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CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 70-74

Bone grafting with novel flap design and management of midline diastema: An interdisciplinary perio-ortho approach


Department of Periodontics, Government Dental College and Hospital, Vijayawada, Andhra Pradesh, India

Date of Web Publication18-Mar-2016

Correspondence Address:
Sowjanya Mittapally
Department of Periodontics, Government Dental College and Hospital, Dr. NTRUHS, Gunadala, Vijayawada - 520 004, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.178985

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  Abstract 

The practice of using bone grafts in repairing periodontal defects has been the classical approach to periodontal regeneration in the last 30 years. To optimize the regeneration and preserve soft tissues, many techniques of papilla preservation have been described in the literature. The "whale's tail" technique is a surgical technique designed to preserve interdental tissue in guided tissue regeneration. This clinical case report describes and demonstrates the successful use of "whale's tail" flap in conjunction with bovine bone-derived mineral to reconstruct wide intrabony defect in the esthetic zone. A 28-year-old woman presented with an 8-mm probing depth on the mesial aspect of her maxillary right central incisor with midline diastema along with highly placed labial frenum with deep intrabony defect. A combined periodontal and orthodontic approach improved the anterior esthetic zone.

Keywords: Aesthetic zone, intrabony defect, papilla preservation


How to cite this article:
Jampani ND, Songa VM, Buggapati L, Mittapally S. Bone grafting with novel flap design and management of midline diastema: An interdisciplinary perio-ortho approach . J NTR Univ Health Sci 2016;5:70-4

How to cite this URL:
Jampani ND, Songa VM, Buggapati L, Mittapally S. Bone grafting with novel flap design and management of midline diastema: An interdisciplinary perio-ortho approach . J NTR Univ Health Sci [serial online] 2016 [cited 2022 Jan 20];5:70-4. Available from: https://www.jdrntruhs.org/text.asp?2016/5/1/70/178985


  Introduction Top


Periodontal surgery is mainly performed to gain access to diseased areas for adequate cleaning in order to achieve pocket reduction or elimination, and to restore periodontal tissues lost as a consequence of disease process. The most favorable outcome of the periodontal surgery is regeneration of the lost supporting tissues. [1]

Various biomaterials have been used to achieve periodontal regeneration. Many animal experiments and patient studies show that periodontal regeneration occurs after xenogenous bone grafting. [2],[3]

To ensure predictable results of the periodontal regeneration, primary closure of the interdental space is required. In order to achieve this, many techniques of papilla preservation have been described in the literature. [4],[5],[6] In 2009, Bianchi and Bassetti described a surgical technique called the "whale's tail" technique designed to preserve interdental tissue in guided tissue regeneration. [7]

In many of the midline diastema cases, orthodontic treatment alone can help to close a diastema. A combination of periodontal and orthodontic techniques may be advocated when, for example, there is a highly placed labial frenum with an intrabony defect. [8]

The aim of this study is to describe a clinical case where the "whale's tail" technique combined with the orthodontic approach was employed to obtain periodontal regeneration that resulted in successful management of the patient with diastema closure.


  Case report Top


A 28-year-old female patient reported to our outpatient department with the complaint of pus discharge from the gums and spacing in the upper front teeth region [Figure 1]. The oral hygiene status of the patient was fair and she did not have systemic problems. A comprehensive periodontal examination was done.
Figure 1: Pus discharge from the right central incisor

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On clinical examination, a periodontal abscess with periodontal pocket of 8-mm probing depth and a clinical attachment loss of 6 mm were found on the mesial aspect of her maxillary right central incisor along with the midline diastema with highly placed papillary labial frenum [Figure 2]. An intraoral periapical radiograph revealed a vertical bone defect on the mesial aspect of her maxillary right central incisor [Figure 3].
Figure 2: Highly placed labial frenum

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Figure 3: Intraoral periapical radiograph revealed vertical bone defect in relation to the mesial aspect of maxillary right central incisor

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The initial periodontal treatment consisting of periodontal abscess drainage followed by complete scaling along with curettage and root planing on the right maxillary central incisor was completed, and the patient was called again after 1 week to assess the clinical condition and management of aberrant frenum. The routine blood investigations were found to be within normal limits and frenectomy was done under local anesthesia [Figure 4] and the patient was put under the maintenance phase. The patient was reviewed after 1 month, and there was satisfactory healing after frenectomy [Figure 5]. As there was a wide intrabony defect in the esthetic zone, bone grafting was performed along with the "whale's tail" technique as proposed by Bianchi and Bassetti [7] [Figure 6] [Figure 7] [Figure 8] [Figure 9] [Figure 10].
Figure 4: Frenectomy was done

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Figure 5: One-month postoperative (frenectomy) clinical photograph

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Figure 6: Two vertical full-thickness incisions were given from the mucogingival line to the distal margin of the two central incisors on the buccal surface. A horizontal incision joined the vertical incisions at the apical aspect of the flap. In the coronal aspect of the flap, intrasulcular incisions were made at buccal, interproximal, and palatal sides

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Figure 7: A full-thickness flap was elevated from the buccal to the palatal side through the diastema

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Figure 8: Reactive inflammatory tissue and necrotic cementum were carefully removed from the osseous defects and the root surface

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Figure 9: The defect was filled with granules of spongiosa of natural bovine bone mineral

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Figure 10: The flap was repositioned from the palatal to the buccal side and the biomaterials were completely covered by the flap and their margins were sutured without tension, far away from the defect

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[Figure 11] shows a 3-week postoperative clinical photograph.
Figure 11: Three-week postoperative clinical photograph

