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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 74-78

Think lateral, think thick!: A novel technique for recession coverage by lateral pedicle flap obtained from edentulous area along with subepithelial connective tissue graft


Department of Periodontics, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belagavi, Karnataka, India

Date of Submission07-Aug-2020
Date of Decision13-Apr-2022
Date of Acceptance31-May-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. Shruti Paradkar
584, Yogesh, S.V Road, Near S.T. Colony, Ratnagiri - 415 612, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_61_20

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   Abstract 

Treatment of gingival recession is a prime concern due to an increase in hypersensitivity and high esthetic demands. There are various proposed treatment options for treating this mucogingival defect. Treating Miller's Class III recession is definitely a true challenge for the periodontists. Defects adjacent to the edentulous region, present with additional difficulty due to collapse of ridge postextraction, leading to the gingival defect. Here is a case report, presenting Class III recession defect adjacent to the edentulous site of the lower left second premolar, which was treated with the help of lateral pedicle flap obtained from the adjacent edentulous area along with subepithelial connective tissue graft, a bilaminar technique.

Keywords: Gingival recession, Pedicle flap, Periodontium


How to cite this article:
Paradkar S, Shivanaikar S, Das S, Rathod K. Think lateral, think thick!: A novel technique for recession coverage by lateral pedicle flap obtained from edentulous area along with subepithelial connective tissue graft. J Interdiscip Dentistry 2022;12:74-8

How to cite this URL:
Paradkar S, Shivanaikar S, Das S, Rathod K. Think lateral, think thick!: A novel technique for recession coverage by lateral pedicle flap obtained from edentulous area along with subepithelial connective tissue graft. J Interdiscip Dentistry [serial online] 2022 [cited 2022 Oct 4];12:74-8. Available from: https://www.jidonline.com/text.asp?2022/12/2/74/354453


   Clinical Relevance to Interdisciplinary Dentistry Top


  • Combination of lateral pedicle graft and subepithelial connective tissue graft used from the adjacent edentulous region for correction of the defect, which provides the following benefits:
  • Less technique sensitive
  • Single surgical site
  • Maintenance of plasmatic blood circulation
  • Excellent blending of color and morphology of the transpositioned tissue.
  • Gain in the keratinized tissue
  • Transformation of thin biotype into thick gingival biotype.



   Introduction Top


Deepening of the gingival tissue remains a major prevalent issue due to increasing esthetic apprehensions, root hypersensitivity, and trouble in oral hygiene maintenance. Gingival recession is an apical shift of the gingival margin from its position 1–2 mm coronal to or at the level of cementoenamel junction (CEJ) with exposure of the root surface to the oral cavity.[1] Consequence of gingival recession involves inability of nonkeratinized tissue to firmly bound to the underlying periosteum, leading to failure in withstanding daily insult of tooth brushing and masticatory forces.[2] The increasing concern has led to the unearthing of various innovative techniques to replace the lost, damaged, and diseased gingival tissues. The use of these techniques, in combination with tissue grafts or biomaterials, has been suggested to increase the predictability of clinical outcomes by increasing attached gingiva, flap thickness, and guiding tissue growth.[3]

Among several techniques, the lateral pedicle flap (LPF) is one of the efficacious modality for covering gingival recession of one or more teeth, permitting better esthetics, increasing keratinized gingiva, and decreasing hypersensitivity and cervical caries. Grupe and Warren first described LPF as a surgical method that helped in mending gingival recessions by sliding the full thickness flap laterally to cover the denuded root, through maintenance of the blood supply to the transpositioned tissue apically.[4] However, additional recession and bone loss in the donor area, lead to various modifications of this technique with the use of submarginal incision at the donor site to prevent denuded osseous surfaces made by Grupe and Warren 1966 and Espinel in 1981;[5] split-thickness flap to minimize recession at donor site given by Staffileno in 1964;[6] making cut back incision at the base of the flap to minimize the tension was given by Corn in 1964; and usage of the free graft to cover the donor area by Knowles and Ramfjord in 1971.[7]

