"United Pedicle Flap" for management of multiple gingival recessions.

Numerous surgical procedures have evolved and are being modified with time to treat gingival recession by manipulating gingival or mucosal tissues in various ways. However, the decision to choose the most appropriate technique for a given recession site still remains a challenging task for clinicians. Mucogingival deformities such as shallow vestibule, frenal pull, or inadequate attached gingiva complicate the decision and limit the treatment options to an invasive procedure involving soft tissue grafts. The situation is further comprised if there is a nonavailability of adequate donor tissue and patients' unwillingness for procedures involving a second surgical site. In such situations, the recession either remains untreated or has poor treatment outcomes. This case report presents a modified pedicle graft technique for treatment of multiple gingival recessions with shallow vestibule and inadequate attached gingiva. The technique is a promising therapeutic alternative to invasive surgical procedures such as soft tissue grafts for treatment of multiple gingival recessions.

INTRODUCTION

Gingival recession is one of the most prevalent mucogingival deformities caused by the displacement of gingival margin apically from the cementoenamel junction (CEJ).[12] The treatment of gingival recession is important as its presence compromises both esthetic and gingival health. Patients with gingival recession and decreased zone of attached gingiva often present with marginal gingivitis, abundant deposits of plaque and calculus, sensitive root, cervical root caries, or cervical abrasion.[3]

Recently, with an increased demand for esthetics and understanding of the dynamics of healing, various surgical procedures have evolved to treat gingival recession.[345] These procedures aim to provide complete root coverage by manipulating gingival or mucosal tissues either by a pedicle-based therapy (i.e., rotational or coronal advanced flaps [CAF]), autogenous soft tissue grafts acquired from separate donor sites (connective tissue graft, free gingival autograft or alloderm), guided tissue regeneration techniques, or orthodontically driven root coverage.[3456789] The decision to choose the most suitable root coverage technique that present with minimum trauma and optimum results for a given site remains a challenging task for the clinicians. Many patient and site-related factors should be evaluated before choosing a root coverage procedure. Some of the important factors that strongly influence the choice and outcome of treatment include number and location of recession (localized or multiple tooth recession involving the mandibular or maxillary arch), amount of gingival recession (narrow or wide recessions; deep or shallow recession), underlying osseous topography, the amount of attached gingiva, vestibular depth, location of frenal or muscle attachment, availability of donor tissues, and the gingival biotype.[29] Many a times, one or more of these factors may not be favorable for the clinician to adopt the ideal technique for a given recession site.

For example, in multiple gingival recessions with inadequate amount of attached gingiva, high frenum attachment, and shallow vestibule, a soft tissue graft would be the ideal treatment option. However, the nonavailability of adequate donor tissue from either the palate or edentulous ridge, or patients' unwillingness for an invasive procedure involving a second surgical site, precludes clinicians from performing a soft tissue graft. Moreover, a CAF is also contraindicated in such situations due to the inadequacy of attached gingiva. The CAF if performed in such situation increases the chances of postoperative recession due to constant muscular pull on the flap. The chance of postoperative recession is further increased if CAF is performed for mandibular recessions due to the gravitational pull on the flap. A laterally positioned pedicle graft (LPPG) and its various modifications, although are favorable for localized recession defects with adequate interdental keratinized tissue, are also contraindicated in multiple gingival recession with inadequate attached and shallow vestibule.[910111213]

Thus, the treatment options for multiple gingival recessions with inadequate attached gingiva, shallow vestibule, and nonavailability of donor tissue are limited. In such situations, the site of the recession either remains untreated or presents with poor treatment outcome.

This case report presents a novel modification in the flap design to treat multiple gingival recessions with inadequate amount of attached gingiva and shallow vestibule. This minimally invasive technique may prove to be a promising therapeutic alternative to conventional root coverage procedures such as soft tissue grafts and CAF for treating multiple gingival recessions with mucogingival deformities.

