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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 96-99

Management of gingival recession in mandibular molar using lateral pedicle flap technique


1 Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Puducherry, India
2 Department of Periodontology, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Date of Web Publication13-Feb-2017

Correspondence Address:
V Priyadharshini
Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Pillayarkuppam, Puducherry - 607 402
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-6027.199985

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  Abstract 

Gingival recession is a common mucogingival deformity, and various treatment options are available. Patients with exposed root surfaces can possibly develop root sensitivity, root caries, and pose a major esthetic problem. Among various procedures, laterally positioned pedicle graft (LPG) is a widely used technique to cover gingival recession defects. The main advantages of the LPG are that it is relatively easy, not time-consuming, produces excellent esthetic results, and no second surgical site is involved for donor harvesting. This case report presents a case of Class III gingival recession in relation to molar adjacent to an edentulous site that was successfully treated with lateral pedicle technique.

Keywords: Edentulous site, gingival recession, lateral repositioned flap, molar


How to cite this article:
Priyadharshini V, Triveni M G, Mehta D S. Management of gingival recession in mandibular molar using lateral pedicle flap technique. Int J Oral Health Sci 2016;6:96-9

How to cite this URL:
Priyadharshini V, Triveni M G, Mehta D S. Management of gingival recession in mandibular molar using lateral pedicle flap technique. Int J Oral Health Sci [serial online] 2016 [cited 2017 Jul 21];6:96-9. Available from: http://www.ijohsjournal.org/text.asp?2016/6/2/96/199985


  Introduction Top


The vital goal of periodontal plastic surgery is to accomplish a good functioning of the periodontium and an esthetically acceptable gingiva. Though gingival recession can occur without any symptom, it can give rise to pain from exposed dentine, patient's concern about loss of the tooth, poor esthetics, or root decay. It also poses a problem while performing oral hygiene procedures.[1] The morphology of the recession defect and its adjacent tissues dictates the best technique for root coverage which in turn leads to best clinical results. The success of the therapy depends on the long-term maintenance of stable gingival positions.

The lateral pedicle flap (LPF), also called the sliding flap or rotated flap, was first introduced by Grupe and Warren [2] in 1956. It has been well documented that coronally repositioned flap combined with connective tissue graft is the most predictable technique for Miller's Class I and II gingival recession defects.[3],[4],[5] However, this procedure demands the requirement of a second surgical site which can be undesirable for some patients. The LPF technique avoids the need for the second surgical site, and various studies have shown that with an appropriate case selection, this technique is an effective method in treating isolated gingival recession.[6] This case report presents a case of an isolated gingival recession in relation to a mandibular molar adjacent to an edentulous site that was treated successfully with LPF.


  Case Report Top


A 20-year-old male reported to the department of periodontics with the chief complaint of sensitivity in relation to the lower left back tooth. His anamnesis revealed no systemic health problems, and his family history was noncontributory. He gave a dental history of having extracted a tooth adjacent to the sensitive tooth due to decay which healed uneventfully. A thorough clinical examination revealed that the patient had Miller's Class III gingival recession in relation to #36 [Figure 1]. The dimensions of the recession were 4 mm deep and 3 mm wide. Taking advantage of the adjacent keratinized edentulous site, a lateral sliding flap was planned for root coverage.
Figure 1: Class III gingival recession in relation to 36

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Presurgical therapy

The surgical procedure was explained to the patient and an informed consent was obtained. Prior to the surgery, the patient was given oral hygiene instructions, supragingival scaling, and root planing was done. Then, the clinical parameters such as probing depth, recession depth and width were recorded before and after the surgery.

Surgical treatment

After the patient demonstrated an acceptable standard of plaque control, he was scheduled for surgery. Prior to administration of local anesthetic, the patient rinsed his mouth with 15 ml of 0.2% chlorhexidine to reduce the bacterial load. The exposed roots of the recipient teeth were scaled and planed. The surgical site was anesthetized using 2% Xylocaine HCl with adrenaline (1:200,000). The recipient bed was prepared by de-epithelizing the area adjacent to the recession site [Figure 2]. Mid-crestal and vertical incisions were given at the edentulous space adjacent to #36, and a full-thickness mucoperiosteal flap was reflected [Figure 3]. Periosteal releasing incisions were placed to slide the pedicle flap. After appropriately adapting the flap onto the recession site, the flap was sutured with 5-0 prolene suture [Figure 4] and the area was protected with periodontal pack. The patient was instructed to take analgesic (paracetamol and ibuprofen) thrice daily and was advised not to brush in that area for a week but to rinse his mouth with 0.2% chlorhexidine twice daily. During the next 4 weeks, only gentle toothbrushing was permitted.
Figure 2: De-epithelialization of the recipient bed done in relation to 36

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Figure 3: Full-thickness mucoperiosteal flap reflected and laterally positioned in relation to 36

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Figure 4: Suturing of the lateral pedicle flap done

