| Abstract|| |
The frenum exerts a pull upon the tissue and can lead to the continuation of the lesion, and the keratinized tissue provides increased resistance to the periodontium. Various techniques have been used to deepen the vestibule and increase the keratinized mucosa. However, there is no case report on correcting the frenal pull and increasing the keratinized mucosa around dental implant using denudation procedure. This article presents a case of frenal pull that was corrected with denudation procedure with the incision line within the keratinized tissue.
Keywords: Denudation, dental implant, keratinized mucosa
|How to cite this article:|
Park JB. Correcting the frenal pull and increasing the width of keratinized mucosa around endosseous implants using denudation procedure. Indian J Dent Res 2008;19:362-5
The frenum exerts a pull upon the tissue and can lead to the continuation of the lesion,  and the keratinized tissue provides increased resistance to the periodontium, contributes to the stabilization of the gingival margin position, and aids in the dissipation of physiological forces. 
|How to cite this URL:|
Park JB. Correcting the frenal pull and increasing the width of keratinized mucosa around endosseous implants using denudation procedure. Indian J Dent Res [serial online] 2008 [cited 2020 May 28];19:362-5. Available from: http://www.ijdr.in/text.asp?2008/19/4/362/44527
Various techniques have been used to deepen the vestibule and increase the keratinized mucosa. , There is no published case report on correcting the frenal pull and increasing the keratinized mucosa around the dental implant using denudation procedure.
Here I report a case of frenal pull that was corrected with denudation procedure with the incision line within the keratinized tissue.
| Case Report|| |
A 54-year-old male patient was referred to the Department of Periodontology at the Armed Forces Capital Hospital, Seongnam-si, Korea for evaluation of the upper left molar area. The patient experienced discomfort on his oral mucosa during tooth brushing and complained of reduced space for the tongue. On intraoral examination, there was a frenal pull in the upper left molar area and the keratinized tissue on the most mesial implant was 2 mm [Figure 1]. There was no periodontal defect or bleeding on probing. The modified plaque and gingival indices were one and zero, respectively.  The patient did not have any other medical conditions and was not on any medications that were associated with a compromised, soft healing response. The decision was made to apically displace the attachment of the frenulum and augment the gingival zone through the denudation procedure. The patient's consent was obtained after a detailed explanation concerning the present state, alternative treatment plans, and the surgical procedure was given.
Immediately before the procedure, the patient rinsed for two minutes with 0.12% chlorhexidine digluconate solution (Hexamedine, Bukwang, Seoul, Korea). Following an injection of 2% lidocaine with 1:100,000 epinephrine local anesthetic, a horizontal incision was made within the keratinized tissue, 1 mm above mucogingival junction. The horizontal incision was made distal to mesial, and then the incision continued vertically beyond mucogingival junction. A full-thickness flap was reflected [Figure 2] and the reflected flap was sectioned to dislocate the connective tissue from the periosteum [Figure 3]. Efforts were made to expose as much bone as possible in the area between the initial horizontal incision and the coronal margin of the flap. The periosteum was secured with sling sutures to the crown [Figure 4], and the overlying flap was secured with interrupted sutures [Figure 5].
A periodontal dressing (COE-PACK, GC, Tokyo, Japan) was applied, and routine postoperative instructions were given. The patient was placed on a five day course of amoxicillin 500 mg three times a day, mefenamic acid 500 mg initially, and then mefenamic acid 250 mg four times aday; and chlorhexidine digluconate 0.12% three times a day for 2 weeks. The patient was asked not to chew or brush the surgical area for the first four weeks postoperatively. Ten days after surgery, the periodontal dressing and any remaining sutures were removed, and the grafted area was carefully cleaned with a 0.12% chlorhexidine solution [Figure 6]. The patient received oral hygiene instructions and was shown how to achieve a roll-stroke brushing technique. No major postoperative complications developed and the pain levels reported by the patient were minimal. The patient was followed-up regularly to monitor healing and for plaque control. The evaluation at three months after surgery showed that the probing depth was 3 mm and the average increase of keratinized tissue was 4 mm [Figure 7]. The frenal pull had been overcome and the patient was satisfied with the results.
| Discussion|| |
The need for keratinized tissue around endosseous implants is a controversial topic. It has been suggested that the indication for gingival augmentation is discomfort during tooth brushing and/or chewing.  There is another report on teeth with subgingival restorations and narrow zones of keratinized gingiva showing statistically significant higher gingival scores compared to teeth with submarginal restorations and wide zones of keratinized gingiva.  It was also suggested that proper oral hygiene procedure may be facilitated in the presence of an adequate band of keratinized mucosa. 
Various techniques have been used to deepen the vestibule and increase the keratinized mucosa. In this case report, denudation procedure was used to correct frenal pull and to increase keratinized tissue without significant complications. The main advantages over an autogenous masticatory mucosal graft (free gingival graft (FGG)), is that it does not need palatal donor tissue and it makes the procedure simpler and less invasive. The shrinkage of FGGs is a well-known clinical phenomenon that occurs during wound healing in the first postoperative month.  Hatipoπlu et al., evaluated the vertical dimensional changes of FGGs at 10, 21, and 180 days of follow-up and the mean shrinkage of the graft size was 15.8%, 19.7%, and 24.8%;  Also, larger graft from palate is needed considering shrinkage of graft.
It was reported that when there were adequate marrow spaces interdentally, restoration of bone may be achieved, but the thinnest radicular bone area demonstrated greater bone loss postoperatively. , Bone denudation procedure could be performed in this case because there was sufficient bone on the buccal side, which could be confirmed in the sagittal section of the computed tomography after delivery of prosthesis. In addition, the incision line was made below the coronal area to reduce the bone resorption in the coronal area. However, the reduced blood supply on the coronal part may have caused postoperative gingival recession.
Karring et al., studied the wound healing events of denudation procedure and reported that granulation tissue originated from the residual periosteal connective tissue, periodontal ligament, bone marrow space, and the adjacent gingival and alveolar mucosa.  In this case, the incision was made within keratinized tissue and full perimeter of the exposed bone immediately after surgery was mostly surrounded by keratinized tissue, and this led to the formation of new keratinized tissue. In this way, efforts were made to minimize the effect from possible remaining alveolar mucosa and maximize the effect from the surrounding keratinized tissue. The authors also mentioned about sequential responses after denudation procedure and keratinized epithelium could be found on day 9.  In this case, the periodontal dressing was removed 10 days after surgery and the denuded area was almost covered by soft tissue and the pain level was reported to be minimal.
Periodontal dressing was used in this case as it protects the surgical site from trauma and enhances the patient comfort by covering exposed bone and connective tissue.  It also gives a psychological feeling of protection and well-being with its use.  Noneugenol dressing was used to minimize the irritation. 
| Conclusion|| |
The treatment site showed good healing with increase in keratinized tissue without probing or significant complications. The denudation procedure could be applied to correct the frenal pull and to increase the width of keratinized tissue around implant.
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Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]