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Table of Contents
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 140-144

Gingival fenestration defect in the maxillary anterior region treated with coronally positioned flap using platelet-rich fibrin membrane


1 Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
2 Periodontist, Garg's Dental Remedies, Gurgaon, Haryana, India

Date of Web Publication28-Apr-2016

Correspondence Address:
Dhruvakumar Deepa
Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.181378

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   Abstract 


This report describes the management of gingival fenestration of maxillary right lateral incisor using platelet-rich fibrin (PRF) and coronally repositioned flap procedure. Earlier reports have been documented where fenestration defects around implants are treated with PRF. To the best of our knowledge, this is the first case reported with PRF and chronic renal failure in gingival fenestration around natural tooth. Initial oblique incisions were placed on either side of the defect at the level of the cementoenamel junction #12, followed by vertical incisions extending beyond the mucogingival junction into the alveolar mucosa. After flap elevation, recontouring of the irregular prominent bony margin was performed. Thorough root planing was done; freshly prepared PRF was placed over the root surface and sutured; overlying flap was coronally repositioned and sutured with 5-0 silk sutures. The results of the case demonstrated satisfactory healing of the gingival fenestration defect with excellent color, texture match with the surrounding area along with the keratinized tissue formation emphasizing the importance of using PRF as a membrane in esthetically demanding areas.
CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY
PRF could be a good option in treating fenestration which provides good healing and color match especially in esthetically demanding areas.

Keywords: Coronally positioned flap, esthetics, gingival fenestration, growth factors, platelet-rich fibrin, wound healing


How to cite this article:
Deepa D, Jain N. Gingival fenestration defect in the maxillary anterior region treated with coronally positioned flap using platelet-rich fibrin membrane. J Interdiscip Dentistry 2015;5:140-4

How to cite this URL:
Deepa D, Jain N. Gingival fenestration defect in the maxillary anterior region treated with coronally positioned flap using platelet-rich fibrin membrane. J Interdiscip Dentistry [serial online] 2015 [cited 2019 Jun 17];5:140-4. Available from: http://www.jidonline.com/text.asp?2015/5/3/140/181378




   Introduction Top


Afenestration is a window of bone loss on the facial or lingual aspect of a tooth that places the exposed root surface directly in contact with gingiva or alveolar mucosa. It could be distinguished from dehiscence in that the fenestration is bordered by alveolar bone along its coronal aspect. Such defects occur on approximately 20% of the teeth; they occur more often on the facial than on the lingual side, more commonly seen in anterior teeth and are frequently bilateral.[1] The prominent labial root contours, malpositioned teeth, palatally/lingually tipped teeth combined with a thin alveolar bone plate are considered as the predisposing factors.[2] The fenestration defects not only complicate the outcome of periodontal surgery but also foster the plaque accumulation and promote the progression of periodontal disease. Therefore, it should be diagnosed at earlier stage and treated to improve the esthetics.

Choukran's platelet-rich fibrin (PRF) has revolutionized the field of regenerative dentistry and motivated the researchers and clinicians further to apply this procedure along with tissue engineering protocol.[3] PRF may be considered the second-generation platelet concentrate because the natural concentrate is produced without any anticoagulants or gelifying agents.[4] Its chief advantages include ease of preparation and lack of biochemical handling of blood, which makes this preparation strictly autologous. PRF could be used to promote wound healing, bone regeneration, graft stabilization, wound sealing, and hemostasis. Because the fibrin matrix is better organized, it efficiently provides direct stem cell migration and facilitates better healing.[3]

This article describes a case report in which PRF was used with coronally positioned flap in the treatment of gingival fenestration defect in the right maxillary lateral incisor tooth region.


   Clinical Presentation Top


A healthy female patient aged 25 years presented in February 2014 to the outpatient department, Department of Periodontology, with a chief complaint of bleeding gums and sensitivity in the upper anterior teeth for 1 month. Intraoral assessment revealed gingival fenestration on the labial surface of #12 which was present in the attached gingiva region extending almost up to the mucogingival junction [Figure 1]. There was no history of trauma or any inflicting habit reported by the patient. There were no mobility and no pocket formation, and the fremitus test was negative ruling out the possibility of trauma from occlusion. Only coronal epithelial bridge was present bracing the tooth. Bleeding on probing was present. No gingival recession or other mucogingival abnormalities present. It was decided to treat the gingival fenestration with PRF and coronally positioned flap. The patient was explained the procedure to cover the fenestration and the written consent for the same was obtained.
Figure 1: Preoperative photograph showing the gingival fenestration defect in maxillary right lateral incisor