Even though the recession coverage falling into the first category of Miller's classification associated with inadequate keratinized tissue can be generally corrected easily with straight-forward procedures, treating those with or without loss of interdental tissues (Miller's Class II, III, or IV) still remains a challenge.[8]

The following case report highlights the management of an isolated Miller's Class III gingival recession in relation to a mandibular second premolar with the help of lateral pedicle graft obtained from adjacent edentulous site along with subepithelial connective tissue graft.


   Case Report Top


A 23-year-old female, with noncontributory medical history presented with a complaint of receding gums and hypersensitivity associated with the left mandibular second premolar (#35). Intraoral examination revealed a gingival recession depth of 6 mm and width of 4mm on the facial aspect (measurement performed with UNC-15 periodontal probe) was observed [Figure 1]. The tooth was vital and nonmobile. The patient gave a history of lower left first molar (#36) extraction 3 years back due to caries. When examined radiographically, 1 mm of interdental bone loss on the mesial aspect of the second premolar was evident. Based on the interproximal attachment loss, Class III gingival recession according to Miller's classification was diagnosed. The patient opted for surgical recession coverage of the defect. Sufficient thickness, width, and length of keratinized tissue at the adjacent edentulous region rendered suitable as donor site. Thus, LPF with the subepithelial connective tissue graft (SCTG) as a bilaminar technique was planned for the root coverage.
Figure 1: Clinical preoperative photograph showing gingival recession defect with 6mm in relation to #35

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Surgical management

After phase 1 therapy comprising thorough scaling and root planing, the surgical procedure was explained to the patient and informed consent was obtained. On the day of procedure, the patient was asked to rinse with 10 ml of 0.2% chlorhexidine solution. The surgical site was anesthetized using 2% lignocaine HCl with adrenaline (1:200,000). The exposed root of the second premolar was scaled and planned to reduce the root prominence. Number 15 C blade was used to prepare the recipient bed by de-epithelizing the area adjacent to the recession site [Figure 2]. Mid-crestal incision was made on the adjacent edentulous area and further extended to make a crevicular incision crossing area apical to the recession defect. Vertical releasing incisions, one at the distal line angle of the #35 and the other mesial to #37, were made extending the alveolar mucosa to enable sufficient displacement of the pedicle flap. Partial-thickness flap was reflected making sure that the donor flap size was 1.5 times wider than the area of the recession [Figure 3]. Flap tension was minimized by providing a cut-back incision at the base of the flap.
Figure 2: Preparation of recipient bed

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Figure 3: Laterally pedicle flap of partial thickness reflected from adjacent edentulous site

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After profound anesthesia, the donor tissue site for palatal SCTG was selected from the area distal to canine and mesial to the maxillary first molar. The “Trap-door” technique was employed to harvest the SCTG by marking the desired size with the help of tin foil template.[9] The obtained SCTG was trimmed, adapted, immobilized immediately on the exposed root surface, at the level of the cementoenamel junction, and sutured to the periosteum with the help of 4.0 vicryl suture [Figure 4]. The donor site was secured with interrupted sutures, and a surgical stent was placed to facilitate the hemostasis and the patient comfort. The reflected sliding pedicle flap was rotated laterally to completely cover both, the graft and the defect by extending 2 mm coronally to the cementoenamel junction and sutured with sling and interrupted sutures to avoid the movement [Figure 5]. The surgical area was covered with the periodontal dressing after thorough irrigation. The patient was prescribed with amoxicillin 500 mg and ibuprofen 400 mg thrice daily for 5 days. The patient was refrained from brushing at the surgical site for 2 weeks and was advised to rinse with 0.12% chlorhexidine gluconate twice daily for 2 weeks.
Figure 4: Sub-epithelial connective tissue graft harvested, trimmed and transferred to the recipient site and immobilized at the level of the CEJ. CEJ: Cementoenamel junction

