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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 4  |  Page : 237-239

Management of orthodontically induced mucogingival fenestration: A rare case report


Department of Periodontology, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India

Date of Submission15-Mar-2020
Date of Decision05-Mar-2020
Date of Acceptance09-Sep-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Nidhi Chaudhary
Department of Periodontology, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_5_20

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  Abstract 


Gingival fenestrations are of uncertain etiotogy having rarely been reported in the dental literature. It seems to have multifactorial origin and is commonly associated with the anterior region of the arch especially the incisors. The etiology of such defects can be due to decreased thickness of the alveolar housing, contour of the root apex, orthodontic tooth movement and endodontic pathology. To established an accurate diagnosis and proper institution of multidisciplinary comprehensive treatment protocol for salvaging teeth with complex orthodontic –periodontal problem. A 24- year old female patient reported to the department of Periodontics with exposed root in relation to maxillary right central incisor. History revealed previous orthodontic treatment 2-3 years back. On intra oral examination tooth exhibited grade 1 mobility and midline diastema. Apical portion of the root was seen perforating the buccal cortical plate and the mucosa. An interdisciplinary treatment was instituted which included root canal treatment followed by root end resection and soft tissue management. This case report resulted in an uneventful healing with coverage of the complete root apex and diastema closure with complete patient satisfaction. Combined orthodontic-periodontal problems offer great challenges to a clinician, therefore, an accurate diagnosis and treatment planning should be made accordingly for optimum outcome.

Keywords: Interdisciplinary periodontics, mucogingival fenestration, ortho-perio problems


How to cite this article:
Pant VA, Chaudhary N, Singh PK. Management of orthodontically induced mucogingival fenestration: A rare case report. Indian J Dent Sci 2020;12:237-9

How to cite this URL:
Pant VA, Chaudhary N, Singh PK. Management of orthodontically induced mucogingival fenestration: A rare case report. Indian J Dent Sci [serial online] 2020 [cited 2020 Dec 3];12:237-9. Available from: http://www.ijds.in/text.asp?2020/12/4/237/298032




  Introduction Top


Mucosal fenestration can be described as a situation where the periodontal breakdown occurs leading to loss of the overlying alveolar bone and mucosa, resulting in exposure of the root apex. The etiology for the same is due to malpositioning of teeth, deficiencies of, or thin alveolar cortex, prominent morphology of root apex, orthodontic tooth movement, or severe periradicular inflammation with bone destruction.[1] Mucosal fenestration is most commonly seen in the maxillary and mandibular anterior region, especially on the labial aspect because of tooth angulation placing root apices in labial position.[2],[3],[4],[5],[6]

Orthodontic treatment is made possible by the fact that when equal physiological force is applied on the tooth, the bone resorbs faster than the cementum. On the pressure side, there is compression of the periodontal ligament and resorption of the bone, whereas on the tension side, there is stretching of the periodontal ligament and apposition of new bone. In these conditions, within the physiological limit undermining, resorption occurs. In the case of tipping or torquing, any faulty or excessive force might lead to resorption of the labial cortical plate, resulting in mucosal fenestration and exposure of the root tip.

Hereby, we present a case of mucosal fenestration leading to root apex exposure in the maxillary anterior region as a result of excessive orthodontic forces and its management.


  Case Report Top


A 24-year-old female patient was referred to the outpatient department of periodontology by some treating orthodontist with exposed root apex in relation to the maxillary right central incisor. The patient had a history of undergoing fixed orthodontic treatment 2 years back. The orthodontic brackets were removed by the orthodontist after mucosal fenestration. On clinical examination, the apical portion of the root was seen perforating the buccal cortical plate with overlying mucosal fenestration [Figure 1] with Grade I mobility and midline diastema. Accumulations of plaque and calculus were seen deposited on the exposed root surface. The probing depth of the gingival sulcus were within the normal limits. Radiographs revealed periapical radiolucency [Figure 2], probably due to excessive torquing.
Figure 1: Preoperative clinical image depicting mucosal fenestration

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Figure 2: Preoperative radiograph

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Treatment plan included root canal treatment [Figure 3] of the affected tooth followed by reduction of buccal prominence and apicoectomy, further followed by mucosal approximation.
Figure 3: Completed endodontic therapy of the affected tooth

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After obtaining informed consent from the patient the surgical site was anesthetized using 2% lignocaine with 1:100,000 adrenaline. Reduction of the buccal prominence of the root using diamond burs and apicoectomy of the root apex were performed. De-epithelialization of the affected soft-tissue margin was done followed by mucosal fenestration closure using 4-0 Mersilk suture [Figure 4]. The patient was prescribed antibiotics and anti-inflammatory analgesic medications. The patient was recalled after 10 days for suture removal. The wound healed uneventfully with complete mucosal closure [Figure 5]. After 1 month, diastema closure was performed with composite material for esthetic reasons. The patient was completely satisfied after 3 months [Figure 6].
Figure 4: Operative image of mucosal approximation

