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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 56-61

Lateral pedicle graft – A predictable treatment option for isolated gingival recession


1 Associate Professor, Department of Periodontics, Government Dental College, Raipur, Chhattisgarh, India
2 Professor and Head, Department of Periodontics, Government Dental College, Raipur, Chhattisgarh, India
3 Post Graduate Student, Department of Periodontics, Government Dental College, Raipur, Chhattisgarh, India
4 Post Grduate Student, Department of Orthodontics, Government Dental College, Raipur, Chhattisgarh, India

Date of Submission23-May-2022
Date of Acceptance03-Jun-2022
Date of Web Publication28-Jun-2022

Correspondence Address:
Dr. Shirish Kumar Kujur
Government Dental College, Raipur, Chhattisgarh 492 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpcdr.ijpcdr_15_22

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  Abstract 


Marginal gingival recession is a typical source of worry, especially when it occurs in the anterior teeth as a result of functional and esthetic issues. Recession can cause esthetic degeneration, dentin hypersensitivity, and the inability to undertake regular oral hygiene practices. Gingival recession problems have been treated with a variety of surgical procedures. This article discusses a case where the lateral pedicle technique was used to successfully cover the root of a single tooth. The soft tissue next to the recession is positioned over the defect in this approach. This resulted in a periodontium that was both esthetically and functionally healthy, as well as positive patient acceptability. A clinically substantial level of root coverage was achieved as a result of this operation.

Keywords: Gingival recession, lateral position flap, pedical graft, root coverage


How to cite this article:
Kujur SK, Gupta V, Sreeraj V S, Anuraj K R, Dahiya S. Lateral pedicle graft – A predictable treatment option for isolated gingival recession. Int J Prev Clin Dent Res 2022;9:56-61

How to cite this URL:
Kujur SK, Gupta V, Sreeraj V S, Anuraj K R, Dahiya S. Lateral pedicle graft – A predictable treatment option for isolated gingival recession. Int J Prev Clin Dent Res [serial online] 2022 [cited 2022 Aug 16];9:56-61. Available from: https://www.ijpcdr.org/text.asp?2022/9/2/56/348710




  Introduction Top


The gingival margin is clinically characterized as a scalloped line that runs 1–2 mm coronal to the cementoenamel junction (CEJ). An apical movement of the gingival edge from its position 1–2 mm apical to or at the level of the CEJ with exposure of the root surface to the oral cavity is termed as gingival recession.[1] However, the periodontal recession is a more accurate term because alveolar bone and cementum are also lost.[2] The prevalence of gingival recession range from 20% to 100% in adults.[3] Dentinal hypersensitivity, pain, difficulty with oral care, root caries, an unsightly gingival look, and periodontal attachment loss can all be because of gingival recession. Multiple approaches have been used to replace lost, damaged, or diseased gingival tissues. The gingival recession is well defined by three major classifications.[4],[5] Corrective surgical therapies in Miller classes I and II are more predictable, but surgical technique, operator ability, and behavioral factors still have a direct impact on the postoperative period and final result.[5]

The treatment of gingival recession and related complications is based on a thorough examination of the etiological variables as well as the extent of tissue involvement. The first focus of treatment for a patient with gingival recession should be on addressing the underlying causes. The degree of the gingival recession has to be monitored for signs of further progression. Gingival recession flaws can be corrected using a range of mucogingival surgical techniques that increase the width and height of keratinized or connected gingiva. It is difficult to predict the success rate of root coverage techniques because it depends on a number of parameters, including the recession's categorization and location, as well as the methodology used. Pedicle grafts, free gingival grafts, connective tissue (CT) grafts, and directed tissue regeneration are some of the current root-covering procedures.

