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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 130-134

Bone-enhanced periodontal plastic surgery: A case series


1 Department of Periodontics, Sathyabama Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Periodontics, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu, India
3 Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences and Research, Chennai, Tamil Nadu, India

Date of Submission22-Aug-2018
Date of Acceptance13-Nov-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Yamini Rajachandrasekaran
Sathyabama Dental College and Hospital, Chennai -- 600 119, Tamilnadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_64_18

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   Abstract 


In recent years, esthetics has become apparently a crucial attribute in the periodontal treatment and is paving the way for newer modalities in the management of gingival recession. Gingival recession is one of the pivotal soft tissue problems that often constitute a challenge to a periodontist. The prognostic predictability in the management of gingival recession has been questionable when adequate bone support is not available. This case series propounds a technique that combines periodontal plastic surgery along with bone grafts, to give space for soft tissue coverage and adequate support. Case series brings a novel technique to the limelight, wherein bone substitutes are added to the conventional periodontal plastic surgical procedures, to enhance support for the soft tissue. Case series includes three patients with Millers Class II and Class III recession, involves a technique, which combines xenograft along with any one of the conventional plastic surgical procedures such as coronally advanced flap or pedicle flap. Pre- and post-operatively, clinical and radiographical parameters were evaluated. Satisfactory Clinical outcome was obtained when bone substitute were added to conventional periodontal plastic surgeries for root coverage and hence it prerequisites the need for long term evaluation.

Keywords: Bone regeneration, dental, esthetics, gingival recession, plastic xenograft, surgery, tooth root


How to cite this article:
Rajachandrasekaran Y, Adhappan M, Anand N, Gita B, Deepika G. Bone-enhanced periodontal plastic surgery: A case series. J Interdiscip Dentistry 2019;9:130-4

How to cite this URL:
Rajachandrasekaran Y, Adhappan M, Anand N, Gita B, Deepika G. Bone-enhanced periodontal plastic surgery: A case series. J Interdiscip Dentistry [serial online] 2019 [cited 2020 Jan 22];9:130-4. Available from: http://www.jidonline.com/text.asp?2019/9/3/130/273663




   Clinical Relevance to Interdisciplinary Dentistry Top


The ultimate goal of periodontal therapy is to restore the attachment apparatus. This case series, presents a technique for the management of gingival recession with a combination of conventional plastic surgical procedures, bone substitute that was used to create some space for osseo conduction and soft tissue coverage over denuded roots.


   Introduction Top


Gingival recession is one among the soft tissue problems that confront a periodontist and is generally allied with esthetic concern, fear of tooth loss, and tooth hypersensitivity. There is a certain, assorted scheme for treating gingival recession such as subepithelial connective tissue grafts, with or without coronally advanced flap, pedicle flap, and guided tissue regeneration,[1] yet outcome variability prevails.

The healing process and histologic outcome remain controversial, in spite of the predictable clinical outcomes achieved using connective tissue grafts.[2] The histologic evidence, predominately derived from animal studies or from few case reports which were conducted by the extraction of treated teeth, has shown that connective tissue graft and coronally advanced flap procedures achieved a considerable amount of periodontal regeneration.[3] Nevertheless, the ultimate goal of periodontal treatment is to completely restore the attachment apparatus. Currently, available therapies have shown limited and unpredictable results because there is no new bone formation over the denuded roots. Hence, this case report involves a technique, which combines xenograft along with any one of the conventional plastic surgical procedures such as coronally advanced flap or pedicle flap to gain support for soft tissues.


   Case Reports Top


Three cases are presented in this case series after obtaining informed consent from patients.

Case 1

A 32-year-old male patient came with a chief complaint of downward growth of gingiva in relation to lower front teeth region for the past 1 year. The patient was a nonsmoker, with good general health.

Intraoral examination revealed that the patient has good oral hygiene with total plaque score of 16%[4] and presented with Millers Class II gingival recession in relation to 31,[5] which measured the length of 3 mm and width of 1 mm, and the width of attached gingiva was 1 mm [Figure 1]a. We determined the level of the bone using radiographs where we measured, in millimeters, the distance between cement–enamel junction (CEJ) to the alveolar crest (AC) and the root length (RL).[6] The difference between these two measurements was calculated (RL-[CEJ to AC]) which is divided by RL and the obtained value is multiplied by 100 to determine the level of bone percentage present.[6] In this case, the level of bone present was 76.47%.[6] [Figure 1]b.
Figure 1: Case 1: (a) Preoperative image. (b) Preoperative radiograph. (c) Intraoperative image. (d) Postoperative image at 1 year. (e) Postoperative radiograph 1 year

