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Year : 2021  |  Volume : 25  |  Issue : 5  |  Page : 448-450  

Mucogingival augmentation by connective tissue graft for the management of orthodontic-induced alveolar fenestration with soft-tissue deficiency: A multidisciplinary approach

Department of Oral Medicine and Periodontology, Faculty of Dentistry, Cairo University, Egypt

Date of Submission21-Jun-2020
Date of Decision18-Oct-2020
Date of Acceptance30-Nov-2020
Date of Web Publication01-Sep-2021

Correspondence Address:
Ahmed Mohamed Elfana
11 Saraya St., ElManial, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisp.jisp_439_20

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Developing alveolar bone defects is one of the reported complications of orthodontic teeth movement especially in the region of the incisors, which may pose a risk for teeth health and their long term prognosis. In this case report, a 15-year-old female patient with an ongoing orthodontic treatment presented with labially protruded apices of lower anterior teeth and thin overlying soft tissue which caused esthetic and functional concerns. A combined periodontal-orthodontic approach was carried out starting with soft-tissue augmentation using bilaminar technique with sub-epithelial connective tissue graft and single incision access flap, followed by orthodontic repositioning of teeth. The augmented site healed uneventfully, and thick soft-tissue coverage was evident which helped the camouflage of the defect area and allowed for the recommencement of orthodontic treatment. Hence, orthodontic-induced alveolar defects with mucogingival complications can be successfully managed through a multidisciplinary approach with stable results after 1 year.

Keywords: Connective tissue graft, fenestration, orthodontic, periodontal plastic surgery

How to cite this article:
Elfana AM. Mucogingival augmentation by connective tissue graft for the management of orthodontic-induced alveolar fenestration with soft-tissue deficiency: A multidisciplinary approach. J Indian Soc Periodontol 2021;25:448-50

How to cite this URL:
Elfana AM. Mucogingival augmentation by connective tissue graft for the management of orthodontic-induced alveolar fenestration with soft-tissue deficiency: A multidisciplinary approach. J Indian Soc Periodontol [serial online] 2021 [cited 2021 Nov 27];25:448-50. Available from:

   Introduction Top

The alveolar bone is the foundation of the attachment apparatus which provides both mechanical and physiologic support for the teeth. Defects of the alveolar bone can develop in the form of a bony fenestration which is described as the lack of continuity of the alveolar process around teeth, forming a window-like exposure, or in the dehiscence form when the defect reaches the alveolar crest as well.[1] Even though not all alveolar defects are symptomatic or considered a harmful condition, extensive defects can act as a line of least resistance for defect progression, cause soft-tissue loss and expose root surface and consequently jeopardizing teeth health and affecting their prognosis.[2],[3]

Defects of the alveolar bone and soft tissues can be presented as complications of orthodontic tooth movement. This effect is more pronounced in the anterior teeth, and especially in the lower region, due to the thin nature of alveolar bone plates and the direction and prominence of their roots.[4] Periodontal plastic surgery is a procedure that aims to correct deficiencies in soft and/or hard tissue components of the periodontium that are lost due to inflammatory, anatomical or traumatic reasons.[5] In this sense, the connective tissue graft (CTG) is an effective modality for increasing tissue thickness, it can furthermore increase keratinization over time while providing superior long-term esthetic results and hence, it is considered the gold standard for soft-tissue augmentation.[6]

In the following case, alveolar dehiscence with thin soft-tissue coverage at lower anterior teeth as a result of uncontrolled orthodontic teeth movement caused esthetic and functional concerns. Since the orthodontic correction alone posed a risk for aggravating this problem, a multi-disciplinary approach was carried out, starting with soft-tissue augmentation using CTG followed by orthodontic teeth repositioning as described below.

   Case Report Top

Clinical presentation

A 15-year-old female patient with an ongoing orthodontic treatment that started about 1 year prior was referred to the clinic of periodontology. The patient complained of roots shadow appearance of lower anterior teeth and expressed fear of losing them. She reported being nonsmoker, medical history was noncontributory with no history of any periodontal surgery. Clinical examination showed thin tissue coverage over root apices of lower central incisors as well as lower left lateral incisor, and labial protrusion of teeth apices out of the alveolar bone boundaries [Figure 1]. No tooth mobility was noticed and teeth vitality was confirmed through electrical pulp test.
Figure 1: Preoperative photos showing (a) Thin mucosal coverage and shadow of the roots of lower anterior teeth and (b) Protrusion of teeth apices

