Case Report ___________________________________________________

J Res Adv Dent 2013; 2:3:11-15

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Esthetic Zone Root Coverage with Lateral Pedicle Flap - A case Report
Chandramohan Pabolu1* Kiran Kumar Nagubandi2 Arpita Ramisetty3 Ramesh Babu Mutthineni4
1MDS, 2MDS,

Department of Periodontics, Mamata Dental College, Khammam, Andhra Pradesh, India. Department of Periodontics, Mamata Dental College, Khammam, Andhra Pradesh, India. 3MDS, Department of Periodontics, Mamata Dental College, Khammam, Andhra Pradesh, India. 4MDS, Department of Periodontics, Mamata Dental College, Khammam, Andhra Pradesh, India.

ABSTRACT Background: Gingival recession in its localized or generalized form is an undesirable condition resulting in root exposure. Complete root coverage is one of the primary objectives to be considered when treating gingival recessions. Furthermore, aesthetic demands can be satisfied by soft tissue grafts, the thickness and colour of which should not be distinguishable from those of adjacent soft tissue. This article describes a case report in which a pedicle graft technique has been used for root coverage in relation to mandibular left central incisor. Keywords: Gingival recession, Root coverage, Pedicle graft. INTRODUCTION Gingival recession is a common and undesirable condition. It is defined as the displacement of marginal gingival tissue apical to the cemento-enamel junction with exposure of root surface to the oral environment1. More than 50% of population has one or more sites of gingival recession 1 mm2.The gingival recession is found most commonly on buccal surface as a result of vigorous tooth brushing, whereas it may affect other tooth surface in population with poor oral hygiene3. It has been proposed that recession is multi-factorial, with one type being associated with anatomic factors such as bone dehiscence, malpositioning of teeth, trauma associated with malocclusion. Another type of recession is associated with physiological (aging) or pathological factors (where it occurs as part of pathogenesis of periodontal disease or smoking)3-4. In studying the etiology of gingival recession Gronman5 concluded that tooth malalignment and tooth brushing are most common factors associated with gingival recession. Sangnes and Gjermo6 confrimed that different types of traumatic injuries may result in a variety of gingival lesions. The mechanism by which gingival recession occurs is still unclear; however, it seems that gingival recession probably occurs in the presence of inflammation. Tissue destruction in plaqueinduced periodontal disease in different scenarios causes apical migration of the epithelium and destruction of the periodontal ligament along with bone resorption. Therefore gingival recession may be a consequence of this stage of disease, or it may be seen as a part of the healing process in response to periodontal treatment. Which results in reduction of probing depth and shrinkage of the tissue that leads to tightening of the gingival cuff and formation of long junctional epithelium3. The histological study by Smukler and Landberg7 revealed that gingival recession resulting from faulty tooth brushing is attributed to typical reaction of epithelium and connective tissue to

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Fig 1(a,b): Millers class II gingival recession in relation to 31.

Fig 6: Coe-pack Periodontal dressing placed.

Fig 2(a,b): Initial V shaped incision around the denuded root 31.

Fig 3(a,b): Sulcular incision &vertical incision in relation to 32.

Fig 7: 6 month Post-operative view. injury where the reactive hyperkeratotic epithelium is acanthotic. Therefore, the superficial layer loses its adhesiveness and spontaneously desquamates or are easily dislodged by sustained tooth brush abuse. The inflammatory changes in the subepithelial connective tissue are due to the injury, as induced by the plaque, or more likely as a result from the combined process. Plaque accumulation in narrow clefts can perpetuate inflammatory changes in the connective tissue core, which permits the penetration of proliferating dentogingival epithelium until it coalesces with oral epithelia. Moreover, the loss of adhesiveness and encourages desquamation and /or physical removal8. Gingival recession may represent problem to the patient because of poor esthetics, pain, root sensitivity, root caries, root abrasion, plaque retention, gingival bleeding and /or a fear of tooth loss. Therefore, several surgical techniques are described to manage the gingival recession defects including increasing the keratinized tissue, frenectomy and root coverage techniques with

