CASE REPORT Aesthetic management of a nonvital tooth with severe tissue destruction. Radhakrishnan Nair K,1 Praveena G,2 Mohammed Ashik,3 Sreeja Kuttan Pillai,4 Ajay P Joseph5
ABSTRACT Pulpo periodontal lesion of long duration causes severe destruction of periodontal tissues which results in denudation of root surface refered to as mucosal fenestrations. Mucosal fenestrations are rarely reported and it requires an accurate diagnosis and meticulous treatment planning. Debridement and disinfection of the root canal and surgical management of the soft tissue and bony defect is required to cover the denuded root surface along with procedures for the maintainence of good oral hygiene. This is a case report of a forty eight year old woman presented with a discoloured incisor tooth and a chronic draining abscess with a history of road traffic accident of twenty years. Tooth had mobility within limits, was non tender with a labial gingival recession of seven mms. Root canal treatment followed by periapical surgery was done with the procedures involving filling of the bony defect with a combination of platelet rich fibrin and hydroxy apetite graft followed by guided tissue regeneration and a coronally positioned flap.There was a residual gingival recession after three months which was aesthetically managed by a modified metal ceramic crown. Recall after nine months showed the tooth with a healthy gingival tissue and was without any further recession. Keywords: Fenestration, Guided tissue regeneration, Surgical flaps.
KEYWORDS:
Introduction
anterior or mandibular anterior region especially on labial aspect(1,2). Treatment option for the tooth is root canal treatment with or without root-end resection and retrograde filling.(3,4,5) There are several treatment options for the management of mucosal fenestration which includes blind root surface instrumentation and mouth rinsing with chlorhexidine(2), full thickness mucogingival flap with primary(6) or secondary(1) healing full thickness mucogingival flaps with guided tissue regeneration and bone grafting(6) , and pedicle flap operations(3) depending upon the severity and extent of tissue destruction. Management of mucosal fenestration due to extensive tissue damage is often difficult especially when combined with periapical bone loss. Surgical procedure of filling the bony defect with platelet rich fibrin(PRF) after mixing with synthetic bone graft is known to promote bone formation and wound healing(7).Guided tissue regeneration(GTR) is a concept utilized for the regeneration of periodontal tissue. This is a case report which describes surgical management of an endo perio lesion with mucosal fenestration by an inter disciplinary approach. Root canal treatment and retrograde filling was done initially followed by surgical procedures of filling the bony defect with a mix of platelet rich fibrin and a synthetic bone graft.Soft tissue closure was done by a coronally repositioned flap after applying a collagen membrane for guided tissue regeneration. There was a residual mucosal defect after three months which was covered by a modified metal ceramic crown to blend aesthetically with the surrounding soft tissue structures. A nine months follow up showed the tooth with a healthy gingiva without further recession.
Chronic periapical infection of tooth occurs as a sequele of trauma and it causes extensive tissue damage. This condition is manifested as a draining sinus on the attached gingiva and extensive tissue breakdown causes denudation of root surface. Mucosal fenestration describes the situation where the portion of tooth root is exposed to the oral environment following the Case Description breakdown of overlying bone and alveolar mucosa. A fortyeight year old female patient reported to the Mucosal fenestration may be attributed to imbrications department complaining of discolouration and pus or mal positioning of teeth, deficiencies of, or thin discharge of upper right front tooth since four years. alveolar cortex, prominent morphology of the root Patient gave a history of a road traffic accident twenty apex, or severe periradicular inflammation with bone years back. According to the patient, soon after this destruction. The most common site includes maxillary incident she had discomfort on the upper right front anterior or mandibular anterior region especially on (1,2) IJCD • JUNE, 2014 • 5(1)region for the next few days. In later years she tooth labial aspect . Treatment option for the tooth is root 1 © 2014 Int. Journal of Contemporary Dentistry noticed a discoloration in the tooth and intermittent pus canal treatment with or without root-end resection and
CASE REPORT incident she had discomfort on the upper right front tooth region for the next few days. In later years she noticed a discoloration in the tooth and intermittent pus discharge. Patient gave a history of normal health without any systemic illness.On extra oral examination no abnormality were detected.Intra oral examination showed yellowish discolouration of upper right central incisor [11]with a crack line on labial surface extending from incisal to cervical area.Tooth had mobility within limits, was non tender with a labial gingival recession of seven mm, a sinus opening was seen on attached gingiva (figure 1).Pulp vitality tests of 11showed no response.Intra oral periapical radiograph showed the tooth with a wide root canal and there was extensive peri radicular bone loss.This case was diagnosed as chronic peripical abscess with labial mucosal fenestration in relation to upper right central incisor. Root canal treatment of the tooth with perapical surgery was planned. Root canal therapy was done with the step back preparation and obturation was completed with gutta percha using lateral condensation method after a calcium hydroxide dressing (fig 2).After one week appointment was given for the surgical procedure.Under local anesthesia with 2% lignocaine, a submarginal incision with two vertical incisions involving the affected tooth was made and a full thickness mucogingival flap was raised beyond the mucogingival junction. Curettage at the area of the defect was done to remove all the granulation tissue and a retrograde filling was done with Mineral Trioxide Aggregate(Angelus Brazil white MTA) after root resection and root end preparation. Platelet