Journal of Indian Society of Periodontology

CASE REPORT
Year
: 2019  |  Volume : 23  |  Issue : 2  |  Page : 168--171

An infrequent clinical case of mucosal fenestration: Treated with an interdisciplinary approach and regenerative therapy


Zeba Jafri1, Nishat Sultan1, Nafis Ahmad2, Anika Daing1,  
1 Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia University, New Delhi, India
2 Department of Prosthodontics, Faculty of Dentistry, Jamia Millia Islamia University, New Delhi, India

Correspondence Address:
Dr. Zeba Jafri
Room No. 403, Department of Periodontics, Faculty of Dentistry, Jamia Millia Islamia University, Maulana Mohammad Ali Jauhar Marg, Jamia Nagar, New Delhi - 110 025
India

Abstract

Mucosal fenestration is a clinical finding in which a portion of the tooth root is denuded of the overlying alveolar bone and gingiva or oral mucosa, thus exposing the root to the oral cavity. If left untreated, they may be a source of infection by giving entry to oral pathogen, leading to further progression of periodontal disease. Depending on their site of presence, they may also be a reason of esthetic concern to some patients. This paper reports one such infrequent case of mucosal fenestration of lower incisor region that was well treated by an interdisciplinary approach and regenerative therapy.



How to cite this article:
Jafri Z, Sultan N, Ahmad N, Daing A. An infrequent clinical case of mucosal fenestration: Treated with an interdisciplinary approach and regenerative therapy.J Indian Soc Periodontol 2019;23:168-171


How to cite this URL:
Jafri Z, Sultan N, Ahmad N, Daing A. An infrequent clinical case of mucosal fenestration: Treated with an interdisciplinary approach and regenerative therapy. J Indian Soc Periodontol [serial online] 2019 [cited 2019 Oct 16 ];23:168-171
Available from: http://www.jisponline.com/text.asp?2019/23/2/168/245321


Full Text



 Introduction



Mucosal fenestration is a pathological finding in which a portion of the tooth root is clinically visible in the oral cavity due to the destruction and loss of the overlying alveolar bone, periosteum, and oral mucosa. Mucosal fenestrations are not as common as alveolar bone fenestrations.[1] It has a variety of etiology and has normally seen associated with the anterior region of the arch,[2] especially incisors and more often on the labial side, evidently, because in the anterior region of the arch, the labial cortical plate around teeth is significantly thinner than its lingual counterpart. Overlying gingival biotype, buccally placed root, occlusal factor, aberrant frenum, orthodontic tooth movement, and associated chronic periapical and periodontal infection may also be a contributing factor for its occurrence.

Mucosal fenestration, if not treated, may lead to plaque deposition on the root surface as it is exposed to the oral cavity and can give way to the entry of infection causing further progression in periodontal disease. It may also be a cause of concern for esthetics and root hypersensitivity. Various techniques in earlier literature have been suggested for the treatment of such defects depending on its etiology which includes soft-tissue grafting,[2],[3] flap procedure,[1] a combination of soft-tissue and bone grafting procedures,[2] and guided tissue regeneration (GTR) and bone grafting procedures,[4],[5],[6] which proved to give good results with bony defects.

This paper aims to present a treatment approach of a rare case which clinically represented itself as a mucosal fenestration defect, where the apex of the root was visible through the defect with a distinct darker discoloration akin to a nonvital tooth. An interdisciplinary treatment approach was planned that included endodontic treatment followed by periodontal surgical regenerative therapy with osseous graft placement and GTR procedure for repair of mucosal fenestration defect.

 Case Report



A male patient aged 19 years visited the Outpatient Department of Periodontics with a complaint of a defect in his gums and bad appearance of front teeth.

