as the defect overlies the root. Palpation of a root prominence with finger pressure in an apicocoronal and mesiodistal direction helps feel the absence or presence of the crestal bone. While a fenestration does not yield to probing, it may indicate a dehiscence if there is an attachment loss. Sounding (deep probing under anesthesia) uses tactile sensation to differentiate between softer bone and sharper tooth surfaces.[10],[11] Three-dimensional imaging with computed tomography, especially cone-beam computed tomography (CBCT) is a helpful tool to detect and diagnose the otherwise obscure defects. Furusawa et al.[12] reported a case of an apical fenestration misdiagnosed as persistent apical periodontitis and subsequent use of CBCT to detect the alveolar defect.

According to Hall,[10] if a tooth is placed too much prominently in the arch, its root may be denuded of bone for about 1–1.5 mm from CEJ. If the fenestration is present at apical level in a tooth having periradicular pathology, the protruding root apex is re-contoured, the root is cleaned, and root end is filled to allow alveolar bone regeneration.[12] Horizontal and vertical fractures of roots are also a predisposing factor for alveolar defects. Studies have shown that dehiscence is the bone resorption pattern associated with vertical root fractures in maxillary molars/premolars and the mesial root of mandibular molars and involve the buccal plate in 90% of the cases examined. Furthermore, a fenestration defect is formed when fracture is along the root without involving the apical or coronal parts.[13] Saxena et al.[14] reported a case of horizontal root fracture leading to a dehiscence defect in maxillary central incisor that was managed by intraradicular stabilization of fragments and root conditioning with 1% tetracycline hydrochloride.

The introduction of PRF clot, which is an attempt to accumulate platelets and cytokines together in a fibrin clot, offers the advantages of being resorbable, biocompatible, acts as a scaffold and also accelerates bone regeneration.[15],[16] The PRF obtained could be compressed into a sturdy membrane. Furthermore, the exudate squeezed from the PRF membrane is rich in platelets, leukocytes, thrombin, and fibronectin can be used to hydrate the graft material, wash the surgical site, and store autologous grafts. Concurrent use of bone graft and PRF in combined endo-perio lesions has also been reported. In an interesting animal study, Jang et al.[17] combined PRF with silk fibroin powder and showed significantly greater bone formation in the experimental group. In a clinical case of pulpal floor perforation leading to an endo-perio lesion, Bains et al.[18] used MTA as a perforation repair material and PRF plus graft for the osseous defect and found that initial bone healing could be seen as early as 3 months on radiographic follow-up.[19]

In the two presented cases, fenestration and dehiscence osseous defects were successfully treated with combined interdisciplinary endodontic-periodontal approach.[20] The regenerative management of osseous defects developed in traumatized incisors was performed using cost effective PRF clot along with bone graft material.

 
   References Top

1.
Brand RW, Isselhard DE. Anatomy of Orofacial Structures. 7th ed. St. Louis: Mosby; 2003.  Back to cited text no. 1
    
2.
Nimigean VR, Nimigean V, Bencze MA, Dimcevici-Poesina N, Cergan R, Moraru S. Alveolar bone dehiscences and fenestrations: An anatomical study and review. Rom J Morphol Embryol 2009;50:391-7.  Back to cited text no. 2
    
3.
Singh S, Panwar M, Arora V. Management of mucosal fenestration by multidisciplinary approach: A rare case report. Med J Armed Forces India 2013;69:86-9.  Back to cited text no. 3
    
4.
Davies RM, Downer MC, Hull PS, Lennon MA. Alveolar defects in human skulls. J Clin Periodontol 1974;1:107-11.  Back to cited text no. 4
    
5.
Rupprecht RD, Horning GM, Nicoll BK, Cohen ME. Prevalence of dehiscences and fenestrations in modern American skulls. J Periodontol 2001;72:722-9.  Back to cited text no. 5
    
6.
Pluemskakunthai W, Kuroda S, Shimokawa H, Kasugai S. A basic analysis of platelet rich fibrin: Distribution and release of platelet derived growth factor BB. Inflamm Regen 2013;33:164-72.  Back to cited text no. 6
    
7.
Gupta V, Bains VK, Singh GP, Mathur A, Bains R. Regenerative potential of platelet rich fibrin in dentistry: Literature review. Asian J Oral Health Allied Sci 2011;1:22-8.  Back to cited text no. 7
    
8.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:299-303.  Back to cited text no. 8
    
9.
Loomba K, Loomba A, Bains R, Bains VK. A proposal for classification of tooth fractures based on treatment need. J Oral Sci 2010;52:517-29.  Back to cited text no. 9
    
10.
Hall WB. Decision Making in Periodontology. 3rd ed. St. Louis: Mosby; 1988. p. 202.  Back to cited text no. 10
    
11.
Vandersall DC. Concise Encyclopedia of Periodontology. Ames Iowa: Blackwell Munksgaard; 2007. p. 155.  Back to cited text no. 11
    
12.
Furusawa M, Hayakawa H, Ida A, Ichinohe T. A case of apical fenestration misdiagnosed as persistent apical periodontitis. Bull Tokyo Dent Coll 2012;53:23-6.  Back to cited text no. 12
    
13.
Tamse A. Vertical root fractures in endodontically treated teeth: Diagnostic signs and clinical management. Endod Topics 2006;13:84-94.  Back to cited text no. 13
    
14.
Saxena RM, Divya S, Shashikumar P, Gujjari SK, Anoop M. Management of horizontal radicular fracture – An interdisciplinary approach. J Surg 2013;2:29-31.  Back to cited text no. 14
    
15.
Gupta SJ, Jhingran R, Gupta V, Bains VK, Madan R, Rizvi I. Efficacy of platelet-rich fibrin vs. enamel matrix derivative in the treatment of periodontal intrabony defects: A clinical and cone beam computed tomography study. J Int Acad Periodontol 2014;16:86-96.  Back to cited text no. 15
    
16.
Mathur A, Bains VK, Gupta V, Jhingran R, Singh GP. Evaluation of intrabony defects treated with platelet-rich fibrin or autogenous bone graft: A comparative analysis. Eur J Dent 2015;9:100-8.  Back to cited text no. 16
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17.
Jang ES, Park JW, Kweon H, Lee KG, Kang SW, Baek DH, et al. Restoration of peri-implant defects in immediate implant installations by Choukroun platelet-rich fibrin and silk fibroin powder combination graft. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:831-6.  Back to cited text no. 17
    
18.
Bains R, Bains VK, Loomba K, Verma K, Nasir A. Management of pulpal floor perforation and grade II Furcation involvement using mineral trioxide aggregate and platelet rich fibrin: A clinical report. Contemp Clin Dent 2012;3 Suppl 2:S223-7.  Back to cited text no. 18
    
19.
Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod 2005;31:97-100.  Back to cited text no. 19
    
20.
Bains R, Bains VK, Loomba K, Verma K, Loomba A. Syndesmocorono-radicular tooth: An endo-perio challenge. J Interdiscip Dent 2013;3:114-9.  Back to cited text no. 20
    


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