Six year follow-up of a root coverage procedure on a lower molar tooth with lateral pedicle flap.

Loss of periodontal attachment and subsequent recession is one of the most common deformities that affects the periodontium. Gingival recession is a muco-gingival defect, which is commonly treated for esthetic and physiologic reasons. Adequate thickness of attached gingiva and root coverage is essential in restored teeth for proper masticatory function as well as for oral hygiene maintenance. Various root coverage procedures Nill have been proposed to correct recession defects, including coronally advanced flap and lateral pedicle flap (LPF). A case report is presented dealing with the treatment of a gingival recession on a mandibular molar tooth using LPF with a 6-year follow-up.

INTRODUCTION

Gingival recession and inadequate attached gingiva can cause major functional and esthetic problems. Clinically, it leads to a higher incidence of root caries, hypersensitivity, abrasion, compromised periodontium, smile related problems and esthetic as well as functional concerns. Literature has identified many reasons for gingival recession, including high muscle attachments, frenum pull, iatrogenic factors, traumatic brushing, tooth malposition etc.[1] The sequelae of gingival recession consists of non-keratinized tissue not firmly bound to the underlying periosteum, resulting in inability to withstand daily insult of tooth brushing and masticatory forces.[2]

Review of literature

An Enormous amount of articles are available that clearly document the successful treatment of gingival recession and inadequate attached gingiva with various mucogingival surgical approaches.[3] Various techniques were designed to treat gingival recessions, including coronally advanced lateral pedicle flap (LPF) graft, free gingival graft, connective tissue graft, Guided tissue regeneration etc. The LPF was presented in its original form by Grupe and Warren.[4] The prerequisite for this method is a sufficiently wide and thick gingiva on the adjacent tooth. The method is best suitable for gingival recession with narrow mesiodistal dimension.

Pfeifer and Heller[5] reported that reattachment to the exposed root surface is more likely to occur with full thickness laterally positioned flaps. The full thickness flaps are appropriate for root coverage and partial thickness flaps are suitable to protect the exposed roots. Nelson et al.[6] reported that mean percentage of root coverage using laterally repositioned flap ranges from 34% to 82%.

CASE REPORT

A 62-year-old female patient, presented to the dental clinic with a chief complaint of bad breath along with bleeding gums, difficulty in mastication and inability to maintain deposit free teeth in relation to the right lower back region. On clinical examination, there were local factors present and she had faulty tooth brushing practice. An isolated Miller's Class III recession defect[78] was observed in relation to the mesial root of 46 [Figure 1]. Tooth 45 was missing and un-replaced. The edentulous space was slightly collapsed due to mesio-buccal tilting of 46. There was visible food impaction in between 46, 47 and 48. Dental caries was diagnosed distal to 46 and 47. Patient was systemically healthy without any deleterious habits.

Figure 1

Pre-operative view

Phase 1 therapy consisting of thorough oral prophylaxis and root planning was performed on 46 and caries was restored. Vitality check showed a non-vital 47. Root canal treatment was done for 47. Oral hygiene practice was corrected and the patient was recalled after a month. Patient maintained a good oral hygiene. LPF was planned for the root coverage and was explained to the patient and an informed consent was obtained.

The gingival recession was in relation to the mesial root of 46 and was measured. The dimensions were 4 mm wide and 8 mm deep. Donor site was adjacent edentulous area in relation to 45. There was sufficient width, length and thickness of keratinized tissue present. Oral hygiene and patient maintenance was satisfactory.

Surgical technique

Number 15 blade was used to make a crestal incision on the adjacent edentulous area in relation to 45 and was extended to make a crevicular incision that crossed the apical area around the gingival recession. Vertical releasing incisions were performed on both sides, one distal to the mesial root of 46 and the other distal to 44. The pedicle flap size was 1.5 times wider than the area of the recession. Vertical incisions were extended to the alveolar mucosa so that the pedicle flap could be reflected sufficiently to enable the lateral displacement without tension. A full thickness flap was then reflected sufficiently from the donor site and displaced without tension at the recipient site. Suturing was done using 4-0 non resorbable silk suture. Area was cleaned and Coe pack applied [Figures 2–4]. Cap Amoxicillin 500 mg tid, tablet meftal forte tid and chlorhexidine mouth wash thrice daily for 5 days were prescribed. Patient was advised to have a soft diet and avoid brushing in the area of surgery. Sutures were removed after 10 days. Healing was satisfactory.

Figure 2

Incision and flap reflection

Figure 4

Pack placed

Flap laterally displaced and sutured

Follow-up observations

After completion of the procedure, approximately 7 mm of recession attained clinical attachment gain and adequate width of attached gingiva was appreciated [Figure 5]. After 6 months, coverage increased to 8 mm probably due to creeping attachment [Figure 6]. On review the periodontium looked healthy and the maintenance was satisfactory even after the 3rd year. Hence the next phase of treatment was started.

Figure 5

Review after 10 days

Figure 6

Review after 6 months

Restorative phase of treatment

Following crown preparation, a 4-unit bridge was constructed from 44 to 47 [Figure 7]. Follow-up visits were scheduled 2 months post-operative and subsequently after 4, 5 and 6 years [Figures 8–11]. Maintenance was satisfactory and the gingiva maintained the same level of attachment throughout 6 years without any clinical sign of inflammation.

Figure 7

3 year follow-up with prosthesis placed

Figure 8

4 year follow-up

Figure 11

Post-operative intra oral periapical radiograph

5 year follow-up

Follow-up after 6 years

DISCUSSION

The current case deals with the complete rehabilitation of periodontium and masticatory function of the patient. The success of any muco-gingival surgical procedure depends on various factors like elimination and/or control of etiological factors, predisposing factors like trauma from occlusion, evaluation of inter-dental bone, correction of brushing habits and most importantly the choice of most appropriate surgical technique, which are inherent to each clinical situation and region to be treated.[789]

The advantages of laterally repositioned flap over other flap procedure are the presence of its own blood supply after the transfer of the graft and high survival rate on the roots.

The above case needed adequate width of attached gingiva as well as root coverage for restoring the periodontium and for making the tooth as an abutment. The adjacent edentulous area along with thick biotype gave us a good indication for a LPF. Additional advantages of the procedure were reduced hypersensitivity and good blood supply to the reflected flap with a high percentage of root coverage.

CONCLUSION

In this report, LPF was used to cover Miller Class III recession defect in the right lower mandible posterior molar. The 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. The present case stands exceptional with its 6 years follow-up stating the predictable nature of this root coverage procedure.