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Case management

The treatment sequence was planned to halt active orthodontic teeth movement and to augmentation of the overlying tissue over the affected area. With an informed consent from the patient's guardian. Preseurgical supra and subgingival debridement were carried out on the initial visit before surgical intervention and oral hygiene instructions were emphasized. The surgical intervention started by recipient bed preparation; anesthetic infiltration of the lower anterior region was administrated using 2% mepivacaine HCl with 1:20,000 levonordefrin. A horizontal single incision using parker blade no: 15 was made along the mucogingival junction (MGJ) and extended mesial and distal to both ends of defects. Flap reflection started over the area of thin mucosa in full-thickness over the fenestration defects to provide for adequate flap thickness, and then continued as split-thickness apically to provide anchorage periosteum for suturing the CTG apically. On reflection, alveolar bone loss was observed over the roots of lower central incisors and lower left lateral incisor with of fenestration defects ranging from 4 to 6 mm in height. CTG was obtained from palatal donor site through Edel's trap-door technique.[7] The graft was determined to be extended by 3 mm beyond the area of the defect on both ends distally, with an overall width of 16 mm, height of 8 mm, and a thickness of up to 2 mm. The harvested graft was secured in place by the means of interrupted sutures to the gingiva coronally and the periosteum apically using a 5-0 resorbable polyglycolic acid suture. Since there was some flap tissue loss during reflection of delicate tissues, some flap advancement took place which was facilitated by the split-thickness reflection carried out. Primary closure was done using interrupted sutures to the attached gingiva with the same suture material [Figure 2].
Figure 2: Surgical steps of periodontal plastic surgery. (a) Single horizontal incision at the mucogingival junction; (b) Trap door incision at the donor site; (c) Connective tissue graft stabilization and (d) Flap suturing

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Postoperative care and follow-up

The patient was instructed the use of amoxicillin 250 mg one capsule three times daily for 5 days, ibuprofen 200 mg analgesic one tablet three times daily for 5 days as well as using chlorhexidine 0.12% mouthwash twice daily for 2 weeks. She was also instructed to avoid mechanical trauma and to refrain from tooth brushing at the lower anterior area. During the healing period, no major adverse effects were reported. After 3 months, the surgical site showed good soft-tissue thickness, excellent camouflage of roots, and good blending with surrounding tissues with the patient's satisfaction with the overall esthetic result. Orthodontic treatment was resumed to reposition root apices back into alveolar housing and after 1 year, stabilization of the treatment outcomes was noticed [Figure 3].
Figure 3: Postoperative follow-up (a) After 3 months and (b) After 1 year

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   Discussion Top

The main goal of orthodontic therapy is to provide for a physiologic tooth position that can maintain teeth health and function. However, orthodontic movement may result in alveolar bone and soft-tissue defects, especially when excessive torque or proclination of lower anterior teeth carries the risk of developing such defects, this is namely more pronounced as the alveolar plate is naturally thin in that area.[4]

In the present case, the development of bony fenestration and the thin overlying mucosa due to the labially tipped roots posed an esthetic concern for the patient, a risk for the health of the affected teeth, and the resumption of orthodontic correction. It is documented that gingival tissue thickness is a detrimental factor for bone and soft-tissue loss at sites with Inflammation during orthodontic treatment.[8] Thus, for the management of the present case, a combined periodontal-orthodontic approach started with a periodontal plastic surgery phase to meet esthetic demands, change the tissue quality by providing dense connective tissue coverage over the roots and to allow for more predictable outcomes for the orthodontic correction phase.[9]

CTG was chosen over free gingival graft (FGG) as the latter results in poor color match with surrounding tissues which is a major limitation for its use in the esthetic zone.[10],[11] On the other hand, the bilaminar technique utilizing CTG provides better blood supply to the graft, flap closure facilitates integration within the recipient site, which also results in excellent color and texture match.[11] The primary incision was made along the MGJ to spare the attached gingiva and papilla. No vertical incisions were used as they are known to interrupt flap vasculature.[12] The incision was extended on both ends of defects to allow for flap reflection without tension and to help to accommodate a CTG with wider dimensions than defects area.