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  Results Top


Healing was uneventful. The patient was called every week for the first 1 month. The sutures were removed after 15 days. Oral hygiene instructions were reinforced at every appointment. Healing after 3 months revealed good amount of attached gingiva with 100% recession coverage and excellent gain in clinical attachment [Figure 5].
Figure 5: Healing after 3 months postoperatively

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  Discussion Top


Gingival recession is defined as the apical migration of the marginal gingival tissue beyond the cementoenamel junction resulting in the exposure of the root surface. The most important factors causing gingival recession are considered to be periodontal disease and improper oral hygiene measures, along with some predisposing factors such as thin gingival biotype, a prominent root surface, buccally positioned teeth, frenum pull, and bone dehiscences.[7] Literatures quote that extraction induces bone resorption that is more significantly seen on the buccal aspect of the tooth.[8],[9] The consequences of simple extraction procedures have not always been accurately evaluated. Various mucosal and osseous complications such as bone resorption with collapse of the alveolar process, a gingival cleft, or gingival recession can arise in the area surrounding the extraction site.[10] In the present case, gingival recession could have happened due to a traumatic extraction of 35. This must have led to the development of gingival recession on the buccal aspect of 36, causing sensitivity to the patient.

The success of any mucogingival surgical procedure depends on the restoration of a healthy periodontal apparatus and is based on four cardinal principles: success, reproducibility, lack of morbidity and economy.[11] If the technique is easier, the more predictable the result becomes as the need for technical skill of the surgeon is reduced. Laterally positioned flap technique was introduced by Grupe and Warren in 1956, and it represents one of the first in the series of procedures designed to cover exposed root surfaces.[12] In 1966, Grupe modified the lateral pedicle technique using submarginal incision at the donor site so that no denuded osseous surfaces would be created.[13] Other modifications of lateral pedicle grafts were given by Staffelino in 1964 who did split thickness flap to minimize recession at donor site, Corn in 1964 did a cutback incision at the base of the flap to minimize the tension in the flap, and Knowles and Ramfjord in 1971 did a free graft to cover the donor area.[14] In the present case, considering the patient's presentation, an LPF approach was chosen taking advantage of the adjacent edentulous site to cover gingival recession in mandibular molar. There is only one other case report in literature where a 6-year follow-up was done after performing a similar procedure.[15] The advantage of using LPF over other root coverage procedures is that it requires only a single surgical site, with no separate donor site, and offers an excellent color matching of the graft tissue in harmony with the surrounding tissues as observed in the present case. This procedure gave successful outcome, wherein the patient was relieved of sensitivity.

As there was adequate tissue available from the edentulous site, there was no problem in achieving primary closure at the donor site, hence it healed uneventfully. Since the LPF carries its own blood supply, excellent healing and high survival rate were established. One of the major limitations in performing a LPF procedure is gingival recession at the donor site and insufficient width of attached gingiva, both of which were avoided due to the presence of adjacent edentulous site.

Treating mucogingival problems in molars can be debatable. The primary concern for this patient was sensitivity and hence a procedure that best suits the patient's condition was done which helped correct the mucogingival problem. To conclude, this technique is highly reliable for root coverage and for increasing the width of attached gingiva. However, case selection and surgical technique are imperative for a predictable outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zucchelli G, Testori T, De Sanctis M. Clinical and anatomical factors limiting treatment outcomes of gingival recession: A new method to predetermine the line of root coverage. J Periodontol 2006;77:714-21.  Back to cited text no. 1
    
2.
Grupe HE, Warren RF Jr. Repair of gingival defects by a sliding flap operation. J Periodontol 1956;27:92-5.  Back to cited text no. 2
    
3.
Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival recession. A systematic review. Ann Periodontol 2003;8:303-20.  Back to cited text no. 3
    
4.
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. 4
    
5.
Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.  Back to cited text no. 5
    
6.
Zucchelli G, Cesari C, Amore C, Montebugnoli L, De Sanctis M. Laterally moved, coronally advanced flap: A modified surgical approach for isolated recession-type defects. J Periodontol 2004;75:1734-41.  Back to cited text no. 6
    
7.
Löe H, Anerud A, Boysen H. The natural history of periodontal disease in man: Prevalence, severity, and extent of gingival recession. J Periodontol 1992;63:489-95.  Back to cited text no. 7
    
8.
Araújo 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. 8
    
9.
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. 9
    
10.
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. 10
    
11.
Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Root coverage revisited. Periodontol 2000 2001;27:97-120.  Back to cited text no. 11
    
12.
Grupe H, Warren R. Repair of gingival defect by sliding flap operation. Periodontology 1956;27:92-5.  Back to cited text no. 12
    
13.
Grupe HE. Modified technique for the sliding flap operation. J Periodontol 1966;37:491-5.  Back to cited text no. 13
    
14.
Goldstein M, Brayer L, Schwartz Z. A critical evaluation of methods for root coverage. Crit Rev Oral Biol Med 1996;7:87-98.  Back to cited text no. 14
    
15.
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. 15
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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