|Year : 2015 | Volume
| Issue : 2 | Page : 95-98
Button anchored coronally advanced flap: Perio-ortho continuum
Nitin Kaushik, Harpreet Singh Grover, Yogender Singh, Amit Bhardwaj
Department of Periodontology, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
|Date of Web Publication||11-Dec-2015|
Department of Periodontology, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana
Source of Support: None, Conflict of Interest: None
Periodontal plastic surgical procedures aimed at the coverage of exposed root surface have evolved into routine treatment modalities. Coronally advanced flap (CAF) was the most frequently used mucogingival procedure to achieve root coverage. Gingival recession resulting in root exposure is a common problem faced by clinicians. The continuous endeavor for innovation of newer interdisciplinary treatment modalities has resulted in the use of a passive object such as the orthodontic button being used to provide the initial stabilization in cases of root coverage using a CAF. The objective of this case report is to evaluate the effectiveness of a new treatment approach which consists of CAF procedure combined with orthodontic button application for the stabilization of flap for the treatment of Miller's Class I recession defects. After the application of orthodontic buttons in the middle third of the tooth surface, a split-full-split flap was raised for tooth number 43, and the flap was sutured 3-4 mm coronal to cementoenamel junction, and the central part of flap was suspended with sutures to the orthodontic button to maximize the stabilization of the immediate postoperative flap location. Clinical parameters such as probing depth and clinical attachment level were recorded at 1 month postoperatively. Complete root coverage was achieved when evaluated from baseline to 3 months along with gain in clinical attachment level and keratinized tissue. The final esthetics, both color match and tissue contours, were highly acceptable. One-month postoperative results showed that the CAF combined with the orthodontic button for stabilization is a very effective approach even in the treatment of Miller's Class I recession defects.
Keywords: Coronally advanced flap, gingival recession, orthodontic button
|How to cite this article:|
Kaushik N, Grover HS, Singh Y, Bhardwaj A. Button anchored coronally advanced flap: Perio-ortho continuum. J Dent Allied Sci 2015;4:95-8
|How to cite this URL:|
Kaushik N, Grover HS, Singh Y, Bhardwaj A. Button anchored coronally advanced flap: Perio-ortho continuum. J Dent Allied Sci [serial online] 2015 [cited 2020 Jan 26];4:95-8. Available from: http://www.jdas.in/text.asp?2015/4/2/95/171535
| Introduction|| |
The main goal of periodontal therapy is to improve periodontal health and thereby to maintain a patient's functional dentition throughout his/her life. However, esthetics represents an inseparable part of today's oral therapy, and several procedures have been proposed to preserve or enhance patient esthetics. The term "periodontal plastic surgery" (PPS), first suggested by Miller (1988), was defined as "surgical procedures performed to prevent or correct anatomical, development, traumatic or plaque disease-induced defects of the gingiva, alveolar mucosa, or bone" (The American Academy of Periodontology 1996). One of the most frequent indications of PPS is the treatment of buccal gingival recessions. Soft tissue recession, defined as an exposure of the root surface caused by an apical shift of the gingival margin, results in an unesthetic appearance, root hypersensitivity, and root caries. , The treatment of choice for recession coverage should address the biological as well as the patient's esthetic demands.  The various specialties in dentistry-conservative dentistry, prosthodontics, orthodontics, and periodontics, all strive to achieve this visually satisfying result either solitarily or in tandem with each other. , However, the continuous venture for innovation of newer interdisciplinary treatment modalities has resulted in the use of a passive object such as the orthodontic button being used in cases of root coverage to provide the initial stabilization for coronally advanced flap (CAF) surgeries as presented in our case report.
| Case Report|| |
A 19-year-old male patient reported to the Department of Periodontology, with a chief complaint of sensitivity in the right lower front teeth region for 3 months and also complains of receding gums for 2 months. Complete case history reveals that the patient was systemically healthy, nonsmoker, and not taking any medication.
On clinical and radiographic examination, Miller's Class I recession of 3 mm was diagnosed in relation to 43. The patient's gingival biotype was thin [Figure 1].
The gingival recession, probing depth, and clinical attachment level were measured using a UNC-15 periodontal probe.
Orthodontic buttons were bonded to the midfacial aspect of 43 using flowable composite before starting with surgical procedure [Figure 2].
|Figure 2: Orthodontic button bonded at midbuccal and vertical releasing incisions were given in relation to 43|
Click here to view
The first step to success is a painless procedure, and therefore, inferior alveolar nerve block and local infiltration were given in relation to 43 using local anesthesia (xylocaine with 2% adrenaline).