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Phase I therapy comprising scaling, polishing, subgingival root planing and curettage, correction of occlusal disharmony had been followed and re-evaluated after 4 weeks. In the surgical phase, coronally advanced flap,[7] with xenograft substitute, was planned. After administering 2% lignocaine (1:80,000) (Lignox 2% AIndoco, India), intracrevicular incision was made from mesiolabial aspects of 33–43. A split-thickness flap was elevated followed by full-thickness flap extending up to mucogingival junction and a split-thickness beyond the mucogingival junction. Hence, it was a split–full–split approach. The exposed root surfaces were debrided completely with a curette (1/2 Gracey curette, Hu-Friedy Mfg. Inc., Chicago, IL, USA). Root-conditioned and biomodification is done with 17% of EDTA. Bone defects and exposed root surfaces were filled with a mixture of deproteinized bovine, xenograft particles (Advanced Biotech products (P) Ltd) [Figure 1]c. The tension-free flaps which provided adequate support for the grafts were coronally advanced and sutured in place by sling sutures using 5–0 bioabsorbable vicryl suture (Johnson and Johnson Pvt. Ltd., India). Periodontal pack (GC America Inc.,) was placed and postoperative instructions were given. The patient was re-evaluated at an interval of 4 weeks, 3 months, and 6 months. On examination, postoperative healing at the end of 1 year [Figure 1]d revealed 3 mm gain in clinical attachment level, and there was 2 mm gain in keratinized tissue, while radiographic evidence of 11.76% of bone gain was achieved in 1 year[6] [Figure 1]e.

Case 2

A 26-year-old female patient came with a chief complaint of hypersensitivity, downward growth of gingiva in relation to lower front tooth region for the past 7 months. The patient was a nonsmoker, with good general health. On intraoral examination, the patient had good oral hygiene with a total plaque score of 15%[4] and presented with an isolated Millers Class II,[5] gingival recession in 31 which measured 2 mm in length, 2 mm in width, and the width of attached gingiva was 0 mm [Figure 2]a. On radiographic examination, the level of bone was 75%[6] [Figure 2]b.
Figure 2: Case 2: (a) Preoperative image. (b) Preoperative radiograph. (c) Intraoperative image. (d) Postoperative image at 1 year. (e) Postoperative radiograph at 1 year

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Following Phase I therapy and re-evaluation, the surgical phase was planned with lateral re-positioning flap[8] and xenograft substitutes. After administering 2% lignocaine (Lignox 2%AIndoco, India), the recipient site was prepared, where the de-epithelization did along the denuded root surface; at the donor site with no. 15 blade, vertical incision was made from the gingival margin of tooth no. 32 extending into the oral mucosa, short oblique releasing incision given at the distal corner of the flap. Bone defects and exposed root surfaces were filled with a mixture of deproteinized bovine, xenograft particles (Advanced Biotech products (P) Ltd) [Figure 2]c, and the flap was slided laterally to the recipient site and adequate support for the graft was achieved followed by suturing using simple interrupted sutures with 5–0 bioabsorbable vicryl (Johnson and Johnson Pvt Ltd India). Periodontal pack (GC America Inc) was placed and postoperative instructions were given. The patient was re-evaluated at a period of 1 week, 4 weeks, and 6 months. On examination, postoperative healing at the end of 1 year revealed 3 mm gain in clinical attachment level and 2 mm gain in the attached gingiva [Figure 2]d. Radiographic evidence of 15.62% of bone gain was achieved in 1 year[6] [Figure 2]e.

Case 3

A 33-year-old female patient came with the chief complaint of hypersensitivity in lower front tooth region for the past 6 months. The patient was a nonsmoker with good general health.

On intraoral examination, the patient had good oral hygiene with total plaque score of 17%[4] and presented Millers Class III gingival recession in relation to 31,[5] which measured 4 mm in length and 2 mm in width [Figure 3]a, attached gingiva of 2 mm. On radiographic examination, the level of bone is 66.66%[6] [Figure 3]b. Following Phase I therapy and re-evaluation, coronally advanced flap procedure was planned and carried out as mentioned in Case 1.[7] Case was re-evaluated at a period of 1 week, 4 weeks, and 6 months. Postoperative healing at the end of 1 year revealed 2 mm gain in clinical attachment level and 1 mm gain in the attached gingiva [Figure 3]c. Radiographic evidence of 5.34% of bone gain is achieved in 1 year[6] [Figure 3]d.
Figure 3: Case 3: (a) Preoperative image. (b) Preoperative radiograph. (c) Postoperative image at 1 year. (d) Postoperative radiograph at 1 year

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   Discussion Top


Most of the periodontal plastic surgical procedures employed have not shown predictable long-term results as there is less evidence of these techniques showing true regeneration.[1] Regeneration of the bone has to be considered along with soft tissue coverage for long-term success as the soft tissue margin will revert to the previously existing bone level as a process of healing; thus, the underlying bone loss should also be considered by the clinician and treat the condition as a whole for long-term results. Roman et al. stated that “on connective tissue grafting, there was no evidence of periodontal ligament, alveolar bone, and connective tissue attachment.”[9] McGuire et al. showed no histological evidence of cementum, bone, or periodontal ligament following root coverage procedures.[10] Therefore, regeneration could be achieved by incorporating some regenerative materials.

