JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 63-67

Single-step surgery for treating chronic periodontitis and increasing the width of keratinized gingiva in Mandibular Anterior Region: A case report

Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India

Date of Submission16-Jul-2020
Date of Decision18-Aug-2020
Date of Acceptance02-Sep-2020
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. Madhuri Alankar Sawai
Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia University, Maulana Mohd. Ali Jauhar Marg, New Delhi - 110 025
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_43_20

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Chronic periodontitis is precipitated as periodontal pockets, gingival recession (GR), decreased keratinized gingiva, and vestibular depth (VD). In the mandibular anterior region, it is frequently seen as GR and decreased VD. The development of high frenal attachment due to loss of periodontal support further increases the rate of progression of the disease and compromises the condition of the incisors. As mandibular incisors have short roots, they usually tend to become mobile early during the progression of periodontal disease. In this case report, a single-step surgery was done, which included periodontal flap surgery with bone augmentation in relation to mandibular anterior teeth. Following this, the width of keratinized tissue was increased using Diode laser by deepening the vestibule. This combined procedure can cover the exposed roots and increase the width of keratinized gingiva.

Keywords: Chronic periodontitis, diode lasers, gingival recession, keratinized gingiva, periodontal flap surgery, vestibular deepening

How to cite this article:
Sawai MA, Bhardwaj A, Jafri Z, Sultan N, Daing A. Single-step surgery for treating chronic periodontitis and increasing the width of keratinized gingiva in Mandibular Anterior Region: A case report. J Int Clin Dent Res Organ 2021;13:63-7

How to cite this URL:
Sawai MA, Bhardwaj A, Jafri Z, Sultan N, Daing A. Single-step surgery for treating chronic periodontitis and increasing the width of keratinized gingiva in Mandibular Anterior Region: A case report. J Int Clin Dent Res Organ [serial online] 2021 [cited 2022 Aug 7];13:63-7. Available from: https://www.jicdro.org/text.asp?2021/13/1/63/319524

   Introduction Top

Chronic periodontitis is a slowly progressing disease of the periodontium. It is usually precipitated as clinical attachment loss (CAL), decreased width of keratinized tissue (KT), and vestibular depth (VD).[1] The CAL can be in the form of periodontal pocket (PP) formation or gingival recession (GR). In the mandibular anterior region, it is very commonly seen as GR which may extend till the mucogingival junction (MGJ). As the disease progresses, there is formation of a high frenum which aggravates the clinical condition. The mandibular incisors have short roots and thin alveolar housing. Thus, they tend to become mobile as the disease progresses. When the GR extends to or beyond the MGJ, the teeth are left with minimal or no attached gingiva (AG). As these teeth are important from an esthetic point of view, treatments should be directed toward retaining these teeth.

The width of AG is 3.3–3.9 mm in the mandibular incisor region.[2] However, when chronic periodontitis occurs, there is GR along with decreased width of AG. The literature suggests that there should be at least 1 mm of width of AG for maintaining good oral hygiene.[3] However, with the occurrence of chronic periodontitis, the width of AG can substantially reduce and alter the prognosis of teeth. Sometimes, the flap surgery performed for treating chronic periodontitis can result in decreased width of AG.

Friedman has stressed on the importance of maintaining an adequate zone of AG after periodontal surgery. The “apically repositioned flap” was introduced by him, in which the entire mucogingival complex was preserved and shifted apically to the level of alveolar bone.[4] This would result in a healthy periodontium but at a more apical level. However, it would leave exposed roots which can be a cause of concern to the patient.

Lost periodontium can be regenerated using bone grafts, barrier membranes, soft-tissue grafts, growth factors, and their combinations. However, the treatment option for mandibular anterior teeth is limited to supportive periodontal therapy which is difficult to perform for the patient due to decreased VDs. Presence of high frenal attachment and tooth mobility can further hamper the maintenance.

In this case report, a single-step surgery was performed according to the technique introduced by Bhardwaj et al.[5] The procedure involves a combination of two surgical steps. The first step is to perform a periodontal flap surgery with bone augmentation which will eliminate PPs. This is followed by vestibular deepening to increase the width of keratinized gingiva using diode lasers.