The patient was young, healthy with no significant medical history. His previous dental history revealed that he had a history of trauma 2 years back, in which his anterior teeth and right upper and lower central incisors were fractured. He underwent dental treatment for the same that included root canal therapy followed by crown placement on both the teeth. The patient remained asymptomatic for a year when he started noticing a defect in his gum related to his lower front teeth. He again visited the dentist where his scaling was done and was advised to massage his gums with a chlorhexidine gel. The patient had been regularly massaging his gum ever since and did not report back to his previous dentist to seek further treatment.

His intraoral examination revealed fair oral hygiene. Upper and lower right central incisors had a porcelain-fused-to-metal crown of which the lower was dislodged from the tooth. A mucosal with alveolar bone fenestration on the labial surface was apparent in relation to lower right mandibular central incisor, and a portion of the root which appeared apex of the root of mandibular right central incisor was visible through the defect [Figure 1]a. The fenestration was slightly elongated in shape, measuring approximately 5 mm × 3 mm in diameter. The area was free of pus and calculus, and the surrounding gingiva appeared healthy. There were no periodontal pocket, no mobility, and no communication of fenestration with the gingival sulcus on periodontal probing. A transgingival probing or bone sounding under local anesthetic infiltration gave the impression of probable loss of alveolar bone along the length of the root facially. An intraoral periapical radiograph showed the concerned tooth slightly under obturated with diffuse radiolucency around its root [Figure 1]b. The treatment was planned with repeat endodontic therapy in the affected tooth followed by periodontal surgical correction by raising a full-thickness flap.{Figure 1}

Treatment

On first sitting, the root exposed through the defect was scaled and planed and full-mouth scaling was also done. The internal surface of the gingiva and margin of the fenestration were gently curetted. The old obturated material was removed from the canal and was meticulously cleaned and reshaped using ProTaper files under copious irrigation with 2.5% sodium hypochlorite. The canal was medicated with calcium hydroxide paste, and the access cavity sealed for 1 week with a temporary restorative material. On the subsequent visit, the paste was flushed out of the canal using thorough irrigation with normal saline and dried and obturated with gutta-percha.

After 1 week of endodontic treatment, periodontal surgery was carried out under local anesthesia. The thin epithelial lining of the mucosal defect was removed first with 11 No. blade [Figure 2]a, followed by elevation of a full-thickness mucoperiosteal flap [Figure 2]b. There was a complete loss of alveolar cortical plate on the labial side up to the root apex, and the lower portion of the root showed a significant amount of calculus deposits [Figure 2]c. Calculus from root was scaled, root planing was done, and the pathology was completely debrided from the surgical area [Figure 2]d. Around 1 mm of the root apex was resected. Synthetic bone graft material β-tricalcium phosphate (TCP) (resorbable tissue replacement [RTR] syringe–Septodont: RTR bone substitute of TCP) [Figure 2]g was packed into the defect, around the root apex and over the denuded root surface [Figure 2]e. A bioresorbable collagen barrier membrane (PerioCol-GTR-Eucare Pharmaceuticals Private Limited, India: collagen membrane) [Figure 2]h was placed over the bone graft and sutured with resorbable sutures to the adjacent periosteum and connective tissue [Figure 2]f. The elevated flap was replaced and sutured using interrupted sutures with 4–0 vicryl. The de-epithelized mucosal defect was also approximated and sutured [Figure 2]i. Coe-Pak was placed over the surgical site, and the patient was given postoperative instructions. The patient had been prophylactically prescribed antibiotic, amoxicillin 500 mg, from the day before surgery and anti-inflammatory from the day of surgery for 5 days and was put on 0.2% chlorhexidine mouthwash. The patient was recalled for review after 7 days. Healing was uneventful and the follow-up visits showed complete healing and correction of mucosal defect [Figure 3].{Figure 2}{Figure 3}

 Discussion



Despite varied etiology, mucosal fenestration secondary to chronic periapical inflammation has been reported more often in the literature,[1],[2],[7],[8] which in many cases is associated with an extreme buccal inclination of root or with a very thin buccal cortical plate.[1] The fragile overlying mucosa or gingiva with thin biotype becomes more vulnerable to outside frictional injury and gets easily damaged resulting in exposed root surface. Exposure of the root promotes plaque and calculus deposition, as also shown in this particular case, which further prevents mucosal approximation.