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   Case Management Top


After scaling and polishing, the internal surface of the gingiva and margin of the fenestration were gently curetted. At the surgical appointment, after 2 weeks of Phase I therapy, the area was anesthetized with 2% lignocaine hydrochloride with epinephrine at 1:100,000. Oblique incisions were given at the level of the cementoenamel junction on mesial and distal #12, followed by the vertical incisions extending beyond the mucogingival junction, into the alveolar mucosa.[5] Partial thickness till mucogingival junction followed by full-thickness flap was elevated. The irregular contour of the marginal bone was recontoured with the round bur [Figure 2] and [Figure 3]. After thorough planing of the root surface, freshly prepared PRF membrane [Figure 4] was placed and sutured to the underlying recipient bed with 5-0 silk sutures with the suture ends placed outside the wound site [Figure 5]. Overlying flap was then placed back and sutured with 5-0 sutures, covering the PRF membrane [Figure 6]. Periodontal dressing was placed. The patient was prescribed with amoxicillin 500 mg 3 times a day for 5 days and paracetamol 500 mg 6th hourly for 5 days.
Figure 2: Incisions and flap elevation

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Figure 3: Recontouring of the root prominence

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Figure 4: Prepared platelet-rich fibrin membrane

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Figure 5: Platelet-rich fibrin membrane placed and sutured

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Figure 6: Overlying flap secured with 5-0 silk sutures

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Preparation of platelet-rich fibrin [4]

Ten milliliters of the patient's blood was drawn from the right antecubital vein before the start of the surgery and was transferred into the glass coated plastic test tube. This blood sample was centrifuged immediately for 10 min at 3000 revolutions/min (without an anticoagulant, most platelets are activated a few minutes after contacting the glass tube walls, which initiates the coagulation cascade. Fibrinogen is initially concentrated in the upper part of the tube before the circulating thrombin transforms it into fibrin). The centrifuged blood mass presented with a structured fibrin clot in the middle of the tube, between the red corpuscle layer at the bottom and the acellular plasma on the top. The upper straw-colored layer was then removed and middle fraction was collected, 2 mm below to the lower dividing line, which is the PRF. The mechanism involved in this was the fibrinogen concentrated in upper part of the tube, combined with circulating thrombin due to centrifugation to form fibrin. A fibrin clot was then formed in the middle between the red corpuscles at bottom and acellular plasma at the top. The middle part was platelets trapped massively in fibrin meshes. The success of this technique entirely depends on time gap between the blood collection and its transfer to the centrifuge, and it should be done in less time. Resistant autologous fibrin membranes were obtained by driving out the fluids trapped in fibrin matrix. Hence, PRF was compressed between two tongue blades and shaped as membrane [Figure 4].


   Clinicial Outcomes Top


The postoperative period was uneventful and the sutures were removed after 10 days [Figure 7]. There was complete coverage of the fenestration defect. After 1 month, the patient was recalled to assess the amount of tissue maturation. Color and texture of the gingiva were satisfactory with signs of keratinization too [Figure 8]. No complications were evident clinically during the follow-up. At the end of 1 year, patient reported with mild gingivitis due to lack of oral hygiene maintenance, but no effect on gingival fenestration was evident [Figure 9], and [Figure 10] shows 2-year follow-up postoperative photograph with good results.
Figure 7: Ten days postoperative clinical photograph showing complete coverage of the fenestration defect

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Figure 8: One-month postoperative photograph showing good color and texture match with the adjacent gingiva

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Figure 9: Postoperative photograph after 1 year

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Figure 10: Postoperative 2 years

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   Discussion Top


The gingival fenestration is most likely a transitory stage in the development of a gingival cleft that occurs when a combination exists of thin gingival tissue and nodular calculus located on the root surface associated with a periodontal pocket.[6] As the periodontal pocket progresses in an apical direction, the gingival fiber groups, as described by Goldman,[7] are lost and the tissue becomes more freely movable by forces such as lip pressure, tooth brushing, or force of food during mastication. The movement of the gingival tissue, combined with a sulcular irritant in the form of subgingival calculus and plaque, can create a window in the gingiva using combined mechanical and chemical destructions of tissue, producing a gingival fenestration. Because of the loss of blood supply, the unsupported epithelial bridge which forms the superior portion of the fenestration is short lived. Hence, if gingival fenestration is found, it should be considered an area of gingival recession to the apical border of the fenestration and treated with the various forms of therapy available to correct this situation if any correction is required.[8]