   Case Report Top

A 19-year-old female patient reported to the Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia, with the chief complaint of loosening of gums in relation to her lower front teeth for the past 2 years. The patient was medically fit and did not give a history of any past dental treatment. Her history of present illness revealed that she noticed occasional bleeding from the gums and loose gums for the past 2 years. A year later, the complaint of bleeding gums aggravated and was associated with a foul odor. Intraoral examination showed reddish-pink gingiva with an increase in the size of gingiva in teeth #21, #22, #23, #26, and #27. The contour of the gingiva was accentuated with the gingival margin apical to the cemento-enamel junction (CEJ) in teeth #24 and #25. In the adjacent anterior teeth, the gingival was coronal to the CEJ. There was no width of AG in teeth #24 and #25, whereas in teeth #22, #23, #26, and #27, there was approximately 5 mm of keratinized gingiva. Class III Miller's GR was present with Grade I mobility in teeth #24 and #25. Radiographically, there was mild–moderate bone loss (approximately 3–4 mm from the CEJ) [Table 1].
Table 1: Periodontal parameters of the surgical site

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Traumatic bite was present in the mandibular incisors. The diagnosis was localized moderate–severe chronic periodontitis in teeth #24 and #25 with localized gingivitis with teeth #22, #23, #26, and #27. It was decided to do a single-step periodontal flap surgery to eliminate PPs, augment bone, and increase the width of AG by vestibular deepening using diode lasers.

The patient was explained the treatment plan and written consent was taken. Routine blood investigations were done, which were within normal range. Phase I therapy was instituted and surgery was scheduled once the patient was efficiently maintaining oral hygiene [Figure 1].
Figure 1: preoperative photograph

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Local anesthesia with adrenaline (1:100,000) was administered. Traumatic bite was relieved, and flap surgery incisions were given. Labially, an internal bevel incision (approx. 2 mm from the marginal gingiva) was given in teeth #22, #23, #26, and #27, whereas crevicular incision was given labially in teeth #24 and #25 and the lingual aspect [Figure 2]. This was done to thin the tissue and obtain a uniform gingival height and thickness. Full-thickness flaps were elevated beyond the MGJ and debridement was done [Figure 3]. Bone augmentation was done with Sybograf™ synthetic bone graft material in the mandibular central incisors [Figure 4]. The labial and lingual flaps were pulled coronally and closed with interrupted loop sutures (MERSILK™ 3-0) to cover the bone graft and to cover the exposed root surface as much as possible. A slight pull was noted on the flaps [Figure 5]. Vestibular deepening was then conducted by giving a horizontal incision in the mandibular labial vestibule using diode lasers, which extended between the first premolars in the mandibular arch. This relieved the pull on the buccal flap [Figure 6]. The diode laser (DenLase, Diode Laser Therapy System, Daheng Group Inc., China – 810 nm) was used at the settings of 1 W in a continuous mode. At the base of the surgical site, periosteal fenestration of about 1-2 mm width was done to remove the periosteum and connective tissue extending from tooth #22 to tooth #27 [Figure 7]. The surgical area was then irrigated with Betadine solution and covered with COEPAK™ dressing [Figure 8]. Postoperative instructions were given, and antibiotics and anti-inflammatory analgesics were prescribed for 5 days. The patient did not develop any postoperative complications. She was reviewed after 3 days. Ten days later, periodontal dressing and sutures were removed [Figure 9].
Figure 2: incision for periodontal flap surgery

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Figure 3: flap debrided

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Figure 4: placement of bone graft

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Figure 5: Periodontal flap sutured after coronal displacement

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Figure 6: diode laser incision in the vestibule

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Figure 7: incision completed with diode laser

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Figure 8: periodontal dressing in place

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Figure 9: 15-day postoperative photograph

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The patient was asked to maintain good oral hygiene and recalled after 1, 3, 6, and 9 months postoperatively [Figure 10] and [Figure 11]. At 9 months, there was significant gain in the width of keratinized gingiva (4–5 mm in teeth #24 and #25), increase in VD, and normal probing depths (1–2 mm) in the mandibular anterior teeth. The mobility of the mandibular central incisors was absent, and the soft tissues did not show any signs of inflammation. There was some root coverage with the central incisors and a healthy band of attached tissue in relation to all anterior teeth. The patient was able to maintain a good oral hygiene due to enough VD [Figure 12].
Figure 10: 1-month postoperative photograph

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Figure 11: 3-month postoperative photograph

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Figure 12: 9-month postoperative photograph

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   Discussion Top

Chronic periodontitis in mandibular anterior teeth is usually precipitated as decreased width of AG and GR extending close to or apical to MGJ with tooth mobility.[6] As the gingival margin moves apically, there will be reduced VD. The freni and muscle attachments which encroach on the marginal gingiva distend the gingival sulcus. This causes plaque accumulation, increases the rate of progression of GR, and initiates their recurrence even after treatment.

Lang and Loe had suggested that ≤1.0 mm of AG would facilitate the introduction of plaque into the gingival crevice due to movable gingival margins.[3] This would make conventional tooth brushing difficult and aggravate the existing periodontal condition.[7] The consensus report of the American Academy of Periodontology has suggested that a minimum of 2-mm apicocoronal width of KT is essential to maintain gingival health.[8] Hence, increasing the width of AG by gingival grafts or connective tissue grafts is done to improve the prognosis of teeth.[9] However, obtaining these grafts would need a second surgical site or, at times, would be insufficient to cover the long-span recession defects in multiple teeth.