rich fibrin (PRF), which was prepared by taking patient’s blood sample and centrifuging it for twelve minutes at 2700 rpm , was mixed with Sybograf-T which is a synthetic hydroxyl appetite and tri calcium phosphate(Eucare pharmaceuticals, India) to form a uniform mix(fig 3). This mix was packed uniformly on periapical defect and along the margins of denuded root surface (fig 4). A collagen membrane (periocol membrane, eucare, India) was placed over the denuded root surface. Since there was seven mms of gingival recession, the mucogingival flap was coronally repositioned and sutured. Suturing was done with 3-0 absorbable synthetic suture (fig5). Periodontal dressing (Coepack GC America, Alsip, IL, USA) was placed to avoid contamination of the surgical site. Post surgical analgesics and antibiotics prescribed. Chlorhexidine mouthrinse 0.12% was prescribed to be used three times daily for 2 weeks. Three months after surgery, the surgical site appeared to be healed completely, and was planned for a metal ceramic crown. There was a residual gingival recession of two mms on the labial surface after three months of surgery. The tooth was prepared to receive a crown as it was discoloured and with a crack line on the surface. A modified metal ceramic crown was made with an extension for the receeded area and pink ceramics was added on this part to mimick the gingival tissue (fig6) The patient was satisfied with the appearance after the
procedure. A review after nine months showed a healthy gingiva with the crown margin merging aesthetically with the surrounding gingival tissue (fig7).
Discussion Cases of mucosal fenestration have been earlier reported in history. Most common occurrences have been reported in maxillary and mandibular incisors.The exact etiology is not known but review of literature suggest that abnormally labioversed root tips, very thin labial plates and the presence of chronic periapical inflammation may be the probable cause. Mucosal breakdown and exposure of the root tip to the oral cavity leaves the root-tip vulnerable to plaque accumulation and calculus formation. These events make spontaneous soft-tissue coverage of the exposed root-tip improbable. Various treatment modalities advocated in the literature for the management of mucosal fenestrations include lateral pedicle flap, Guided Tissue Regeneration (GTR) and apicoectomy combined with endodontic treatment.(8,9) This tooth had a history of trauma which had occurred twenty years back which is the cause for the chronic periapical infection. Longstanding periapical infection resulted in extensive tissue damage surrounding the tooth which is the cause for the mucosal fenestration. Management of the non-vital tooth was done by rootcanal therapy followed by periapical surgery and retrograde filling. Mineral Trioxide Aggregate is a widely accepted retrograde filling material which is biocompatible with good sealing ability and capable of promoting periradicular tissue regeneration(10).Bony defect was treated with bone replacement graft mixed with platelet rich fibrin. Platelet rich fibrin is the second generation autologous concentration of human platelets. Various growth factors present in platelets include Platelet derived growth factor( PDGF),Transforming growth factor beta(TGF-beta),Vascular endothelial growth factor( VEGF). Platelet rich fibrin(PRF) derived from patients blood is in the form of platelet gel which is used in conjunction with bone graft in this case offers several advantages including wound healing, bone growth and maturation, graft stabilization, wound sealing and homeostasis and it improves the handling properties of graft materials.[7]It is found that hydroxyapetite when added to PRF increases the regenerative effects observed with PRF in the treatment of human three wall intrabony defects.(11) Soft tissue defects were treated here by the use of resorbable membrane using Guided Tissue regeneration (GTR) based concept and by coronally advancing the flap approximation.Guided tissue regeneration (GTR) is well established for the regeneration of supporting periodontal tissue in those teeth with periodontal disease. Many studies have
IJCD • JUNE, 2014 • 5(1) © 2014 Int. Journal of Contemporary Dentistry
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CASE REPORT
Fig.1 Pre operative view.
Fig.2 Radiograph after root canal therapy
Fig.3 Preparing the mix of PRF and synthetic bone graft.
Fig. 4 Filling of bony defect with the mix.
Fig.5 After suturing of flap.
Fig.6 After three months with crown
Fig.7 Nine months after the procedure.
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IJCD • JUNE, 2014 • 5(1) © 2014 Int. Journal of Contemporary Dentistry
CASE REPORT reported the success of this procedure not only in animals but also in humans(12).Clinical outcome of nanocrystalline hydroxyapatite bonegraft in combination with collagen membrane demonstrated better clinical outcomes compared with open flap debridement alone(13).Connective tissue graft(CTG) is considered as the gold standard for the root coverage procedure. CTG harvesting is often associated with increased patient morbidity, prolonged surgical time and the possibility of postoperative complications such as bleeding, numbness and sensibility changes in the donor area(14,15).To overcome these inconveniences, attempts are made to develop new materials aiming to replace CTG to improve patient acceptance and minimize morbidity. Guided Tissue Regeneration is an excellent treatment alternative to Connective Tissue Graft in root coverage procedures. Guided Tissue Regeneration was used in our case not only as a root coverage procedure, but also as a strategy of endodontic surgery where the ultimate goal was to regenerate the attachment apparatus that is cementum, periodontal ligament, and alveolar bone. Scientific evidence indicates that principles of GTR using a resorbable barrier membrane can be successfully applied in endodontic surgery to correct alveolar bone defects confined to periapical region, even those with erosion of buccal or lingual cortex[10].Postoperative follow up showed a satisfactory healing with a residual gingival recession of two mms which was aesthetically masked by a modified metal ceramic crown. Nine months after surgery the tooth was symptomless with a healthy soft tissue contour.
