JIOS

Button-assisted Coronally Advanced Flap: An10.5005/jp-journals-10021-1232

Innovative Ortho-perio Amalgamation
Case Report

Button-assisted Coronally Advanced Flap: An Innovative

Ortho-perio Amalgamation
1
Shruti Maroo, 2Harpreet Singh Grover, 3Shailly Luthra

ABSTRACT Received on: 20/2/13

Introduction: Esthetics has become an essential criterion of the
overall treatment plan in dentistry that comprises of a healthy and
beautiful smile at any age. Multidisciplinary approach involving
orthodontics and periodontics results in the maintenance of a
beautiful smile and a healthy periodontium. The continuous
endeavor for innovation of newer interdisciplinary treatment
modalities has resulted in the use of a passive object like the
orthodontic button being used to provide the initial stabilization in
cases of root coverage using a Coronally advanced flap (CAF).
Objective: The objective of this case report is to evaluate the
effectiveness of a new treatment approach which consists
of coronally advanced flap (CAF) procedure combined with
orthodontic button application for the treatment of Millers
class III recession defects.
Methodology: After the application of orthodontic buttons in
middle third of tooth surface, a split-full split flap was raised
from tooth #22 to #24 and the flap was sutured 3 to 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 were recorded at 1 and 3 months
postoperatively.
Results: 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.
Conclusion: Three months postoperative results showed that
the CAF combined with orthodontic button is a very effective
approach even in the treatment of Millers Class III recession
defects.
Accepted after Revision: 19/3/13
Introduction
The changing face of dentistry has ushered in a new era
where the present day aim is to have a healthy and esthe
tically pleasing dentition. Thus, esthetics has become an
essential criterion of the overall treatment plan in dentistry,
which comprises of a healthy and beautiful smile at any
age.1 The various specialties in dentistryconservative
dentistry, prosthodontics, orthodontics, and periodontics
all strive to achieve this visually satisfying result either
solitarily or in tandem with each other. Multidisciplinary
approach involving orthodontics and periodontics often
involves maintaining a healthy periodontium and treatment
of modalities like correction of midline diastema due to
high frenal attachment,2 supracrestal fiberotomy3 after
completion of orthodontic treatment to prevent relapse, and
soon. But the continuous endeavor for innovation of newer
interdisciplinary treatment modalities has resulted in the use
of a passive object like 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

Keywords: Gingival recession, Coronally advanced flap,
Orthodontic button.
How to cite this article: Maroo S, Grover HS, Luthra S. Button-
assisted Coronally Advanced Flap: An Innovative Ortho-perio
Amalgamation. J Ind Orthod Soc 2014;48(2):133-137.
Source of support: Nil
Conflict of interest: None
1,3
Resident, 2Professor and Head
1-3
Department of Periodontics and Oral Implantology, SGT
Dental College, Hospital and Research Institute, Gurgaon
Haryana, India
Corresponding Author: Shailly Luthra, Resident, Department
of Periodontics and Oral Implantology, SGT Dental College
Hospital and Research Institute, Gurgaon, Haryana, India, e-mail:
shaillyluthra@gmail.com
A 40-year-old male patient reported to the outpatient
department of SGT Dental College, Hospital and Research
Institute, Gurgaon with a chief complaint of sensitivity to
hot and cold fluids in upper left front teeth region since
2 months along with a concern for his receding gums. Patient
was a nonsmoker, systemically healthy, and had not been on
any medications.
On clinical (Figs 1 and 2) and radiographic examination
(Fig. 3)-Millers Class III gingival recession along with
tooth abrasion was diagnosed in relation to 23, 24, and 25.
The gingival biotype of the patient was thick. The patient
underwent a session of oral prophylaxis along with instruc
tion for maintenance of oral hygiene. Glass ionomer cement
restorations were done in relation to the above-mentioned
teeth.

The Journal of Indian Orthodontic Society, April-June 2014;48(2):133-137 133

Shruti Maroo et al

The following clinical measurements were taken to the

Fig. 1: Preoperative photograph showing
gingival recession on 23
nearest millimeter for the above-mentioned teeth at baseline
(before surgery after initial periodontal therapy) 1 and
3 months after surgery (Table 1).
1. Gingival recession depth (GRD), measured as the
distance between the most apical point of the CEJ and
the gingival margin (GM).
2. Gingival recession width (GRW), measured as the dis
tance between the mesial GM and the distal GM of the
tooth (measurement was recorded on a horizontal line
tangential at the CEJ).
3. Probing depth (PD), measured as the distance from the
GM to the bottom of the gingival sulcus.
4. Clinical attachment level (CAL), measured as the
distance from the CEJ to the bottom of the sulcus.
5. Apicocoronal width of keratinized tissue (KTW), mea
sured as the distance from the mucogingival junction
(MGJ) to the GM, with MGJ location determined using
a visual method.
6. Recession depth reduction.
7. Complete/Partial Root Coverage.
GRD, PD, CAL, and KTW measurements were perfor
med at the midbuccal point of the involved teeth. A Hu-
Friedy periodontal probe (UNC-15 periodontal probe) was
used for all clinical measurements.
Before the surgery, orthodontic buttons were applied on
each of the above-mentioned teeth with flowable composite
on the middle 1/3rd of the facial aspect of the tooth after
etching and bonding (Fig. 4).