First biochemical analysis of the PRF composition indicated that this biomaterial consists of an intimate assembly of cytokines, glycanic chains, and structural glycoproteins enmeshed within a slowly polymerized fibrin network. The biologic activity of the fibrin molecule is enough in itself to account for the significant cicatricial capacity of the PRF, and the slow polymerization mode confers to the PRF membrane a particularly favorable physiologic architecture to support the healing process.[3]

Injury to blood vessels during periodontal surgical procedures causes blood extravasation, subsequent platelet aggregation, and fibrin clot formation. The major role of fibrin in wound repair is hemostasis, but fibrin also provides a matrix for the migration of fibroblasts and endothelial cells that are involved in angiogenesis and responsible for remodeling of new tissue. Platelet activation in response to tissue damage and vascular exposure results in the formation of a platelet plug and blood clot as well as the secretion of biologically active proteins.[9] Platelet alpha granules form an intracellular storage pool of growth factors including platelet-derived growth factor, transforming growth factor-β (including β-1 and β-2-isomers), vascular endothelial growth factor, and epidermal growth factor.[10] Insulin-like growth factor-1 can exert chemotactic effects toward human osteoblasts.[11] Following platelet activation, alpha granules fuse with the platelet cell membrane transforming some of the secretory proteins to a bioactive state.[12],[13] Active proteins are secreted and bind to transmembrane receptors of target cells to activate intracellular signaling proteins.[14] Finally, this results in the expression of a gene sequence that directs cellular proliferation, collagen synthesis, and osteoid production.[15]

Gingival and mucosal fenestrations and dehiscence are rare entities but whenever present, pose a difficult situation for the clinician. There have been various nonsurgical and surgical procedures that have been documented for treatment. The present case report describes a rare situation where a gingival fenestration developed in the maxillary right lateral incisor was successfully treated with combination of PRF and coronally repositioned flap procedure, showcasing the procedure as a viable treatment option in such cases.


   Summary Top


Why is this case new information?

To the best of our knowledge, this is the first case report of gingival fenestration treated with PRF.

What are the keys to successful management of this case?

Early diagnosis and treatment with PRF resulted in good healing and color match which was esthetically acceptable to the patient.

What are the primary limitations to the success of the case?

If performed meticulously, there are no limitations and success rate is high.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Newman MG, Takei HH, Klokkevold PR, Carranza FA Jr. editors. Carranza's Clinical Periodontology. 10th ed. St. Louis, Missouri: Saunders, Elsevier Inc.; 2006 p. 84-5, 1140.  Back to cited text no. 1
    
2.
Elliot JR, Bowers GM. Alveolar dehiscence and fenestrations. Periodontics 1963;1:245.  Back to cited text no. 2
    
3.
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. 3
    
4.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44.  Back to cited text no. 4
    
5.
de Sanctis M, Zucchelli G. Coronally advanced flap: A modified surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol 2007;34:262-8.  Back to cited text no. 5
    
6.
Lane JJ. Gingival fenestration. J Periodontol 1977;48:225-7.  Back to cited text no. 6
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7.
Goldman HM. The topography and role of the gingival fibers. J Dent Res 1951;30:331-6.  Back to cited text no. 7
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8.
Deepa D, Khattak BP. Gingival fenestration in mandibular incisors. A case report. J Indian Dent Assoc 2009;3:342-3.  Back to cited text no. 8
    
9.
Hamdan AA, Loty S, Isaac J, Bouchard P, Berdal A, Sautier JM. Platelet-poor plasma stimulates the proliferation but inhibits the differentiation of rat osteoblastic cells in vitro. Clin Oral Implants Res 2009;20:616-23.  Back to cited text no. 9
    
10.
Su CY, Kuo YP, Tseng YH, Su CH, Burnouf T.In vitro release of growth factors from platelet-rich fibrin (PRF): A proposal to optimize the clinical applications of PRF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:56-61.  Back to cited text no. 10
    
11.
Lind M. Growth factor stimulation of bone healing. Effects on osteoblasts, osteomies, and implants fixation. Acta Orthop Scand Suppl 1998;283:2-37.  Back to cited text no. 11
    
12.
White JG, Krumwiede M. Further studies of the secretory pathway in thrombin-stimulated human platelets. Blood 1987;69:1196-203.  Back to cited text no. 12
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13.
Zucker-Franklin D, Benson KA, Myers KM. Absence of a surface-connected canalicular system in bovine platelets. Blood 1985;65:241-4.  Back to cited text no. 13
[PUBMED]    
14.
Gassling VL, Açil Y, Springer IN, Hubert N, Wiltfang J. Platelet-rich plasma and platelet-rich fibrin in human cell culture. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:48-55.  Back to cited text no. 14
    
15.
Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-96.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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