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Disclosure: Authors declare that there is no conflict of interests regarding publication of this paper. 15.
References 1. 2. 3. 4. 5. 6.
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Rawlinson A. Treatment of a labial fenestration of a lower incisor tooth apex. Br Dent Jour 1984;156:448–9. Lin LJ. The treatment of fenestrated root: case reports. J Dent Science 1989;9:137–40. Lehman J III, Meister F Jr, Gerstein H. Use of a pedicle flap to correct an endodontic problem: a case report. J Endod 1979;5:317–20. Dawes WL, Barnes IE. The surgical treatment of fenestrated buccal roots of an upper molar: a case report. Int Endod J 1983;16:82–6. Yang Z-P. Treatment of labial fenestration of maxillary central incisor. Endod Dent Traumat 1996;12:104–8. Tseng C-C, Chen Y-HM, Huang C-C, Bowers GM. Correction of a large periradicular lesion and mucosal defect using combined endodontic and periodontal therapy: a case report. Int J Periodont Restor Dent 1995;15,377–83. Sunitha Raja V, Munirathnam Naidu E. Platelet rich fibrin : evolution of a second generation
platelet concentrate – A review. Indian J Dent Res 2008;19:42-7 Dawes WL, Barnes IE. The surgical treatment of fenestrated buccal roots of upper molars. Int Endod J 1983;16:82-86. Von Arx T, Cochran DL. Rationale for the application of the GTR principle using a barrier membrane in endodontic surgery: a proposal of classification and literature review. Int J Periodont Restor Dent 2001;21:127-139. Torabinejad M, Chivian N. Clinical application of mineral trioxide aggregate. J Endod 1999; 25: 197-205. Pradeep AR. Pavan Bajaj, Nishanth S. Rao,Esha Agarwal, SavithaB.Naik. Platelet-Rich Fibrin Combined With a Porous Hydroxyapatite Graft for the Treatment of Three-Wall Intrabony Defects in Chronic Periodontitis: A Randomized Controlled Clinical Trial. J of Periodont 2012(march 16),Epub ahead of print Nyman S, Gottlow J, Karring T, Lindhe J. The regenerative potential of the periodontal ligament: an experimental study in the monkey. J Clini Periodont 1982;9:257–65. Singh VP, Nayak DG,Uppoor AS, Shah D. Clinical and radiographic evaluation of Nano-crystalline hydroxyapatite bonegraft (Sybograf®)in combination with bioresorbable collagen membrane (Periocol®) in periodontal intrabony defects. Dent Res J (Isfahan) 2012;9:60–7 Buff LR, Burklin T, Eickholz P, Monting J, RatkaKruger, P. Does harvesting connective tissue grafts from the palate cause resistent sensory dysfunction? A pilot study. Quint Int 2009;6:479–89. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial connective tissue graft palatal donor site: anatomic considerations for surgeons. Int J Periodont & Restor Dent 1996;2:130–7.
IJCD • JUNE, 2014 • 5(1) © 2014 Int. Journal of Contemporary Dentistry
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CASE REPORT About the Authors
1. Dr. Radhakrishnan Nair K HOD and Professor Department of Conservative dentistry and Endodontics Azeezia College of Dental sciences and Research Meeyanoor, Kollam.691537, Kerala,India. Email id-
[email protected]
2
Dr. Praveena G,
Professor Department of Conservative dentistry and Endodontics Azeezia College of Dental sciences and Research Meeyanoor, Kollam Email id -
[email protected]
3
Dr. Mohammed Ashik
Post graduate student, Dept of Conservative Dentistry and Endodontics, Azeezia College of Dental sciences and Research, Meeyanoor, Kollam. Email
[email protected]
4 Dr.Sreeja kuttan pillai Post graduate student, Dept of Periodontics, Azeezia College of Dental sciences and Research, Meeyanoor, Kollam Email id-
[email protected]
5
Dr. Ajay P Joseph
Post graduate student, Dept of Conservative Dentistry and Endodontics, Azeezia College of Dental sciences and Research, Meeyanoor, Kollam. Email
[email protected]
Address for correspondence:
Dr. Radhakrishnan Nair K HOD and Professor Department of Conservative dentistry and Endodontics Azeezia College of Dental sciences and Research Meeyanoor, Kollam.691537 ,Kerala,India. Email id-
[email protected]
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IJCD • JUNE, 2014 • 5(1) © 2014 Int. Journal of Contemporary Dentistry