Semilunar vestibular technique: A novel procedure for multiple recession coverage (a report of two cases).

The procedures for root coverage have been greatly refined over the past few decades. Still as compared to the other periodontal surgical procedures, predictability of mucogingival procedures remains uncertain which is more in patients who present with multiple recessions or recession complicated with periodontal involvement. Techniques which claim success almost always involve a second surgical site. A novel technique avoiding second surgical site and good predictability for multiple recessions was described by Dr. P.D. Miller in a conference at Pune in 2011. A semilunar vestibular incision technique described by Dr. P.D Miller was performed on two patients who presented with multiple recessions in the maxillary anterior teeth. About 90-100% root coverage was observed when the patients were on a follow-up for 1-year with a significant increase in the vestibular depth. The semilunar vestibular incision technique used in two cases resulted in predictable root coverage with a good color blend, an esthetic marginal morphology and most importantly the avoidance of the second surgical site.

INTRODUCTION

Miller's classification divides the recession into two main categories, those caused due to toothbrush trauma and those caused due to periodontal disease.

While the procedures for root coverage in the first category are more predictable, the involvement of periodontium makes the outcome more complicated in the second category. Related to Grade I and II class, the predictability of root coverage outcome also depends on whether it involves a single tooth or multiple teeth. Results with single root coverage are not complicated by inadequate vascular supply from surrounding areas whereas multiple recession defects are complicated with less than adequate vascularity apart from avascular root surface, thin gingival biotype, inadequate gingival and muscular inserts near gingival margins, and poor tooth alignment. This restricts the choice of surgical treatment in multiple recession defects.[1] Although, the predictability of treatments in localized recession defects are extensively studied, the scientific literature is sparse regarding the treatment of multiple recession type defects and randomized controlled trials are needed to identify the indication for each surgical technique and any prognostic factor.

In order to minimize the number of surgeries and to improve the clinical outcomes, all the contiguous recessions should be treated at the same time and if possible, removal of soft tissue from distant areas of mouth should be avoided to minimize patient discomfort.[2]

The present technique in following cases, describes a method of coverage of multiple recessions with the advantage of increasing the width of attached gingiva, enhancing the depth of the vestibule and avoidance of the second surgical site.

CASE REPORTS

Case 1

A 27-year-old patient reported to the Department of Periodontics and Oral Implantology with chief complaint of receding gums. Clinical examination revealed buccal recession in maxillary left central incisor, lateral incisor, canines, 1st and 2nd premolars. The recession was measuring 4 mm in maxillary left central incisor and lateral incisor, 7 mm in maxillary left canine and first premolar, and 4 mm in second premolar [Figure 1]. After taking a thorough case history, recession coverage procedure was performed after 1-week of scaling and root planing. The case was evaluated periodically for a period of 3 months.

Figure 1

Preoperative photograph showing buccal recession of 4 mm in 21, 22; 7 mm in 23, 24, and 4 mm in 25

Surgical technique

Semilunar vestibular incision

Patient was anesthetized by giving injection of LA containing 2% lignocaine with 1:80,000 adrenaline. The design of the flap consisted of the following incisions:

A semilunar incision was made in the vestibule extending from mesial aspect of central incisor (21) to distal aspect of second premolar (25) [Figure 2]

Figure 2

Semilunar incision given in the vestibule from mesial of 21 to distal of 25

An intracrevicular incision was made following the curvature of the receded gingival margin and ending about 2–3 mm short of the tip of the papillae. De-epithelization of the papillae was done [Figure 3]

Figure 3

Intracrevicular incision following curvature of receded gingival margin

A full thickness dissection was performed apically from the intrasulcular incision up to 3–4 mm and then partial thickness flap was raised, and dissection was connected to the vestibular incision.

Coronal mobilization of the flap was considered adequate when the marginal portion of the flap was able to passively reach a level coronal to the CEJ of the tooth. The root surfaces were mechanically treated with the use of curettes. The facial soft tissue of the anatomic interdental papillae coronal to the horizontal incisions was de-epithelized to create connective tissue beds to which surgical papillae of the coronally advanced flap are sutured with the 4-0 Mersilk suture [Figure 4]. Coe-Pack was placed over the treated site. Patient was prescribed a nonsteroidal anti-inflammatory agent thrice a day for 3 days to prevent postoperative discomfort and amoxicillin 500 mg thrice a day for 5 days to prevent infection. Patient was advised not to brush the teeth in the treated area and to rinse with chlorhexidine solution 3 times daily. A total of 14 days after the surgical procedure, the sutures were removed. The patient was evaluated periodically for a period of 3 months [Figure 5].