Surgical Procedure
Fig. 2: Preoperative photograph showing gingival recession on
23 along with stent recordings
After administration of local anesthesia (Xylocaine with
0.2% adrenaline), a horizontal incision was given starting
from tooth 22 to 24 (Fig. 5). The papillae were elevated as
split thickness flap, followed by full thickness flap apical

Table 1: Clinical parameters at baseline, 1 and

3 months postsurgery
Baseline 1 month 3 months
23 23 23
GRD (mm) 2 0 0
GRW (mm) 3 0 0
PD (mm) 1 3 2
CAL (mm) 3 3 2
APW (mm) 5 5 6
Recession depth 2 2
reduction
Root coverage (%) 100% 100%
(23 represents the tooth number according to FDI. APW: apico-
coronal width of keratinized tissue); CAL: Clinical attachment
level; GRD: Gingival recession depth; GRW: Gingival recession
Fig. 3: Intraoral periapical X-ray of #23 showing interdental bone loss width; PD: Pocket depth

134
 JIOS

Button-assisted Coronally Advanced Flap: An Innovative Ortho-perio Amalgamation

Fig. 4: Orthodontic buttons fixed on the teeth Fig. 5: Horizontal incisions were given from #22 to #24

Fig. 6: The flap extending from #22 to #24 elevated with a split- Fig. 7: Flap positioned coronally and held in place with
full-split technique suspended sutures around the orthodontic buttons

to the root exposures terminating till 3 to 4 mm apical to

the bone dehiscence exposing denuded bone. The apical
most portion of the flap was undermined to convert it to a
split thickness flap, facilitating coronal displacement of the
flap. The anatomic interdental papillae were deepithelialized
(Fig. 6). The central area of the CAF was stabilized using
suspensory sling sutures [with 5-0 Ethicon-(NW-3316)] on the
buttons. The surgical papilla was stabilized using loop sutures
(with 5-0 Ethicon-(NW-3316) over the interdental connective
tissue bed. The final position of the flap was overcorrected to
be at least 3 to 4 mm coronal to the CEJ of all teeth at the end
of the surgery to compensate for the expected postsurgical
wound contracture (Fig. 7). A periodontal dressing was applied
Fig. 8: Coe-Pak placed to protect sutures and surgical site
to prevent any mechanical trauma (Fig. 8).
daily for the first 15 days. Only soft food diet for the first
Postsurgical Treatment and Follow-up
week was advised. The sutures, buttons, and periodontal
Postoperative instructions were given. The patient was dressing were removed 14 days after surgery (Fig. 9).
instructed to avoid brushing and flossing in the area of The patients were instructed to resume mechanical tooth
surgery and to consume only soft food during the first week. cleaning of the treated areas using a soft toothbrush and a
Amoxicillin 500 mg TDS and Ibuprofen 400 mg TDS for 5 careful roll technique after 3 weeks of surgery was recalled
days were prescribed to the patient. A 0.2% chlorhexidine for prophylaxis 2 and 4 weeks after suture removal. The
digluconate mouth rinse was prescribed 4 times (60 seconds) patient was evaluated at 1 month (Fig. 10) and 3 months
The Journal of Indian Orthodontic Society, April-June 2014;48(2):133-137 135
Shruti Maroo et al
Fig. 9: Fifteen days postoperatively
Fig. 11: Three months postoperatively
postoperatively (Figs 11 and 12). The recall showed unevent
ful healing along with root coverage with reduction of dentin
hypersensitivity without any probing defect or significant
complication.
Discussion
It has been demonstrated that the initial adhesion of the clot
to the root surface is of critical importance in the healing
process.4 A thin clot promotes tensile strength and stability
of the wound. The surgical technique and the early post
operative period are the keystones to achieving successful
root coverage.
In conventional root coverage procedure, as proposed by
Sanctis and Zuchelli in 2007, a split-full-split flap is raised
along with vertical-releasing incisions (VRIs) extending
beyond mucogingival junctions. 5 These VRIs provide
stability to the flap, but it has disadvantages which includes
damage to lateral blood supply, unesthetic visible white
scars. It has also been reported that there is less increase in
apicocoronal width on keratinized tissue because VRI delays
or disturbs realignment of mucogingival junction. Absence
of VRI limits bleeding during surgery which decreases
136
Fig. 10: One month postoperatively
Fig. 12: Three months postoperatively with stent recordings
surgical time and forces blood clot stabilization.6 So in
order to avoid these adverse effects VRI was eliminated and
orthodontic buttons were used.
Orthodontic buttons are routinely used by the ortho
dontists as an inactive component to provide strong bond for
attachment of accessories such as elastics. In this case, these
have been used as a passive component for holding sutures so
as to provide maximum stability to the flap in the coronally
displaced position during 2 weeks of wound healing.
The split-thickness elevation at the level of the surgical
papilla guarantees anchorage and blood supply in the inter
proximal areas mesial and distal to the root exposure; the
full-thickness portion, by including the periosteum, confers
more thickness, and thus better opportunity to achieve root
coverage, to that portion of the flap residing over the previ
ously exposed avascular root surface; the more apical split-
thickness flap elevation facilitates the coronal displacement
of the flap. Therefore, optimum root coverage results, good
color blending of the treated area with respect to adjacent
soft tissues and complete recovery of the original (presur
gical) soft tissue marginal morphology can be predictably
accomplished by means of this surgical approach.7