Fig 4(a,b): Pedicle flap reflected

Fig 4(a,b): Flap laterally displaced and sutured

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varied reported clinical effectiveness9. However Takie etal10 stated that prognosis for Miller class I and class II is good to excellent where as partial root coverage can be expected for class III and class IV has very poor prognosis with current techniques. The lateral pedicle graft was described by Grupe and Warren11 in 1956. The purpose was to gain attached gingiva and to cover areas of gingival recession, especially those on the facial surfaces of mandibular anterior teeth. The lateral positioned flap can be used to cover the isolated, denuded roots that have adequate donor tissue laterally and vestibular depth11. CASE REPORT A 17-year old healthy male presented to the department of Periodontics, Mamata dental college with chief complaint of receding gums in the lower front teeth region. On examination there was Millers class II gingival recession in the lower left central incisor region with a recession depth 4mm and Clinical Attachment Loss (CAL) of 6mm. Trauma from occlusion and tooth malposition with respect to the involved tooth was ruled out clinically. Pre surgical protocol Patient was motivated and educated, and oral hygiene instructions were given. Thorough scaling and root planing was done and the patient was periodically recalled to assess his oral hygiene and gingival status before taking up the case for periodontal surgery. Surgical technique Local anesthesia was used to anesthetize the recipient site. The exposed root surface was scaled and planed using curettes to remove plaque, accretions and surface irregularities (fig1, 1a) Prepare the recipient site A no.11 scalpel blade is used to make V- shaped incision around the denuded root, removing the adjacent epithelium and connective tissue (fig-2, 2a) Preparation of donor site The donor flap should be at least 1 1/2 times the size of the recipient area to be covered and 3- 4

times longer the wide. A vertical incision is made with no.11 scalpel blade at the donor site (fig 3, 3a). It is extended far apically into the mucosal tissue to permit adequate mobility of the flap. The base of the flap must be wide to permit adequate vascularity. Sulcular incision extending from the V shaped incision to the vertical incision is made using no.11 blade. The flap is sharply dissected, making sure to carefully preserve all the interproximal papilla ( fig 4, 4a). Preparation of pedicle flap A full thickness pedicle was raised using blunt dissection, the flap should be free enough to permit movement to the recipient site, with no tension. When attempting to position the pedicle flap over the recipient site, if tension is encountered, a cut back or releasing incision is made to dissipate the tension. The pedicle flap is positioned coronally 1 to 2mm on the enamel of the recipient tooth or to the maximum height that the interproximal tissue will allow. Suturing is done using 4-0 silk suture (fig5, 5a). Sling suture is placed, which pull the papilla interproximally and hold the tissue tightly against the neck of the tooth. The area is protected with Coe-Pack. Post Operative Instructions: Patient was instructed to take analgesics and antibiotics and was asked to discontinue the tooth brushing around the surgical site during the initial 30 days after surgery. During this period plaque control was achieved with a 0.2% chlorhexidine mouth rinse used twice a day. After this period, gentle tooth brushing with a soft bristle tooth brush was allowed. Sutures were removed after 10 days and the patient was enrolled in a maintenance programme (professional plaque control and oral hygiene instructions). Uneventful healing was seen at the time of suture removal & in the third and the sixth month post operative visits [Fig 7]. Total root coverage was seen at the time of suture removal & the third month post operative visit. A gain of CAL of 4mm was seen at the sixth month post operative visit. DISCUSSION Root coverage of severe gingival recession has become an important treatment modality

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because of the increasing demand for cosmetic and functional treatment. Over the past decades a variety of regenerative procedures have been used to correct gingival recession. The majority of these procedures consist of periodontal plastic surgical (mucogingival) graft techniques, either alone or in combination with guided tissue regenerative procedures2. Various treatment protocols include Free gingival autograft, Free connective tissue autograft12, Pedicle grafts11 (Laterally positioned, coronally positioned13, semilunar pedicle [Tarnow]), subepithelial connective tissue graft 14, GTR, Pouch and tunnel technique 15. The purpose of this procedure was to evaluate a technique in which pedicle flaps was used to cover the Millers class II gingival recession in the lower left central incisor region (31). Laterally positioned flap have been widely used since Grupe and Warren11 introduced this method for the treatment of localized gingival recession. In this procedure, the adjacent keratinized gingiva is positioned laterally, and the surface of the localized gingival recession is covered. The disadvantage of this method is possible bone loss and gingival recession on the donor site. Guinard and Caffesse 16 reported an average of 1mm of post-operative gingival recession on the adjacent donor site. Therefore lateral pedicle flap is contraindicated where the width, height and thickness of the adjacent keratinized gingiva of the donor tissue is inadequate or where an osseous dehiscence or fenestration exists. Many modification methods of Grupe and Warren have been developed to avoid gingival recession at the donor site. Staffileno17 advocated the use of a partial thickness flap to avoid the recession at the donor site. Grupe18 reported a modified technique to preserve the marginal gingiva by the making a submarginal incision at the donor site. However, laterally positioned full thickness flaps have best prognosis for the exposed root surface coverage. Ruben et al 19 demonstrated the method of partial and full thickness pedicle flap; a full thickness pedicle flap is prepared to cover the root surface and a partial thickness flap is prepared near