After 3 months, healing was uneventful. The increase in gingival thickness was evident which allowed for the resumption of orthodontic correction. Small scar was noted on the right end, it may have developed due to thick graft in that part, but it was not considered as a functional impairment since the scar is dense fibrous tissue. Orthodontic reposition of teeth angulation continued and after 1 year, the augmented area retained sufficient thickness and showed adequate blending with surrounding mucosa.

Pathological alveolar fenestration is not a common condition and its management has been rarely reported in the literature. In the present case report, bilaminar technique for the management of alveolar fenestration with single incision at the MGJ was unique to preserve the integrity of the attached gingiva and the access flap, and the usage of CTG showed esthetic results and integration with surrounding tissues. In a case report, FGG combined with bone substitute was used to treat a contained bony fenestration as a result of a chronic periapical lesion.[13] This technique may not be suitable for esthetically demanding patients as FGG may yield a suboptimal esthetic outcome, in addition to the concern of graft survival over the avascular bone substitute bed. Another case report described the use of CTG for the correction of a fenestration defect as a result of teeth malposition.[14] However, in contrast to our report, the procedure involved vertical releasing incisions and the patient rejected the corrective orthodontic phase, therefore a risk of recurrence remains. In a contained alveolar defect with concurrent fenestration, a case report described the successful deployment of bone allograft combined with platelet-rich fibrin.[15] In our case report, however, the alveolar defect was not contained to support bone substitutes, but that was not a setback as adequate bone volume allowed for the repositioning of teeth into physiological position.

   Conclusion Top

A band of dense CTG inserted using single incision access flap at the level of MGJ over areas of orthodontic-induced bone fenestration provided both functional augmentation of gingival tissues over the defects area which enabled the resumption of orthodontic teeth repositioning, and integration of the healed site with good color and esthetically pleasing outcome which remained stable after 1 year of the surgical intervention.


The author would like to thank Dr. Youmna Elfiky for the management of the orthodontic treatment before, during, and after the surgical intervention, and also to thank Dr. Omnia Khaled and Mr. Marco Gietema for their support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Larato DC. Alveolar plate fenestrations and dehiscences of the human skull. Oral Surg Oral Med Oral Pathol 1970;29:816-9.  Back to cited text no. 1
Löst C. Depth of alveolar bone dehiscences in relation to gingival recessions. J Clin Periodontol 1984;11:583-9.  Back to cited text no. 2
Genco RJ. Current view of risk factors for periodontal diseases. J Periodontol 1996;67:1041-9.  Back to cited text no. 3
Handelman CS. The anterior alveolus: Its importance in limiting orthodontic treatment and its influence on the occurrence of iatrogenic sequelae. Angle Orthod 1996;66:95-109.  Back to cited text no. 4
Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.  Back to cited text no. 5
Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of miller class I and II recession-type defects? J Dent 2008;36:659-71.  Back to cited text no. 6
Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva. J Clin Periodontol 1974;1:185-96.  Back to cited text no. 7
Wennström JL, Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to orthodontic tooth movement in monkeys. J Clin Periodontol 1987;14:121-9.  Back to cited text no. 8
Kao RT, Pasquinelli K. Thick vs. thin gingival tissue: A key determinant in tissue response to disease and restorative treatment. J Calif Dent Assoc 2002;30:521-6.  Back to cited text no. 9
Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts for aesthetic purposes. Periodontol 2000 2001;27:72-96.  Back to cited text no. 10
Zucchelli G, Amore C, Sforza NM, Montebugnoli L, De Sanctis M. Bilaminar techniques for the treatment of recession-type defects. A comparative clinical study. J Clin Periodontol 2003;30:862-70.  Back to cited text no. 11
Kleinheinz J, Büchter A, Kruse-Lösler B, Weingart D, Joos U. Incision design in implant dentistry based on vascularization of the mucosa. Clin Oral Implants Res 2005;16:518-23.  Back to cited text no. 12
Singh S, Panwar M, Arora V. Management of mucosal fenestration by multidisciplinary approach: A rare case report. Med J Armed Forces India 2013;69:86-9.  Back to cited text no. 13
Kita D, Kinumatsu T, Ishii Y, Yamanouchi K, Saito A. Treatment of gingival fenestration with connective tissue graft: A case report. Bull Tokyo Dent Coll 2018;59:111-9.  Back to cited text no. 14
Bhatsange A, Shende A, Deshmukh S, Japatti S. Management of fenestration using bone allograft in conjunction with platelet-rich fibrin. J Indian Soc Periodontol 2017;21:337-40.  Back to cited text no. 15
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