Grupe and Warren proposed the technique of laterally repositioned flap operation for root coverage of isolated recessions.[6] The presence of sufficient width, length, and thickness of keratinized tissue next to the area of gingival recession are indicators of a laterally positioned flap.[7],[8],[9] This technique is best for covering roots in gingival recession with a narrow mesiodistal dimension. The laterally positioned flap can be employed to cover isolated denuded roots with sufficient donor tissue and vestibular depth laterally. The goal of the present study was to evaluate the effectiveness of the laterally positioned flap to cover isolated gingival recession.



Indications

  • Inadequate attached gingiva at the site of recession
  • Adequate gingiva in adjacent teeth.


Contraindications

  • The insufficient adequate donor tissue
  • Shallow vestibule
  • High frenum attachments
  • Deep interproximal pockets.


Presurgical protocol

Patient was motivated and educated and oral hygiene instructions were given. Thorough scaling and root planing were done and the patient was periodically recalled to assess his oral hygiene and gingival status before taking up the case for periodontal surgery.

Prerequisites

  • Width of the pedicle >width of the recipient bed and exposed root surface by approximately 3 mm
  • At least 3 mm of gingiva in an apicocoronal direction in the donor site.


Surgical technique

Local anesthesia was used to anesthetize the recipient site. The exposed root surface was scaled and planned using curettes to remove plaque accretions and surface irregularities. After local anesthesia, (2% lignocaine hydrochloride with 1:80,000 epinephrine) the marginal epithelium surrounding the tooth to be covered was removed to prepare a recipient bed. Horizontal and vertical incisions are given over the donor site using number 15 blade to release the flap. The partial-thickness pedicle flap from the adjacent tooth was reflected of a width of more than 1½ times the area of gingival recession. Thereafter root conditioning was done with tetracycline HCl on the exposed root surface to allow biological attachment of the grafted tissue to it. The pedicle flap was then covered over the recipient site and finger pressure was applied with a gauze piece until the graft was firmly seated. It was then carefully secured with interrupted stabilization sutures without tension. Good adaptation of the flap to the underlying tissues is essential for adequate diffusion. The periodontal dressing was given after surgery. The patient was discharged with postoperative instructions and medications for 5 days to avoid postoperative pain and swelling. The patient was recalled after 10 days for check-up. The surgical site was examined for uneventful healing. There was no postoperative complication and healing was satisfactory. The defect created at the donor site heals by secondary intention. The patient was instructed to use a soft toothbrush for mechanical plaque control in the surgical area. The patient was monitored on a weekly schedule postoperatively, to ensure good oral hygiene in the surgerized area.

Surgical procedure

Isolated gingival recession in relation to 21 was selected for surgical correction [Figure 1]. Periapical radiolucency was present in relation to 21 [Figure 2]. Root canal treatment was done in relation to 21 [Figure 3]. With the help of orthodontic bracket and wire splinting was done and it achieved some amount of intrusion [Figure 4]. After reducing root prominence, flap was raised from 22 with the help of horizontal and vertical releasing incisions [Figure 5],[Figure 6],[Figure 7]. The flap then rotated and placed over 21[Figure 8]. Sutures were placed with 3-0 silk [Figure 9]. Sufficient recession coverage was noticed in recall appointments [Figure 10] and [Figure 11].
Figure 1: Preoperative

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Figure 2: Intraoral periapical radiograph shows periapical radiolucency with 21

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Figure 3: Root canal treatment done

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Figure 4: Splinting with orthodontic brackets and wire – achieved some amount of intrusion

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Figure 5: Reduction of root prominence

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Figure 6: Preparation of recipient bed and root conditioning

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Figure 7: Incision

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Figure 8: Flap in place

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Figure 9: Sutures in place

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Figure 10: Before treatment

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Figure 11: Postoperative

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Other techniques for recession coverage

Surgical procedures may be broadly divided into two different types: pedicle soft-tissue graft procedures. These types of graft remain attached at their base and involve the positioning of soft tissue over the recession defect; they retain their own blood supply during their transfer to a new location. Examples include:

  • Rotational flap procedures, including laterally positioned flap, double papilla flap.
  • Flap advancement procedures, including coronally repositioned flap.[10]


Free soft tissue graft procedures. Soft tissues are transferred from an area distant to the recession to cover the defect. These techniques are used where there is inadequate donor tissue close to the recipient site or where the aim of treatment is to increase tissue thickness.

