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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 5  |  Page : 648-651  

Gingival fenestration management: A rarefied case entity and literature review


1 Department of Periodontics, SRM Kattankulathur Dental College & Hospital, Potheri, Tamil Nadu, India
2 Department of Endodontics, SRM Kattankulathur Dental College & Hospital, Potheri, Tamil Nadu, India

Date of Submission30-Jan-2020
Date of Decision04-Feb-2020
Date of Acceptance02-Mar-2020
Date of Web Publication28-Aug-2020

Correspondence Address:
Prem B Rajula M
Department of Periodontics, SRM Kattankulathur Dental College & Hospital, Potheri, Tamil Nadu.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.JPBS_77_20

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   Abstract 

Dehiscence and fenestration are commonly confronted alveolar defects. But the combined mucosal and alveolar fenestration is uncommonly reported in the literature as they less often cause pain, and in majority of the cases, only aesthetic complaint is present. This article highlights the case report of a 28-year-old female patient who presented with aesthetic concern about gingival/mucosal fenestration in her right lower central incisor. She had a history of surgical endodontic treatment in the same tooth. In this case, mucosal fenestration was treated with regenerative therapy using bioactive glass with platelet-rich fibrin and free connective tissue graft. The treatment resulted in excellent aesthetic outcome and satisfactory bone healing.

Keywords: Bone graft, connective tissue graft “fenestration labyrinth”, endodontic treatment, fenestration


How to cite this article:
Rajula M PB, Varatharajan K, Mani R, Krishnakumar S. Gingival fenestration management: A rarefied case entity and literature review. J Pharm Bioall Sci 2020;12, Suppl S1:648-51

How to cite this URL:
Rajula M PB, Varatharajan K, Mani R, Krishnakumar S. Gingival fenestration management: A rarefied case entity and literature review. J Pharm Bioall Sci [serial online] 2020 [cited 2020 Sep 22];12, Suppl S1:648-51. Available from: http://www.jpbsonline.org/text.asp?2020/12/5/648/292895




   Introduction Top


Fenestration and dehiscence are the most often confronted alveolar defects.[1] Fenestration appears as a localized breach in the cortical plate without compromising the marginal bone. When the breach extends through the marginal bone, the resultant defect is termed as dehiscence.[2] Gingival/mucosal fenestration is a condition where the blanketing gingiva or mucosa is also denuded, thereby exposing the root surface to the oral environment. Therefore, patients with gingival fenestration most often report for aesthetic management.

Fenestration of mucosa has been portrayed in the literature, but is unusual in comparison with the normal fenestration.[3] Though mucosal fenestrations serve as plaque-retaining areas, rarely do they cause pain. Several modalities of treatment were briefed in the literature. These encompass planing of root along with full- or partial-thickness flap, free gingival grafts, and guided tissue regeneration (GTR).[4] This article portrays an uncommon circumstance where there is combined mucosal and alveolar fenestration after surgical endodontic treatment, which was effectively managed with a mix of bone graft with platelet-rich fibrin (PRF) and free connective tissue graft (CTG).


   Case History Top


A female patient of approximately 28 years presented with a complaint of visible root tip in the lower front tooth region for the past 6 months. The patient history revealed a fall 7 years back, and she underwent root canal treatment followed by periapical surgery. Clinical examination revealed discolored lower central and lateral incisors and the presence of a mucosal fenestration measuring approximately 4 × 3 mm in relation to 41 region, making the root tip visible clinically [Figure 1]. Periapical radiograph revealed radiolucency in the lower anterior region that persisted even after the endodontic treatment [Figure 1]. After Phase-I therapy, the patient was reevaluated and blueprint for surgery to manage both the hard and soft tissue fenestration using the single-stage regenerative technique was established.
Figure 1: Preoperative view. (A) Clinical. (B) Radiograph

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   Surgical Procedure Top


After obtaining informed consent from the patient, the surgical site was anesthetized and a full-thickness flap was elevated from 32 to 42 region, and the alveolar defect was exposed [Figure 2]. The bony defect was thoroughly debrided, and the alveolar defect was packed with bioactive glass (BG) (Perioglas®, Novabone Products Pvt. Ltd., Bangalore, India) mixed with PRF, and the flap was repositioned in the original position and secured with 3-0 black silk sutures.
Figure 2: Intraoperative view. (A) Full-thickness flap elevated and fenestration de-epithelialized. (B) Root planing done and complete pathology removed. (C) Bioactive glass with platelet-rich fibrin placed in the bone defect. (D) Connective tissue graft harvested from palate and sutured