Two vertical incisions were given at 45° beyond the mucogingival junction and delineated the flap. A mucoperiosteal flap was elevated and stabilized at a coronal level for 2-3 min and then sutured using 5-0 black silk suture using the orthodontic button as an anchorage to hold the CAF in position. The final position of the CAF was 3-4 mm above the cementoenamel junction. A periodontal dressing was placed over the surgical area to avoid frictional forces and any external trauma [Figure 3], [Figure 4] and [Figure 5].
|Figure 4: Simple interrupted and sling sutures were given using 3-0 black silk suture|
Click here to view
Postoperative instructions were given. The patient was advised not to use brush and floss at the surgical site and also use soft or semisolid diet during the 1 st week of surgery. During antibiotic therapy, amoxicillin 500 mg TDS and flexon TDS for 5 days were prescribed to the patient.
It was also advised to the patient to use mouth rinses twice daily with 0.2% chlorhexidine digluconate mouthwash for the first 15 days. The sutures, button, and periodontal dressing were removed after 15 days of the surgery. The patient was instructed to maintain oral hygiene, especially at the surgical area after removal of sutures 3 weeks postoperatively. The patient was evaluated 1 week, 1 month, and 3 months postoperatively [Figure 6], [Figure 7] and [Figure 8]. The recall showed uneventful healing along with sufficient amount of root coverage without any complication.
| Discussion|| |
It has been stated that initial adhesion of the clot to the root surface is very important in the process of healing. A thin clot provides stability and tensile strength to the wound. , The surgical technique and early postoperative healing without much movement of the surgical area are the main consideration of success.  In conventional root coverage procedure as proposed by de Sanctis and Zucchelli in 2007, a split full thickness flap was raised along with vertical releasing incisions extending beyond the mucogingival junction. These vertical releasing incisions provide stability to the flap, but it has certain disadvantages such as damage to lateral blood supply. ,
It has also been reported that there is less increase in apico-coronal width of keratinized gingiva because vertical releasing incisions delays or disturbs the alignment of mucogingival junction.  To avoid these limitations of vertical releasing incisions, we stabilized the flap using the orthodontic button as an anchorage with the help of sling sutures. Orthodontic buttons are commonly used by an orthodontist as an inactive component to provide a strong bond for the attachment of accessories such as elastics.
In this case report, the orthodontic button has been used for the reason to hold the CAF in coronal position and also against gravitational pull as this procedure is not indicated in mandible for the same reason. The full thickness mucoperiosteal flap provides bulk for root coverage of treated area and will help in the movement of flap coronally without any hinderance.  Therefore, this results in optimum root coverage, good color matching with the adjacent soft tissue, and excellent recovery of presurgical marginal morphology can be accomplished by this combined procedure. 
| Conclusion|| |
Techniques to achieve expected results in root coverage procedures are very uncommon; one among them is using the orthodontic button. This approach of using orthodontic button is very helpful in achieving desirable results in root coverage procedures as it provides stability of flap coronally and cost-effective. One month results of the present case report are very promising in terms of clinically as well patient-centered parameters.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tugnait A, Clerehugh V. Gingival recession-its significance and management. J Dent 2001;29:381-94.
Paolantonio M. Treatment of gingival recessions by combined periodontal regenerative technique, guided tissue regeneration, and subpedicle connective tissue graft. A comparative clinical study. J Periodontol 2002;73:53-62.
Nowzari H. Aesthetic periodontal therapy: Introduction. Periodontol 2000 2001;27:7.
Grover HS. Button-assisted coronally advanced flap: Reclaiming the ground lost to gingival recession. Clin Dent 2014;8:15-9.
Pini Prato GP, Baldi C, Nieri M, Franseschi D, Cortellini P, Clauser C, et al.
Coronally advanced flap: The post-surgical position of the gingival margin is an important factor for achieving complete root coverage. J Periodontol 2005;76:713-22.
Hwang D, Wang HL. Flap thickness as a predictor of root coverage: A systematic review. J Periodontol 2006;77:1625-34.
Wikesjö UM, Nilvéus RE, Selvig KA. Significance of early healing events on periodontal repair: A review. J Periodontol 1992;63:158-65.
de Sanctis M, Zucchelli G. Coronally advanced flap: A modified surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol 2007;34:262-8.
Ozcelik O, Haytac MC, Seydaoglu G. Treatment of multiple gingival recessions using a coronally advanced flap procedure combined with button application. J Clin Periodontol 2011;38:572-80.
Wennström JL, Zucchelli G. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996;23:770-7.
Pini-Prato G, Baldi C, Pagliaro U, Nieri M, Saletta D, Rotundo R, et al.
Coronally advanced flap procedure for root coverage. Treatment of root surface: Root planning versus polishing. J Periodontol 1999;70:1064-76.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]