Figure 4

Flap sutured to the de-epithelized interdental papillae coronal to the horizontal incisions with 4-0 mersilk suture

Figure 5

Postoperative 3 months photograph showing root coverage of 3 mm in 21.24; 4 mm in 22.23 and 2 mm in 25 and increase in vestibular depth and keratinized tissues

Case 2

A 40-year-old patient reported to the Department of Periodontics and Oral Implantology with chief complaint of receding upper gums and sensitivity to cold. Clinical examination revealed buccal recession in maxillary left lateral incisor, canine, first, and second premolars. The recession was measuring 2 mm in lateral incisor, 4 mm in canine, and 3 mm in first and second premolar [Figure 6]. After taking a thorough case history, semilunar vestibular incision technique was performed after 1-week of scaling and root planing. A semilunar incision was made in the vestibule extending from mesial aspect of lateral incisor (22) to distal aspect of second premolar (25) [Figure 7]. The facial soft tissue of the anatomic interdental papillae coronal to the horizontal incisions was de-epithelized to create connective tissue beds to which surgical papillae of the coronally advanced flap are sutured with the 4-0 Mersilk suture [Figure 8]. Similar postoperative instructions were given. The sutures were removed after 14 days. The case was evaluated periodically for a period of 3 months [Figure 9]. Schematic diagrams of the procedure have been provided [Figures 10–13].

Figure 6

Preoperative photograph showing buccal recession of 2 mm in 22, 4 mm in 23 and 3 mm in 24, 25

Figure 7

Semilunar incision given in vestibule extending from mesial aspect of 22 to distal aspect of 25

Figure 8

Flap sutured to the de-epithelized interdental papillae coronal to the horizontal incisions with 4-0 mersilk suture

Figure 9

Postoperative 3 months photograph showing root coverage of 2 mm in 22, 24, 25, and 3 mm in 23 and increase in vestibular depth and keratinized tissues

Figure 10

Preoperative view (schematic diag)

Figure 13

Postoperative view (schematic diag)

Incision given (schematic diag)

After raising mucoperiosteal flap, it is shifted coronally to cover recession (schematic diag)

RESULTS

The final evaluation at 3 months after surgery showed successful root coverage with gain in the height of keratinized tissue in relation to the teeth. Good color blending of the treated area with the adjacent soft tissue and the reduction of sensitivity was obtained with this procedure. The recession measurement at end of 3 months was 1 mm, 0 mm, 3 mm, 4 mm, and 2 mm for central incisor, lateral incisor, canine, first premolar, and second premolar, respectively for case 1. In case 2, the measurements were 0 mm for lateral incisor, 1 mm for canine, first and second premolars.

DISCUSSION

Covering denuded root surfaces is one of the important goals of mucogingival surgeries and the best results can be achieved by choosing the most appropriate technique.[3] Despite numerous techniques available for the treatment of multiple gingival recession defects, the inherent problems of a limited quantity of available graft, the need for two surgical sites, compromised patient esthetics, postoperative discomfort and complications,[4] and increased costs of treatment have limited the success of one single universal technique that can be used with high predictability, effectiveness, and efficiency without compromising patient centered criteria such as pain, postoperative esthetic outcomes, and costs of treatment.[56]

The predictability of coronally advanced flap ranges from 70% to 99% depending on local and anatomical factors. An apical shift of gingival margin occurs in coronally advanced flap which might be related to thinner thickness/amount of keratinized tissue achieved.[7]

In the present cases, an attempt has been made to assess the predictability and reliability of the semilunar vestibular incision technique for the treatment of recession in multiple teeth. Wound healing after mucogingival surgery relies on clotting, revascularization, and maintenance of blood supply.[8] A vascular graft is more likely to survive on an avascular root surface. This technique provides blood supply from the lateral sides of flap and almost 4 mm of the flap is there to ensure the proper vascularity of flap. This technique facilitates coronal positioning and prevents flap retraction, which is important in the presence of a shallow vestibule where it is extremely difficult to prevent flap retraction. It also increases the width of attached gingiva. Thus, semilunar vestibular incision technique is technically simple causing less trauma and discomfort to the patient, better esthetic appearance, no tension and better control, and stabilization of the coronally advanced flap.

CONCLUSION

The semilunar vestibular incision technique results in predictable results, a good color blending of the treated area with respect to adjacent soft tissues and complete recovery of the original soft tissue marginal morphology. Only disadvantage of the technique is an extensive wound with moderate pain for 2 days postsurgically. Clinical studies using large sample size and long term recall are needed to determine the success and predictability of the technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.