  • Free gingival graft.
  • Subepithelial CT graft.[11]


Coronally advanced flap

This technique is relatively straightforward providing good esthetic results but is only indicated when adequate sulcular depth exists. The coronally advanced flap is commonly used to treat the Miller Classes I and II recession defects. Optimum root coverage results, good color matching to adjacent soft tissues, and recuperation of the original morphology of the gingival margin can be accomplished using this surgical approach.

Semilunarcoronally advanced flap procedure was proposed first by Tarnow in 1986. This technique causes no disturbance of the adjacent papilla, no shortening of the vestibule, and no tension on the flap.

Free gingival graft

In this technique graft comprising both epithelium and underlying CT is taken, usually from the palate, and sutured into position in a recipient site prepared using a splint-thickness flap. The recipient bed should extend at least 3 mm laterally and apically to the recession defect, as this will be the only nutrient supply to the graft during the initial healing phase.

Connective tissue grafts

Free gingival grafts have a number of disadvantages. Esthetics may be compromised because of the color difference between the graft and recipient site tissues, while there is also the problem of a large denuded site in the palate, which must heal by secondary intention. These disadvantages have been overcome by the use of CT grafts, which involve the placement of de-epithelialized CT into the recession defect. Healing of the donor site is by primary intention, reducing discomfort for the patient. The color match with the tissues is also better. CT grafts are commonly harvested from the palate, provided there is the adequate thickness of tissue.

Envelope or pouch flap

The advantages of the technique are the maintenance of the blood supply to the flap, a close adaptation to the graft, and reduction in postoperative discomfort and scarring. Allen (1993) reported the use of a technique where a CT graft is placed in a tunnel preparation.[8]

Guided tissue regeneration techniques

The use of guided tissue regeneration (GTR) procedures for root coverage includes evidence of regeneration of a new periodontal tissue attachment. GTR allows the selective repopulation of a root surface by periodontal ligament cells that can form new CT attachment between the root surface and alveolar bone.


  Discussion Top


Patients may be concerned about poor esthetics, dentine hypersensitivity, inability to undertake oral hygiene procedures, and tooth loss as a result of gingival recessions that occur without symptoms. Patients may be concerned about poor esthetics, dentine hypersensitivity, inability to undertake oral hygiene procedures, and tooth loss as a result of gingival recessions that occur without symptoms. The anatomy of the defect site, the size of the recession defect, the presence or lack of keratinized tissue close to the defect, the width and height of the interdental soft tissue, and the depth of the vestibule or the presence of frenula all influence the surgical procedure chosen.[9] In this case report, a lateral pedicle flap technique was used for successful root coverage. The reported mean percentage of root coverage ranges between 34% and 82%.[10] When there is enough width, length, and thickness of keratinized tissue close to the area of gingival recession, this approach can be used to heal an isolated area of gingival recession.[11] It is well stated that a better root coverage outcomes were only achieved in cases with adequate height and width of keratinized tissue.[12] It is recommended in class I and II shallow recessions according to Miller.[4] If the donor site lacks sufficient connected gingiva or has a fenestration or dehiscence of its supporting bone, it is contraindicated. The flap remains linked at their base, in this case, allowing them to keep their own blood supply while being transported to a new area. Following this operation, blood supply is maintained from the areas flanking the recession defect as well as from the pedicle. For root coverage, the stability and dimension of the laterally positioned flap (the broader the pedicle, the greater the blood supply to the marginal region of the flap) are crucial. Tissue thickness of the flap is an important aspect on the root coverage predictability and an improvement in esthetic outcome.[13] Before surgery, correct localization of the CEJ and mucogingival junction, as well as precise positioning of incisions, are required to achieve optimal esthetics.[14] The laterally positioned flap, when used with a strict case selection, has been demonstrated to be a successful treatment for the isolated gingival recession in studies.[15] The benefits of a pedicle graft include predicted gingival recession correction because to the graft's continuous blood supply, and little postoperative discomfort due to the lack of a second surgery or another surgical site. This procedure also provides superb esthetics because the graft color complements the neighboring gingiva. The potential for bone loss and gingival recession at the donor site are downsides of this approach.[16] In this case, the postoperative esthetic result was satisfactory for the patient. The secondary outcome variables were recession reduction, clinical attachment gain, keratinized tissue gain, esthetic satisfaction, reduced root sensitivity, and postoperative patient pain. Clinical results 3–9 months postoperatively were favorable with no recurrence. Thus, we can say laterally positioned flap is a highly predictable and effective root coverage surgical procedure.