Button-assisted Coronally Advanced Flap: An Innovative Ortho-perio Amalgamation
The presence of the restoration on the cervical area does
not prevent soft tissue coverage by the CAF.8 Instead, it
eliminates excessive convexity of the root surface and flap
is better adapted and sutured without tension.9
According to Pini-Prato only partial root coverage (70%
to 75%) can be accomplished in Class III defects.10 Using
this method, a 100% root coverage was obtained in a Millers
Class III recession. Furthermore, the postoperative course was
less troublesome for the patient as no other surgical sites was
involved. Besides, the costs of mucogingival operations may
increase when other biomaterials materials such as acellular
dermal matrix, enamel matrix derivative, and bioabsorbable
membrane are included. Orthodontic buttons on the contrary
provide a cost-effective alternate and application of these
buttons on the teeth was convenient and easily acceptable.7
Conclusion
Interdisciplinary approach helps the specialists of contributing
disciplines immensely in diagnosis, treatment planning,
execution of planned treatment, and problem solving for
any untoward complication. Orthodontic treatment may
be adjunctive to periodontal therapy or vice versa. The
results showed that the usage of the orthodontic buttons
and suspended sutures with CAF technique was effective in
gingival recessions. The 3 months results of this case report
were very promising in terms of both clinical (root coverage,
esthetics, keratinized tissue height) and patient-centered
(esthetics) parameters.
The Journal of Indian Orthodontic Society, April-June 2014;48(2):133-137
JIOS
References
1. Ravon NA, Handelsman M, Levine D. Multidisciplinary care:
periodontal aspects to treatment planning the anterior esthetic
zone. J Calif Dent Assoc 2008;36:575-584.
2. Mahamuni AR, Baghele ON. Perio-ortho interdisciplinary
management for midline diastema related to abnormal
frenumA case report. JIDA 2010;4:554-555.
3. Yoshinuma N, Sato S, Makino N, Saito Y, Ito K. Orthodontic
extrusion with palatal circumferential supracrestal fiberotomy
improves facial gingival symmetry: a report of two cases. J Oral
Sci 2009;51:651-654.
4. Wikesj UME, Nilveus RE, Selvig KA. Significance of early
healing events on periodontal repair: a review. J Periodontol
1992;63:158-165.
5. De Sanctis, Zucchelli G. Coronally advanced flap: a modified
surgical approach for isolated recession-type defects. Three year
results. J Clin Periodontol 2007;34:262-268.
6. Zucchelli G, Mele M, Mazzotti C, Marzadori M, Montebugnoli
L, De Sanctis M. Coronally advanced flap with and without
vertical releasing incisions for the treatment of multiple gingival
recessions: a comparative controlled randomized clinical trial.
J Periodontol 2009;80:1083-1094.
7. 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:
572-580.
8. Thanik SD, Bissada NF. Clinical study of connective tissue
grafts for root coverage on teeth with cervical lesions with and
without restoration. J Dent Res 1999;78:119.
9. Miller PD Jr. Root coverage with the free gingival graft. Factors
associated with incomplete coverage. J Periodontol 1987;58:
674-681.
10. Wennstrm JL, Pini Prato GP. Mucogingival therapy. In: Lindhe J,
Karring T, Lang NP, editors. Clinical periodontology and implant
dentistry. 3rd ed. Copenhagen: Munksgaard, 1997:550-596.
137