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Figure 5: The flap rotated laterally to completely cover the graft and the defect and sutured with sling and interrupted sutures

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Clinical outcomes

For the postoperative follow-up, the patient was called every week for the first 1 month and later every 3 months. Healing was uneventful. Sutures were removed after 15 days. After 1 month postsurgery, partial recession coverage of 3 mm was attained, along with 2 mm of gain in keratinized gingiva and 1 mm of attached gingiva [Figure 6] and [Figure 7]. After 6 months, recession coverage increased up to 4 mm probably due to creeping attachment.
Figure 6: Clinical postoperative picture showing uneventful healing after follow-up 2 weeks

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Figure 7: Clinical postoperative picture after 6 months showing gain in keratinized tissue and partial root coverage

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   Discussion Top


Factors contributing gingival recession comprise periodontal disease, improper oral hygiene measures, thin gingival biotype, prominent root surface, buccally positioned teeth, frenum pull, and bone dehiscences.[3] Moreover, extraction results in bone resorption, evident on the buccal aspect of the tooth,[10],[11] causing the collapse of the alveolar process, and leaving the gingival cleft adjacent to the extraction site.[12] Gingival recession seen in the present case report can be attributed to traumatic extraction of 36 leading to the collapse of the alveolar ridge.

The presence of the adjacent edentulous site with a thick gingival biotype of 3 mm and sufficient keratinized tissue, made it appropriate to choose the LPF approach to cover the gingival recession in this case. This procedure offered various advantages over other root coverage procedures including less technique sensitive, single surgical site, excellent blending of color, and morphology of the transpositioned tissue. Adequate tissue availability from the neighboring edentulous site helped in achieving primary closure with uneventful healing. This procedure gave a satisfactory outcome, wherein the patient was relieved of sensitivity.

Use of SCTG was made in this case report along with LPF as a bilaminar technique.[13],[14] LPF in combination with[14],[15] or without SCTG has been suggested by various authors.[16],[17] This combination is beneficial in improving root coverage, reducing the chances of the gingival recession of the flap elevation site,[17] and retaining the benefits of the LPF technique such as flap flexibility and sufficient width of keratinized gingiva. LPF ensures that SCTG is enclosed by a gingival flap; provides sufficient blood supply laterally to increase the plasmatic circulation during initial healing.[18] The present root coverage result was comparable with other studies. Langer and Langer reported an increase in root coverage of 2–6 mm by SCTG technique in which graft was placed over exposed root surface underneath the split-thickness coronally positioned flap.[19]

Literature suggests that SCTG-based procedures significantly benefit the Class III gingival defects, however, the marginal level of gingival tissue of teeth adjacent to the recession defects seems to affect the coverage and should be considered a reference point. Furthermore, the use of SCTG aids in transforming the periodontally thin biotypes into thick biotypes and increasing the amount of keratinized tissue,[20] which can be related in the present case report.

Two cases of similar kind have been reported previously where LPF was obtained from adjacent edentulous regions.[21],[22] To the best of our knowledge, this is the first case report where LPF obtained from the adjacent edentulous region was used along with the SCTG (bilaminar technique) for covering the gingival recession defect, which resulted in adequate gain in keratinized gingiva and have attained partial root coverage. Owing to the greater recession width (of about 4 mm), complete root coverage could not be accomplished, however, sufficient gain in keratinized tissue was achieved.