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A 3-month postoperative radiograph showed adequate bone fill [Figure 12] and the patient was referred to the Department of Orthodontics for the management of midline diastema. Follow-up of the patient after 6 months of orthodontic treatment revealed closure of the midline diastema with satisfactory periodontal health. The soft tissue response was stable and aesthetic [Figure 13]. After treatment, probing depth was reduced to 4 mm with a gain in attachment level of 4 mm and also complete closure of the midline diastema. Final radiograph at 9 months shows remodeling of the graft [Figure 14]. Marginal compactness of the alveolar bone highlights good stability of the treated area.
Figure 12: Three-month postoperative radiograph

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Figure 13: Clinical photograph after 6 months of orthodontic treatment for the management of midline diastema

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Figure 14: Radiograph at 9 months shows remodeling of the graft (before the removal of braces)

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  Discussion Top


The results of this case study have shown that with the "whale's tail" technique, it is possible to regenerate wide intrabony defects in the aesthetic zone. The periodontal pocket probing depth (PPD) reduction and clinical attachment level (CAL) gain of 4 mm were accomplished that were almost similar to the findings of Bianchi and Bassetti who reported a CAL gain (4.57 ± 0.65 mm) and PPD reduction (5.14 ± 0.95 mm) [7] and Damante et al. who reported a gain in attachment level of 4 mm with the "whale's tail" flap. [9]

One study demonstrated that the porous bone mineral was highly osteoconductive and graft particles often appeared to serve as a nidus for bone formation. [2] Here in the presented case, the bovine bone mineral graft was used.

The preservation of papillary integrity is essential for maintaining aesthetics, especially during and after periodontal surgery. The first description of a surgical approach named papilla preservation was published by Takei et al. [4] in 1985 that was designed to obtain a primary closure in grafted sites. In 1995, Cortellini et al. [5] published a modification of the Takei et al. technique, naming it "modified papilla preservation technique." The simplified papilla preservation flap was proposed to provide surgical access to interproximal bony defects while preserving interdental soft tissues, even in narrow interdental spaces and posterior teeth. [6]

In this clinical case study, the systematic use of incisions distant from the defects and biomaterial margins drastically reduced the percentage of flap dehiscence and bacterial colonization of the biomaterials and it was possible to elevate a large flap from the buccal to the palatal side, which allowed the preservation of a large amount of soft tissue and resulted in good primary closure. This technique required attention to detail during flap elevation from the buccal to the palatal side, and careful mobilization of the interdental papilla allowed preservation of vascularization of the buccal flap.

Different treatment modalities for midline diastema include orthodontic removable or simple fixed appliances, excision of the frenum, restoration techniques with direct composites, laminates, veneers, ceramic restorations, extraction of mesiodens, and habit-breaking appliances. [8] As there was a midline diastema in the present case, the patient was referred to the Department of Orthodontics after the periodontal treatment for the management of midline diastema; after 6 months of orthodontic treatment, the midline diastema closed.


  Conclusion Top


In modern dentistry, aesthetics has become the key objective when finalizing a treatment plan, especially in the maxillary incisor region; so an interdisciplinary approach in dentistry is extremely important to ensure a successful outcome. In the aesthetic zone, it is important to understand all the factors that affect the smile and that relate to uneven gingival contours. The integrated perio-ortho approach using the "whale's tail" flap leads to clinical improvement of the hard and soft tissue conditions of wide intrabony defects, maintaining the interproximal tissue to recreate a functional attachment with aesthetic results.

 
  References Top

1.
Kaushick BT, Jayakumar ND, Padmalatha O, Varghese S. Treatment of human periodontal infrabony defects with hydroxyapatite + β tricalcium phosphate bone graft alone and in combination with platelet rich plasma: A randomized clinical trial. Indian J Dent Res 2011;22:505-10.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Camelo M, Nevins ML, Schenk RK, Simion M, Rasperini G, Lynch SE, et al. Clinical, radiographic, and histologic evaluation of human periodontal defects treated with Bio-Oss and Bio-Gide. Int J Periodontics Restorative Dent 1998;18:321-31.  Back to cited text no. 2
    
3.
Nevins ML, Camelo M, Rebaudi A, Lynch SE, Nevins M. Three-dimensional micro-computed tomographic evaluation of periodontal regeneration: A human report of intrabony defects treated with Bio-Oss collagen. Int J Periodontics Restorative Dent 2005;25:365-73.  Back to cited text no. 3
    
4.
Takei HH, Han TJ, Carranza FA Jr, Kenney EB, Lekovic V. Flap technique for periodontal bone implants. Papilla preservation technique. J Periodontol 1985;56:204-10.   Back to cited text no. 4
[PUBMED]    
5.
Cortellini P, Prato GP, Tonetti MS. The modified papilla preservation technique. A new surgical approach for interproximal regenerative procedures. J Periodontol 1995;66:261-6.   Back to cited text no. 5
    
6.
Cortellini P, Prato GP, Tonetti MS. The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J Periodontics Restorative Dent 1999;19:589-99.   Back to cited text no. 6
    
7.
Bianchi AE, Bassetti A. Flap design for guided tissue regeneration surgery in the esthetic zone: The "Whale's Tail" technique. Int J Periodontics Restorative Dent 2009;29:153-9.  Back to cited text no. 7
    
8.
Kennedy Babu SP, Agila S. Perio-Ortho interdisciplinary management for midline diastema related to abnormal frenum and intrabony defect - A case report. Int J App Basic Med Res 2012;2:135-9.  Back to cited text no. 8
    
9.
Damante CA, Sant'Ana AC, de Rezende ML, Aguiar Greghi SL, Passanezi E. Guided Tissue Regeneration and Papilla Preservation with the "Whale's Tail" Flap. JSM Dent 2013;1:1017.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]


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