CASE REPORT

A 37-year-old male patient presented with the chief complaint of root sensitivity in the lower left lateral incisor and canine for the past 1 year. The patient was systemically healthy without any oral abusive habits, did not use of any form of tobacco or alcohol, and had not undergone any periodontal treatment in the last 6 months. On intraoral examination, gingival recessions were observed with respect to mandibular left lateral incisor and canine. There was inadequate attached gingiva, shallow vestibular depth, and broad interdental gingival tissues [Figure 1]. The presence of good keratinized tissue on the either side of gingival recession indicated that a lateral pedicle graft could be a good therapeutic option for root coverage for the individual tooth. However, since conventional LPPG are indicated only for localized recessions, it was contraindicated in our case due to the presence of multiple recessions. Furthermore, a CAF and soft tissue graft was also ruled out since there was an inadequate amount of attached gingiva and shallow vestibular depth along with patient's unwillingness for any invasive procedure involving the second surgical site. Therefore, utilizing the advantage of good papillary gingival tissue on either side of gingival recessions, a novel modification in the conventional pedicle flap design was planned for root coverage [Figure 2a–f].

Figure 1

Preoperative gingival recession with inadequate attached gingiva and shallow vestibule

Figure 2

Diagrammatic representation of “United Pedicle Flap” technique: (a) site with multiple gingival recession with broad internal gingiva tissues, inadequate attached gingiva, and shallow vestibule; (b) initial incisions; (c) flap reflection; (d) rotation and approximation of individual of pedicle by interrupted sutures to form a single unit; (e) lateral and coronal placement of “United Pedicle Flap” on the de-epithelized tissue by interrupted sutures; (f) continues sling sutures for stabilization of the coronally positioned on the de-epithelized interdental papilla

The surgery was performed after 4 months of nonsurgical phase one therapy to allow complete resolution of gingival inflammation. A thorough assessment of all the etiological factors that could be associated with gingival recession such as plaque and calculus-induced infalammation; mechanical forces such as trauma from oral hygiene practices due to inappropriate tooth brushing, flossing, interproximal brush; mechanical trauma from masticatory forces, high-muscle attachments, frenal pull; anatomical factors such as tooth shape, profile, and position in the arch and alveolar bone dehiscence was evaluated and corrected prior to the procedure.[14151617]

The procedure was performed under local anesthetics of 2% lignocaine hydrochloride with 1:80,000 adrenaline. An internal bevel incision followed by sulcular incision was first made all along the recession till the base of the interdental papilla [Figure 3]. The “v” shaped gingival tissue was then removed gently. A full-thickness mucoperiosteal flap was subsequently reflected. The choice of raising a full or partial thickness flap depends on the biotype of the gingival tissue. Partial thickness flap can be raised in patients with thick gingival biotypes. The flap was reflected up to 1 mm apical to the gingival recession after placing horizontal incision at the base of the papilla. The portion of the flap reflected in between two teeth simulated the individual pedicle graft that would be reflected if an LLPG was to be performed for individual gingival recession. Vertical incisions were given on the both mesial and distal side of the recession to allow tension-free movement of the flap [Figure 4].

Figure 3

An internal bevel incision followed by sulcular incisions along the recessions till the base of the interdental papilla

Figure 4

Flap reflected

On flap reflection, meticulous scaling and root planing followed by biomodification with citric acid was performed on the exposed root surface. The “individual pedicle” on the mesial and distal side of each gingival recession was carefully approximated using interrupted suturing technique to form a single unit of “United Pedicle Flap” [Figure 5]. The entire unit was then passively adapted 1 mm coronal to the CEJ after giving releasing incision at the base of the flap or cut back incision, if required, at one end of flap. The entire unit was sutured to the de-epithelized interdental papilla using sling sutures. Tin foil and periodontal surgical dressing were subsequently placed [Figures 6 and 7].

Figure 5

The “individual pedicle” on mesial and distal side of each gingival recession rotated and approximated

Figure 6

Sutures placed to form a “United Pedicle Flap”

Figure 7

Periodontal dressing placed

Analgesic ibuprofen 400 mg 3 times a day for 5 days was prescribed. The patient was instructed not to brush in the operated area and to start 0.12% chlorhexidine gluconate mouth wash twice daily from the second postoperative day till 15 days. The patient was recalled 15 days postoperatively for suture removal.

After 15 days, the formed pedicle grafts were successfully taken up by the recipient bed without any signs of gingival inflammation or necrosis [Figure 8]. A subsequent reevaluation at 1 and 6 months revealed excellent blending and firm attachment of gingival tissues with complete root coverage [Figures 9 and 10]. There was a significant gain in the amount of attached gingiva and the absence of any clinical probing depth or postoperative recession.