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Figure 5: Ten days' postoperative image showing complete approximation of tissues

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Figure 6: Three months' postoperative image showing completely healed mucosal tissue

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  Discussion Top


Gingival fenestration was first reported by Mendenez OR in 1964. Dehiscence and fenestration are all governed by the anatomy and shape of the overlying alveolar bone on the root as well as the alignment of the root in the alveolus.[7] Dehiscence is commonly seen in clinical practice, whereas gingival fenestration is rare.

Fenestration of the root apex is a relatively uncommon complication of pulpal periradicular disease[8],[9] and faulty orthodontic therapy. The probable etiological factors in this case report can be attributed to the extreme buccal inclination of the root due to faulty orthodontic force accompanied with a nonexistent or very thin buccal cortex. Mucosal breakdown and fenestration is exposure of the root tip vulnerable to plaque accumulation and calculus formation. In this case report, the etiology is a faulty orthodontic force because it occurred after orthodontic treatment. In general, the etiology of these defects is not exactly clear, but they are known to occur in areas of thin keratinized mucosa and less commonly due to excessive orthodontic forces. Excessive orthodontic forces first leads to bone resorption, this inflammation when extends to gingiva leads to loss of gingival fibers which leaves the tissues freely mobile to functional forces leading to fenestration defects. These events make spontaneous soft-tissue coverage of the exposed root tip improbable.

Fenestrations and dehiscence defects are more prevalent in the mandibular canine– first molar region followed by the maxillary canine region.[10]

If excessive labial torquing is done during orthodontic treatment, The tooth root comes in approximation with the labial cortex of the alveolar bone. The cortex bends and limited movement would occur. Further force application would cause perforation of the cortical plate followed by bone loss and root resorption.[11]

This case depicts the presence of a fenestration in the apical portion of the right central maxillary incisor labially. Because the root tip was exposed clinically and was buccally proclined, it was reduced by apicoectomy and root canal treatment was performed. De-epithelialization was done to freshen the healed margins of the mucogingival area for better microvascularization and healing. Nonsurgical method for papilla reconstruction by composite restorations is recommended for various cases. In this case, diastema closure with composite was done for better esthetics as well as papillary reconstruction.

To overcome this problem of fenestration, prior to orthodontic treatment, evaluation of the bone structure and anatomy of tooth is necessary so that a stable position is achieved after treatment and adverse effects on tooth-supporting tissues can be minimized.


  Conclusion Top


Combined orthodontic–periodontal problems offer great challenges to a clinician, therefore an accurate diagnosis and treatment planning is mandatory for optimum outcome and minimal adverse effects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/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.
Chen G, Fang CT, Tong C. The management of mucosal fenestration: A report of two cases. Int Endod J 2009;42:156-64.  Back to cited text no. 1
    
2.
Rawlinson A. Treatment of a labial fenestration of a lower incisor root apex. Br Denta J 1984; 156:448-9.  Back to cited text no. 2
    
3.
Lin LJ. The treatment of fenestrated root: Case reports. J Dent Sci 1989;9:137-40.  Back to cited text no. 3
    
4.
Tseng CC, Chen YH, Huang CC, Bowers GM. Correction of a large periradicular lesion and mucosal defect using combined endodontic and periodontal therapy: A case report. Int J Periodontics Restorative Dent 1995;15:377-83.  Back to cited text no. 4
    
5.
Yang ZP. Treatment of labial fenestration of maxillary central incisor. Endod Dent Traumatol 1996;12:104-8.  Back to cited text no. 5
    
6.
Ju YR, Tsai AH, Wu YJ, Pan WL. Surgical intervention of mucosal fenestration in a maxillary premolar: A case report. Quintessence Int 2004;35:125-8.  Back to cited text no. 6
    
7.
Lehman J 3rd, Meister F Jr., Gerstein H. Use of a pedicle flap to correct an endodontic problem: A case report. J Endod 1979;5:317-20.  Back to cited text no. 7
    
8.
Sawes WL, Barnes IE. The surgical treatment of fenestrated buccal roots of an upper molar-A case report. Int Endod J 1983;16:82-6.  Back to cited text no. 8
    
9.
Menéndez OR. Bone fenestration by roots of deciduous teeth. Oral Surg Oral Med Oral Pathol 1967;24:654-8.  Back to cited text no. 9
    
10.
Lane JJ. Gingival fenestration. J Periodontol 1977;48:225-7.  Back to cited text no. 10
    
11.
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. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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