To summarize, this technique can be considered reliable and predictable treatment modality for root coverage and increasing the width of attached gingiva for management of Class III recession defects. Furthermore, it needs to be emphasized upon short-term follow-up of 6 months in this case study, various long-term studies are needed to be conducted to provide solid evidence in the predictability of this technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wennstrom JL. Mucogingival surgery. In: Lang NP, Karring T, editors. Volume 21, 6th ed. Proceedings of the 1st European Workshop on Periodontology. Berlin: Quintessence Publisher; 1994. p. 139-209.  Back to cited text no. 1
    
2.
Khocht A, Simon G, Person P, Denepitiya JL. Gingival recession in relation to history of hard toothbrush use. J Periodontol 1993;64:900-5.  Back to cited text no. 2
    
3.
Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery procedures in the treatment of localized facial gingival recessions: A systematic review. J Clin Periodontol 2014;41 Suppl 15:S44-62.  Back to cited text no. 3
    
4.
Grupe HE, Warren RF. Repair of gingival defects by a sliding flap operation. J Periodontol 1956;27:92-5.  Back to cited text no. 4
    
5.
Espinel MC, Caffesse RG. Lateral positioned pedicle sliding flap revised technique in the treatment of localized gingival recessions. Int J Periodontal Restorative Dent 1981;1:43-51.  Back to cited text no. 5
    
6.
Staffileno H. Management of gingival recession and root exposure problems associated with periodontal disease. Dent Clin North Am 1964;3:111-20.  Back to cited text no. 6
    
7.
Knowles J, Ramfjord S. The lateral sliding flap with free gingival graft. The University of Michigan Schoo of Dentistry, Video Cassette; 1971.  Back to cited text no. 7
    
8.
Miller PD Jr. A classification of marginal gingival recession. Int J Periodontics Restorative Dent 1985;5:8-13.  Back to cited text no. 8
    
9.
Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method of obtaining root coverage. J Periodontol 1992;63:477-86.  Back to cited text no. 9
    
10.
Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212-8.  Back to cited text no. 10
    
11.
Atwood DA. Postextraction changes in the adult mandible as illustrated by microradiographs of midsagittal sections and serial cephalometric roentgenograms. J Prosthet Dent 1963;13:810-24.  Back to cited text no. 11
    
12.
Cohen N, Cohen-Levy J. Healing processes following tooth extraction in orthodontic cases. J Dentofacial Anom Orthod 2014;17:304.  Back to cited text no. 12
    
13.
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. 13
    
14.
Nelson SW. The subpedicle connective tissue graft: A bilaminar re-constructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102.  Back to cited text no. 14
    
15.
Borghetti A, Louise F. Controlled clinical evaluation of the subpedicle connective tissue graft for the coverage of gingival recession. J Periodontol 1994;65:1107-12.  Back to cited text no. 15
    
16.
Smukler H. Laterally positioned mucoperiosteal pedicle grafts in the treatment of denuded roots: A clinical and statistical study. J Periodontol 1976;47:590-5.  Back to cited text no. 16
    
17.
Zucchelli G, Cesari C, Amore C, Montebugnoli L, De Sanctis M. Laterally moved, coronally advanced flap: A modified surgical ap¬proach for isolated recession-type defects. J Periodontol 2004;75:1734-41.  Back to cited text no. 17
    
18.
Gordon HP, Sullivan HC, Atkins JH. Free autogenous gingival grafts. II. Supplemental findings: histology of the graft site. Periodontics 1968;6:130-3.  Back to cited text no. 18
    
19.
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.  Back to cited text no. 19
    
20.
Chambrone L, Tatakis D.Periodontal soft tissue root coverage procedures: A systematic review from AAP regeneration workshop. J Periodontol 2015;86(Suppl.):S8-S51.  Back to cited text no. 20
    
21.
Priyadharshini V, Triveni MG, Mehta DS. Management of gingival recession in mandibular molar using lateral pedicle flap technique. Int J Oral Health Sci 2016;6:96-9.  Back to cited text no. 21
  [Full text]  
22.
Noorudeen AM, Paul AM, Shereef M. Six year follow-up of a root coverage procedure on a lower molar tooth with lateral pedicle flap. J Indian Soc Periodontol 2013;17:661-4.  Back to cited text no. 22
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