In this present case series, xenograft, the bovine-derived bone particle, was combined which proved to be a biocompatible grafting material widely accepted in periodontal regeneration, with adequate evidence of bone fill. According to Maiorana et al., histological evaluation of the sites augmented with bovine bone graft revealed clinically evident bone regeneration and the presence of vessels, indicating bone vitality.[11] Study by Hatano et al, histomorphic examination revealed 38.7% newly formed bone in in 6 months.[12] The analysis by Ruvins et al. presented histologically evident signs of newly formed bone vitality.[13] Results indicated that xenograft biomaterial allows regeneration of fully vital osseous tissue within 6 months postoperatively.

Gholami et al. in their case report combined bone graft, connective tissue graft, and coronally advanced flap procedure for the management of deep gingival recession without buccal bone plate.[14] They considered this technique as efficient procedure for complete root coverage of severe deep Class II gingival recession. In our case series, we have avoided subepithelial connective tissue grafts due to its disadvantages, such as lack of graft availability, proximity to palatine neurovascular complex, and need for a second donor site that is prone to bleeding, pain, and slow healing. An esthetically less pleasing result of the healed tissue, such as pale color, irregular surface of the grafted site, and the need for further gingivoplasty, does not make it a preferred choice.[15],[16]

The availability of adequate flap support to hold the graft during advancement did not necessitate the need to use soft tissue grafts. Nevertheless, in future cases, we could consider using barrier membranes to act as scaffolds and for enhanced regeneration. In the present case series, combining pedicle flap/coronally advanced flap with xenograft resulted in a satisfactory amount of root coverage and gain in keratinized gingiva and bone height. From a hypothetical point of view, we suggest that the use of bone graft in periodontal plastic surgeries for root coverage could contribute to stability of the regenerating tissue. Further longitudinal studies with histological evidence are however necessary to substantiate the healing with true regeneration.

Thus, in the future, the surgical procedures that provide the clinician with a high percentage of root coverage combined with true periodontal regeneration should be considered as a predictable mucogingival surgical technique.


   Conclusion Top


Bone-enhanced periodontal plastic surgery can be considered as a safe, efficient, stable technique for root coverage of severe Class II and III gingival recessions.

The present case series proposes a satisfactory clinical outcome when bone substitutes were added to periodontal plastic surgeries for root coverage and prerequisites the need for a long-term evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002;29 Suppl 3:178-94.  Back to cited text no. 1
    
2.
Sedon CL, Breault LG, Covington LL, Bishop BG. The subepithelial connective tissue graft: Part II. Histologic healing and clinical root coverage. J Contemp Dent Pract 2005;6:139-50.  Back to cited text no. 2
    
3.
Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of Miller Class I and II recession-type defects? J Dent 2008;36:659-71.  Back to cited text no. 3
    
4.
O'Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38.  Back to cited text no. 4
    
5.
Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.  Back to cited text no. 5
    
6.
Lira-Júnior R, Freires Ide A, de Oliveira IL, da Silva ES, da Silva S, de Brito RL. Comparative study between two techniques for alveolar bone loss assessment: A pilot study. J Indian Soc Periodontol 2013;17:87-90.  Back to cited text no. 6
    
7.
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. 7
    
8.
Grupe HE, Warren RF. Repair of gingival defects by sliding flap operation. J Periodontol 1956;27:92-5.  Back to cited text no. 8
    
9.
Roman A, Câmpian R, Domşa I, Soancă A, Gocan H. Subepithelial connective tissue graft for root coverage: Clinical case reports and histologic evaluation. Rom J Morphol Embryol 2010;51:793-7.  Back to cited text no. 9
    
10.
McGuire MK, Scheyer ET, Schupbach P. Growth factor-mediated treatment of recession defects: A randomized controlled trial and histologic and microcomputed tomography examination. J Periodontol 2009;80:550-64.  Back to cited text no. 10
    
11.
Maiorana C, Santoro F, Rabagliati M, Salina S. Evaluation of the use of iliac cancellous bone and anorganic bovine bone in the reconstruction of the atrophic maxilla with titanium mesh: A clinical and histologic investigation. Int J Oral Maxillofac Implants 2001;16:427-32.  Back to cited text no. 11
    
12.
Hatano N, Sennerby L, Lundgren S. Maxillary sinus augmentation using sinus membrane elevation and peripheral venous blood for implant-supported rehabilitation of the atrophic posterior maxilla: Case series. Clin Implant Dent Relat Res 2007;9:150-5.  Back to cited text no. 12
    
13.
Ruvins E, Stein M, Kayserman S. Histologic Analysis of the Newly Formed Bone after Maxillary Sinus Augmentation with Xenograft material. J Implant Adv Clin Dent 2016;8:24-31.  Back to cited text no. 13
    
14.
Gholami GA, Gholami H, Amid R, Kadkhodazadeh M, Mehdizadeh AR, Youssefi N. Bone-added periodontal plastic surgery: A new approach in esthetic dentistry. Ann Surg Innov Res 2015;9:1.  Back to cited text no. 14
    
15.
Cohen ES. Atlas of Cosmetic and Reconstructive Periodontal Surgery. 3rd ed. Ontario: BC Decker Inc.; 2007.  Back to cited text no. 15
    
16.
Eley BM, Manson JD. Periodontics. 5th ed. London, UK: Elsevier Limited; 2004.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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