the donor site to protect the exposed root surface and to prevent bone loss by preserving periosteum. Knowles and Ramfjord20 used a free autogenously gingival grafts to cover the donor site. Espinel and Caffesse21 compared these two procedures and found minimal gingival recession on the donor site with the free autograft gingival graft. They found that if the free gingival autogenous grafts was used, there was no reduction in the width of the keratinized gingiva on the donor site. If the free gingival autogenous grafts was not used, more than 1mm of keratinized tissue on the donor site was lost. Therefore, laterally repositioned flap with free autogenous grafts on the donor site is most favored currently. Studies on clinical root coverage by the laterally positioned flap reported about 70% of success rate 22. CONCLUSION The case reported here shows that lateral pedicle graft is an effective treatment modality for the management of recession defects affecting teeth in the esthetic zones of the mouth. CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 1. DaprilenG, Gatto M, Checchi L. The evaluation of buccal gingival recession in a student population; A 5- years follow up J Periodontol 2007;78;611- 614. Kassab M, Cohen R. The etiology and the prevalence of gingival recession J Am Dent Assoc 2003;134:220-225. Tugnait A, Clerehugh V. Gingival recession- Its significance and management J Dent 2001; 29; 381-389. Serino G, Wennstrom J, Lindhe J, Eneroth L. The prevalence and distribution of gingival recession in subjects with a high standard oral hygiene. J Clin Periodontol 1994;21:57-63. Gornman W. Prevalence and etiology of gingival recession J periodontal 1967;38:316322.

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Sangnes G, Gjermo P. Prevalence of oral soft and hard tissue lesions related to mechanical tooth cleaning procedure. Community Dent Oral Epidemiol 1976;4;77-83. Smukler H, Landsberg J. The tooth brush and gingival traumatic injury. J Periodontol 1984;55:713-719. Agudio G, Pini Prato G, Cotellino P, Parma S. Gingival lesions caused by improper oral hygiene measures. Int J Periodontics Restorative Dent 1987;7(1):52-65. Wennstrom J. Mucogingival therapy Ann Periodontol 1996;1:671-701.

16. Guinard EA, Caffesse RG. Treatment of localized gingival recessions. Part I. Lateral sliding flap. J Periodontol 1978; 49:351-356. 17. Staffileno H. Management of gingival recession and root exposure problems associated with periodontal disease. Dent Clin North Am 1964;8:111-120. 18. Grupe HE. Modified technique for the sliding flap operation. J Periodontol 1966;37:491-495. 19. Ruben MP, Goldman HA, Janson W. Biological considerations fundamental to successful employment of laterally repositioned pedicle flaps and free autogenous gingival graft in periodontal therapy. In: Stahl SS (ed). Periodontal Surgery. Springfield: CC Thomas, 1976. 20. Knowles J, Ramfjord S. The lateral sliding flap with the free gingival graft. The University of Michigan School of Dentistry, Video Cassette, 1971. 21. Espinel MC, Caffesse RG. Comparison of the results obtained with the laterally positioned pedicle sliding flap- Revised technique and the laterally sliding flap with a free gingival graft technique in the treatment of localized gingival recessions. Int J Periodontics Restorative Dent 1981; 1(6):31-38. 22. Nevins M, Cappetta E. An overview of mucogingival surgery to cover the exposed root surface. In: Nevins M, Mellonig J, eds. Periodontal Thearpy: Clinical Approaches and Evidences of Success. Hanover Park IL: Quintessence Publishing; 1998:339-354.

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10. Takei H, Azzi R. Periodontol plastic and esthestic surgery. In: Carranzas Clinical Periodontology 10th ed. Philadelphia: W.B Saunders; 2006:1005. 11. Grupe HE, Warren RE Repair of gingival defects by a sliding flap operation. J Periodontol 1956;27:92-95. 12. Nabers JM. Free gingival grafts. Periodontics 1966;4:243-245 13. Bernimonlin JP. Luscher B,Muhlemann HR. Coronally positioned flap. Clinical evaluation after one year. J Clinic Periodontal 1975;2:113. 14. Langer B and Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontal 1985;56:715-720. 15. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. Int J Periodontics Restestorative Dent 1994;14:217227.

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