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Later, CTG was obtained from the palate through a single incision technique and placed over the mucosal defect and secured with 5-0 catgut suture, and periodontal dressing was given. Antibiotics and analgesics were prescribed, and a rinse of 0.12% chlorhexidine was advised for approximately 2 weeks. Postoperative healing was uneventful, and the sutures were removed after 10 days. The 1-month postoperative follow-up revealed favorable healing [Figure 3]. One-year follow-up showed aesthetically healed mucosal fenestration [Figure 3], and the periapical radiograph revealed resolution of the periapical defect [Figure 3].
Figure 3: Postoperative view. (A) On 7th day. (B) After 1 month. (C) After 6 months. (D) After 1-year follow-up. (E) 6-month radiograph. (F) 1-year radiograph

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   Discussion Top


Gingival fenestrations have been portrayed in the literature but are unusual in comparison with the normal fenestration. It was first described by Menéndez OR in 1967.[5] The term “gingivo-osseous pathologic fenestration” was coined by Serrano,[6] in 1971, to describe this condition. The literature review revealed most commonly involved are deciduous teeth affected by traumatic intrusion, disrupted root resorption, and so on. Regarding permanent teeth, the most commonly involved teeth are incisors. It has multifactorial etiology such as thin alveolar housing, labially positioned teeth, contour at the root apex, occlusal discrepancies, orthodontic tooth movement, and endodontic and periodontal pathosis.

Although the presence of non-vital teeth has been implicated in alveolar and mucosal fenestration as identified in the aforementioned case scenario, Jhaveri et al.[7] reported the same on the distobuccal root of a vital maxillary first molar tooth. In case of non-vital tooth, the already existing defect or the one caused by bone resorption due to disease process caused alveolar fenestration to extend mucosal fenestration by denudation of mucosal covering of root.

The treatment should be decided based on the degree of osseous defect and protrusion at the root apex. Literature review suggests for root surface coverage by the subepithelial CTGs to manage the mucosal defects. Uchida et al.[8] managed a case of mucosal fenestration with GTR and obtained complete coverage.

In this case, we used BG along with PRF to fill the periapical defect, followed by CTG for covering the mucosal fenestration, thereby treating both the alveolar and mucosal fenestration in a single stage. BG is a kind of bioactive ceramic that has an osteostimulatory effect in addition to its osteoconductive properties.[9] It has also shown to have antibacterial effect against subgingival and supragingival bacteria.[9] The selection of CTGs is dependent on connective tissue base establishment, which helps the epithelial cells to migrate from the margins, thus rendering “reattachment” of the soft tissue onto the exposed root surface.[7] This case report is among the first few to use both BG with PRF and free connective graft in the combined fenestration coverage.


   Conclusion Top


Gingival fenestrations are rarely encountered with clinical practice, but when present, they pose a difficult situation for the clinician. Although infrequent, the presence of a denuded root surface penetrating the cortical plate and the overlying mucosa is not just an aesthetic concern for the patients but also pose further challenges of bringing about a poor prognosis. In spite of various treatment techniques that have been documented for the management of mucosal fenestrations, the surgical protocol that we have followed in this case has yielded aesthetic and satisfactory results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Elliot JR, Bowers GM Alveolar dehiscence and fenestration. Periodontics 1963;1:245-8.  Back to cited text no. 1
    
2.
Edel A Alveolar bone fenestrations and dehiscences in dry Bedouin jaws. J Clin Periodontol 1981;8:491-9.  Back to cited text no. 2
    
3.
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. 3
    
4.
Yang ZP Treatment of labial fenestration of maxillary central incisor. Endod Dent Traumatol 1996;12:104-8.  Back to cited text no. 4
    
5.
Menéndez OR Bone fenestration by roots of deciduous teeth. Oral Surg Oral Med Oral Pathol 1967;24:654-8.  Back to cited text no. 5
    
6.
Serrano J Gingivo-osseous pathologic fenestration. Oral Surg Oral Med Oral Pathol 1971;32:697-700.  Back to cited text no. 6
    
7.
Jhaveri HM, Amberkar S, Galav L, Deshmukh VL, Aggarwal S Management of mucosal fenestrations by interdisciplinary approach: a report of three cases. J Endod 2010;36:164-8.  Back to cited text no. 7
    
8.
Uchida 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 Japan Endod Assoc 2004;25:20-6.  Back to cited text no. 8
    
9.
Allan I, Newman H, Wilson M Antibacterial activity of particulate bioglass against supra- and subgingival bacteria. Biomaterials 2001;22:1683-7.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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   Case History
   Surgical Procedure
   Discussion
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