Maurice,
Your thoughts and input are welcome on this case of a pronounced and sudden presentation of a gingival (and osseous) dehiscence that is related to orthodontic therapy.
A 42 y.o. healthy female presented in January 2009 for evaluation of her mandibular anterior gingival recession (buccal) and associated diminished keratinized gingiva. She had been advised to undergo CT grafting by her previous dentist and periodontist to address this problem.
Noting her supra-erupted mandibular central incisors, the associated diminished papillae and enlarged embrasure spaces, the early horizontal bone loss and her Class II division 2 malocclusion, orthodontic evaluation was recommended, with the thought that intrusion of these teeth (# 24 and 25) and, if indicated, comprehensive orthodontic treatment, were likely indicated for long term benefit.
The orthodontist and the patient concurred and comprehensive orthodontic therapy was undertaken. Grafting was deferred, as there was adequate keratinized tissue and an absence of pocketing or inflammation in this and all other areas of the mouth. The patient was advised that grafting, if indicated, would be undertaken post orthodontic therapy.
<b>pre-orthodontic tx</b>
Following four months of uneventful fixed orthodontic therapy, over a period of one to two weeks, the patient noticed a pronounced and rapidly progressing dehiscence associated with tooth # 25. Upon examination recently, there were noted to be WNL interproximal and lingual gingival findings within the LA sextant and tooth # 25 presented with 3 - 4 mm of buccal recession and with 1.5 - 2.0 mm of buccal keratinized tissue present. Although slightly inflamed and tender to probing, there was an absence of B.U.P. and probing revealed a grossly/clinically intact attachment and probing depths of less than 1.5 mm.
four months intra-orthodontic tx
It appears that while buccalizing/intruding/tipping the mandibular anterior dentition, the thin buccal plate of tooth # 25 dehisced, as did its overlying gingiva.
At this point my plan is to promptly address this gingival and osseous lesion surgically, with the objectives of protecting any remaining buccal osseous tissue and maintaining the integrity of the sulcus and attachment apparatus while orthodontic treatment continues over 6 - 12 months.
I am considering the benefits of a combined procedure of frenulectomy and CT graft for root coverage versus the benefits of approaching this area of very thin gingiva via a two step approach (frenulectomy to be followed by a CT graft for root coverage after adequate healing).
I am also considering the benefits to grafting the # 24 site as well, via a tunnel approach, with the objective of shoring up the adjacent soft tissue (consider # 23 and/or # 26 as well?).
Your input on this case and any treatment suggestions are appreciated.
Jeff