Attachment loss with decreased VD usually requires an apically repositioned flap surgery. A major drawback of this procedure is the inability to regenerate alveolar bone naturally or with regenerative procedures. Other limitations such as root exposure, poor esthetics, and dentinal hypersensitivity occur postsurgically.[10] Sometimes, a second surgery for root coverage would be needed. This second surgery would involve an added surgical site for procuring the gingival or connective tissue graft. Thus, a case of chronic periodontitis with decreased width of AG would require multiple surgical treatments.

This single-step procedure introduced by Bhardwaj et al. eliminates PPs by flap surgery with bone augmentation and coronally shifting the marginal gingiva while suturing.[5] The tension created on the flap can be released with a horizontal incision using diode laser in the VD. This would increase the width of the AG by moving the MGJ apically. Hence, in a single surgery, it is possible to eliminate PPs, augment bone, and simultaneously increase the width of AG by increasing the VD. There is no need of a second surgical site to procure soft-tissue grafts. In our case, at 9 months postoperatively, the exposed roots could also be covered to a certain extent, which could be because of the creeping attachment as the patient could effectively maintain oral hygiene.

Thus, there was improvement in all the clinical parameters: width of AG, probing depth, VD, and tooth mobility along with improvement in patient's maintenance of oral hygiene. These results were similar to the result reported by Bhardwaj et al.[5]

The major determining factor of the nature of new tissues which would develop over the exposed periosteum is based on the origin of granulation cells that would migrate over the wound. The cells can migrate from the adjacent gingiva and periosteal connective tissue. They can also migrate from the periodontal ligament, alveolar mucosa, or bone marrow.[11]

In a case reported by Carnio et al., the authors conducted a clinical and histological study with 13-year follow-up of a patient treated with modified apically repositioned flap and reported a phenomenon of “Epiboly.” It means that the epithelial cells which expressed keratin could have repopulated the exposed periosteum faster than the other cells. This could be a plausible reason for the formation of KT in their case when the incision was given in the non-KT.[12] Similarly, in this case reported, we could find a band of nonmovable tissue firmly adherent on the labial surface of the mandibular incisors, which could be KT. However, a histopathological analysis of the soft tissue could not be conducted.

   Conclusion Top

This single-step surgery provides a promising outcome in improving the prognosis of mandibular anterior teeth having moderate-to-severe chronic periodontitis.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

   References Top

Ong G. Periodontal disease and tooth loss. Int Dent J 1998;48:233-8.  Back to cited text no. 1
Bowers GM. A study of width of attached gingiva. J Periodontol 1963;34:202-9.  Back to cited text no. 2
Lang NP, Löe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol 1972;43:623-7.  Back to cited text no. 3
Friedman N. Mucogingival surgery, the apically repositioned flap. J Periodontol 1962;33:328-40.  Back to cited text no. 4
Bhardwaj A, Sultan N, Sawai M, Jafri Z. A novel single-step surgical technique for vestibular deepening using laser in conjunction with periodontal flap surgery. J Indian Soc Periodontol 2016;20:647-50.  Back to cited text no. 5
[PUBMED]  [Full text]  
Takei HH, Scheyer ET, Azzi RR, Allen EP, Han TJ. Periodontal plastic and esthetic surgery. In: Carranza FA, Newman MG, Takei HH, Klokkevold PR, editors. Carranza's Clinical Periodontology. 11th ed.., St. Louis: Elsevier Mosby Inc.; 2012. p. 595-60.  Back to cited text no. 6
Chan HL, Chun YH, MacEachern M, Oates TW. Does gingival recession require surgical treatment? Dent Clin North Am 2015;59:981-96.  Back to cited text no. 7
Scheyer ET, Sanz M, Dibart S, Greenwell H, John V, Kim DM, et al. Periodontal soft tissue nonroot coverage procedures: A consensus report from the AAP regeneration workshop. J Periodontol 2015;86:S73-6.  Back to cited text no. 8
Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free autogenous gingival grafts. J Clin Periodontol 1980;7:316-24.  Back to cited text no. 9
Wennstrom JL, Heijl L, Lindhe J. Periodontal surgery: Access therapy. In: Lindhe J, Lang NP, Karring T, editors. Clinical Periodontology and Implant Dentistry. 5th ed.., Vol. 2. Oxford, UK: Blackwell Publishing Ltd.; 2008. p. 783-822.  Back to cited text no. 10
Karring T, Cumming BR, Oliver RC, Löe H. The origin of granulation tissue and its impact on postoperative results of mucogingival surgery. J Periodontol 1975;46:577-85.  Back to cited text no. 11
Carnio J, Camargo PM, Klokkevold PR, Lin YL, Pirih FQ. Use of the modified apically repositioned flap technique to create attached gingiva in areas of no keratinized tissue: A clinical and histologic evaluation. Int J Periodontics Restorative Dent 2017;37:363-9.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]

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