Figure 8

Postoperative gingival tissue at 15 days after periodontal dressing removal

Figure 9

Postoperative at 1 month

Figure 10

Postoperative gingival tissue at 6 months

DISCUSSION

The “United Pedicle Flap” is a minimally invasive procedure with several advantages over conventional root coverage procedure for the treatment of severe multiple gingival recessions with shallow vestibule and inadequate amount of attached gingiva. First, the technique facilitates root coverage in severe gingival recessions with mucogingival deformities where primary closure by conventional flap could not be possible. The suturing of individual pedicles into a single unit promotes superior healing due to rapid revascularization of blood vessels. Thus, the chance of postoperative recession and necrosis during healing is also decreased. Moreover, the amount of root coverage that was obtained by the “United Pedicle Flap” was more than what we might achieve by a conventional flap or even with individual lateral pedicle. The technique favors treatment of multiple gingival recessions, unlike the conventional pedicle graft technique that is indicated only for localized recession.

The technique is also a promising alternative to soft tissue grafts for the treatment of multiple gingival recessions with shallow vestibule and broad interdental gingiva.[9]“United Pedicle Flap” is esthetically and functionally more advantageous over soft tissues grafts as the base of pedicle grafts remains attached to donor site to facilitate uninterrupted blood supply.[1819] This promotes superior healing and excellent color matching of the healed tissue, unlike soft tissue grafts where an unesthetic whitish scar or necrotic tissue is often observed after healing.[8910181920] The donor site for soft tissue grafts creates a wound that heals slowly and is prone to bleeding with considerable postoperative discomfort. Since there is no involvement of an additional surgical site for obtaining gingival autografts, postoperative discomfort, and pain is considerably reduced with this technique.

“United Pedicle Flap” technique is also advantageous over conventional CAF as it favors more coronal positioning of flap for a given amount of releasing incision. The joining of individual pedicles to form a “United Pedicle Flap” resulted in an increased area of keratinized tissue that facilitated more root coverage as compared to conventional CAF. A conventional CAF is often contraindicated in recessions with inadequate attached gingiva and shallow vestibule as it results in further reduction of vestibular depth and postoperative recession. If CAF is performed for recessions with such mucogingival deformities, most of the root coverage is achieved by the coronal displacement of the alveolar mucosa. This increases the tension in the flap due to constant pull by the fibers of the alveolar mucosa. This causes the alveolar mucosa to return to its previous position resulting in postoperative recession and further reduction in vestibular depth.[20] Since most parts of the “United Pedicle Flap” to achieve root coverage are obtained by the lateral interdental keratinized tissue with a minimal coronal displacement of alveolar mucosa, the muscular pull on the flap, and chances of postoperative recession are minimized.

The “United Pedicle Flap” can be implemented successfully for gingival recessions with good interdental keratinized gingival tissue and absence of clinical probing depth. Moreover, the flap design of “United Pedicle Flap” also provides good primary closure and favors repair of any underlying osseous defects in sites with severe gingival recessions and inadequate amount of attached gingiva. Therefore, the technique can be adopted during flap surgery to achieve root coverage along with good primary closure. The technique would also favor placement of adjuncts such as platelet-rich plasma, soft tissue grafts, and barrier membranes for better treatment outcomes. However, in subjects with thin gingival biotype, interdental bone loss or reduced interdental papillary height, compromised outcome may be achieved. When the loss of clinical attachment involves proximal tooth sites, i.e., Miller's Class III and IV recession defects, only partial facial root coverage is expected with this technique.[5]

CONCLUSION

The “United Pedicle Flap” is a conservative and promising therapeutic alternative for the treatment of multiple gingival recessions with shallow vestibule and broad interdental gingiva. The presence of complete root coverage, gain in clinical attachment, and an absence of probing depths with good esthetic outcomes at the end of 6 months proved the effectiveness of this technique. However, long-term follow-up, prospective and comparative analysis using this technique with other established treatment modalities is warranted to strengthen the fact that “United Pedicle Flap” is a good therapeutic option for root coverage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.