A novel approach in root coverage - Coronally repositioned flap with GTR membrane and frenotomy
A 32-year-old female patient presented to Department of Periodontics, HKES's S. Nijalingappa Institute of Dental Sciences and Research with the chief complaint of swelling of gums in the upper front tooth region which bleeds profusely. Patient gave the history of the presence of the lesion since 1 month. Medical history of the patient was non-contributory. Extra-oral examination did not reveal any facial asymmetry but the sub maxillary lymph nodes were palpable and non-tender. Intraoral clinical examination revealed the presence of exophytic lesions which were located buccal to 11, 21, and 22 involving all parts of the gingiva, i.e., marginal, interdental, and attached gingiva []. The lesion was bright red in color, soft in consistency, and showed profuse bleeding upon slight provocation. A probing depth of 10 mm was seen in relation to 11 and the tooth was grade II mobile. Intraoral periapical radiograph of the region showed a vertical bone loss in relation to 11 [].\nBased on the overall clinical findings it was diagnosed as a case of inflammatory gingival enlargement with an infrabony pocket in relation to 11. Routine blood investigations were advised and it showed normal results. Etiotropic phase of treatment included thorough scaling and root planning followed by oral hygiene instructions.\nAt the time of reevaluation after 3 weeks of scaling and root planning gingiva appeared healthy, but the probing depth was still persisting. There was a millers class I gingival recession in relation to 11 []. Patient was informed about the treatment plan and a GTR-based root coverage procedure using coronally advanced flap along with frenotomy was planned. An informed consent was obtained from the patient.\nAt the time of surgery, the denuded root surface of 11 intended for root coverage was thoroughly root planed. A full thickness trapezoidal flap was prepared by giving a horizontal incision extending from the distal surface of 12 to the distal surface of 21, at the level of CEJ. Two vertical releasing incisions were given along the distal line angle of 12 and mesial line angle of 21. Crevicular incision was given to connect the horizontal and vertical releasing incisions. Full thickness flap was elevated 3-4 mm apical to the crest of osseous dehiscence; partial thickness flap was prepared thereafter []. Epithelial tissue in the interdental papillary area was debrided. Root planning was repeated and an odontoplastic procedure was performed in which the root was made concave to ensure regeneration space. The surgical site was degranulated and bioactive osseous graft was placed in relation to 11. GTR membrane was bent in a tent like fashion with a suture [] and placed over the denuded root surface. A sling suture was used to stabilize the membrane against the root surface []. Before advancing the flap in a coronal direction, frenotomy was performed using no 15 blade to eliminate positive frenal pull [Figures and ]. The flap was displaced coronally until the flap covered the membrane completely, so as to avoid the exposure of the membrane and sutured using a sling suture [].\nThe patient was instructed to apply cold compression on the face over the surgical area during the first few hours post operatively. The following medications were provided: Amoxicillin (500 mg TID for 5 days) and ibuprofen (400 mg BD for 3 days). The patient was instructed not to use any mechanical plaque control device at the surgical site for 1 week and to rinse twice daily with chlorhexidine mouthwash.\nAfter 10 days of healing, the flap appeared to be stable, erythematous, and well perfused. The frenotomy was determined to be healing within normal limits []. The patient was re-evaluated at 2, 4, and 6 months postoperatively, and no recession was observed on the treated tooth [Figures and ].