Case Presentation

A 38 year old male patient presented with a chief complaint of mobile tooth in the upper right front tooth region for the past 6months with an occasional history of bleeding gum on brushing for the past 6 months. He was systemically healthy and hadno apparent relevant medical history and no deleterious habits. Clinical examination revealed fiery red coloured gingiva, soft and oedematous in consistency with enlargement interdental papilla and swollen marginal gingival in 11,12,13,21,22, 23, 31,32,41,42.Periodontal examination revealed a probing depth of around5mm uniformly on Buccal aspect, with a clinical attachment loss of9mm on disto-buccal aspect of 11 and 8mm on mesio-buccal and mid-buccal aspect.There was also minimal width of keratinised tissue in relation to the incisor with grade-3 mobility, supra-eruption and exudation from gingival sulcus in relation to 11,12,21,22. Clinical and radiographic examination of 11 was done which revealed a periapical radiolucency in relation to 11 (absence of alveolar socket) with bilateral vertical bone loss and no periodontal bone support, ruling out initial treatment plan of surgical reimplantation. Cold test was done on the incisor using tetra-fluoro ethylene followed by electronic pulp tester was used to check vitality in relation to 11 further confirmed by. A treatment plan was formulated, as per which patient education, scaling, root planning was done followed by which a provisional splint and a full thickness flap would be elevated. Presurgical provisional splint and phase 1The tooth was divided into three halves incisal, middle 3rd and apical, a horizontal groove was then made using a handpiece (diamond abrasives)in relation to 11 alone along the middle third ofthe tooth while other teeth were spared. No 26-gauge stainless steel ligature wire was braided and placed in the labial aspect of11-23 along the middle 3rd of the teeth. The wire was initially stabilised using 3M flowable composite resin followed by permanentA2 body shade for reinforced stability using a Woodpecker curing lamp. Full mouth complete scaling and root planning anaesthesiawas done in two appointments separated by a week interval. Surgical phase Under adequate local anaesthesia Lidocaine with 1:80,000 units of adrenaline, A full thickness Kirkland flap was raised using No15 blade by giving an intra-crevicular incision in relation to buccal aspect of 11-23. A P24 periosteal elevator was used to reflect theflap, debridement was done using Gracey`s curettes while cotton gauge was used to control excessive bleeding. After a thorough debridement Tetracycline 500mg capsule was separated and mixed with normal saline to form a slurry which was then appliedon the root surface of 11 for 5 minutes and then washed away using a three-way syringe. PRF procured using Choukroun`s method was compressed between 2 cotton gauges to form a membrane which was soaked in slurry of tetracycline then placed over the buccal aspect of11 (figure 2) and the flap was then secured using independent sling silk sutures and Coe pack periodontally dressing was then moulded onto the surgical site. The patient was periodically recalled for a follow-up 1 week later, where the periodontal dressing was removed along with the silk suture and the patient was followed for1 year with periodic follow-ups every 3 months, where the splint was re-evaluated and adjustments were made whenever necessary without removing the splint. During 1 year evaluation it was observed that initially red oedematous gingiva had completely healed and matured into attached gingiva despite poor oral hygiene maintenance. (figure 3) The following case series mentions splinting as a method of stabilisation of mobile teeth while simultaneously tries to emphasise the simple fact that no two patients are the same and they all require custom made treatment plans.