There have been many clinical studies published where GTR therapy was used in cases of periradicular and coronoapical bone defect that have shown promising results.[4],[5],[6] However, these cases did not have associated soft-tissue fenestrations. Established literature does not show any long-term clinical study with a large sample size of mucosal fenestration as the finding is rare. Few cases have been reported in the earlier literature with different treatment approaches depending on its etiology with successful results. It has been seen that although mucosal fenestration without endodontic involvement may best be treated by mucogingival surgery with soft tissue grafts,[2],[3] but where it is accompanied by alveolar bone loss and underlying pathology, open flap technique with regenerative therapy is a better treatment option along with endodontic treatment.[7],[8],[9] A study of five cases conducted by Lin et al. concluded that GTR therapy along with connective tissue graft facilitated fenestration closure and ensured long-term success in the treatment of large intrabony defect with mucosal fenestration.[9] Tseng et al. have treated a large periradicular defect with soft-tissue fenestration with combined endodontic and periodontic therapy where GTR and bone graft were used. It resulted in bone regeneration and complete closure of mucosal fenestration.[7] Uchida et al. also treated a similar case of mucosal fenestration with an underlying bone defect with GTR therapy and achieved good result.[8] The approach taken in our clinical case has also shown good result in accordance with the mentioned studies.[7],[8],[9] The endodontic treatment was aimed to get rid of the microorganisms from the root canal system and to completely obturate the previously under obturated root canal. The periodontal surgical procedure was intended to restore the lost periodontium by raising the full-thickness flap to gain access for debridement of the complete pathology and placement of bone graft and barrier membrane to stimulate bone healing and regeneration. Among the bone graft materials, TCP was used as it has shown good results with significantly higher percentage of bone fill.[10] It has no adverse effects such as allergic reactions and is osteoconductive where osteoblasts adhere to them and form bony tissue on their surface. Use of resorbable collagen membrane used as GTR therapy has also proved to be highly successful when treating endodonticperiodontal lesions and has shown good results, relating to bone growth and connective tissue attachment.[4],[5],[7]

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

1Ju 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.
2Chen G, Fang CT, Tong C. The management of mucosal fenestration: A report of two cases. Int Endod J 2009;42:156-64.
3Deepa D, Jain N. Gingival fenestration defect in the maxillary anterior region treated with coronally positioned flap using platelet-rich fibrin membrane. J Interdiscipl Dent 2015;5:140-4.
4Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R. Efficacy of guided tissue regeneration in the management of through-and-through lesions following surgical endodontics: A preliminary study. Int J Periodontics Restorative Dent 2008;28:265-71.
5Lin GH, Chang LY, Lin WC, Lee SY, Lai YL. Interdisciplinary approach for treating a large through-and-through periapical defect using guided tissue regeneration: A case report. Int J Periodontics Restorative Dent 2014;34:e1-8.
6Blank BS, Levy AR. Combined treatment of a large periodontal defect using GTR and DFDBA. Int J Periodontics Restorative Dent 1999;19:481-7.
7Tseng 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.
8Uchida A, Takahashi K, Nakamura Y, Nakamura A, Suzuki K, Nishikawa H. A case report of endodontic surgery using GTR for a mandibular second premolar tooth whose root apex was exposed in the oral cavity. J Jpn Endod Assoc 2004;25:20-6.
9Lin YC, Lee YY, Ho YC, Hsieh YC, Lai YL, Lee SY, et al. Treatment of large apical lesions with mucosal fenestration: A clinical study with long-term evaluation. J Endod 2015;41:563-7.
10Buser D, Hoffmann B, Bernard JP, Lussi A, Mettler D, Schenk RK, et al. Evaluation of filling materials in membrane – Protected bone defects. A comparative histomorphometric study in the mandible of miniature pigs. Clin Oral Implants Res 1998;9:137-50.