  Conclusion Top


When esthetics is the priority and periodontal health is good then surgical root coverage is a potentially useful therapy. Lateral pedicle graft is the best procedure to treat the isolated gingival recession when adequate attached gingiva is present at the adjacent tooth. The % of root coverage obtained by lateral pedicle flap is 41%–74%. This technique was easier with fewer complications. The advantages of this technique are reduced hypersensitivity, esthetic color matching, good blood supply to the reflected flap with a high percentage of root coverage. The patient was highly satisfied with the treatment outcome. Studies are still going on in this direction for the betterment of this technique and also to come up with the best treatment option to treat all types of recession.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal 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 edition. Proceedings of the 1st European Workshop on Periodontology. Berlin: Quintessence Publisher; 1994;21:139-209.  Back to cited text no. 1
    
2.
Santarelli GA, Ciancaglini R, Campanari F, Dinoi C, Ferraris S. Connective tissue grafting employing the tunnel technique: A case report of complete root coverage in the anterior maxilla. Int J Periodontics Restorative Dent 2001;21:77-83.  Back to cited text no. 2
    
3.
Loe 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. 3
    
4.
Miller PD (1985) A classification of marginal tissue. Int J Periodontol Res Dent 5: 8-13.  Back to cited text no. 4
    
5.
Smith RG (1997) Gingival recession. Reappraisal of an enigmatic condition and a new index for monitoring. J Clin Periodontol 24: 201-205.  Back to cited text no. 5
    
6.
Grupe HE, Warren RF. Repair of gingival defects by sliding flap operation. J Periodontol 1956;27:92-5.  Back to cited text no. 6
    
7.
Sato N. Periodontal Surgery – A Clinic Atlas. Quintessence Publishing Co Inc.,U.S; 2000. p. 342.  Back to cited text no. 7
    
8.
Allen E.P. Pedicle flaps, gingival grafts, and connective tissue grafts in aesthetic treatment of gingival recession. Pract. Periodont. Aesthet. Dent. 1993;5(5):29–38. 40; quiz 40  Back to cited text no. 8
    
9.
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 (4), 714-721.  Back to cited text no. 9
    
10.
Hwang D, Wang HL. Flap thickness as a predictor of root coverage: a systematic review. J. Periodontol 2006; 77 (10), 1625-1634.  Back to cited text no. 10
    
11.
Guinard EA, Caffese RG. Treatment of localized gingival recession part-I lateral sliding flap. J Periodontol 1978; 49 :351-356.  Back to cited text no. 11
    
12.
Verma PK, Srivastava R, Chaturvedi TP, Gupta KK. Root coverage with Bridge Flap - Case Reports. Journal of Indian Society of Periodontology 2013; 17:120-123.  Back to cited text no. 12
    
13.
Kerner S, Sarfati A, Katsahian S, Jaumet V, Micheau C, Mora F, et al. Qualitative cosmetic evaluation after rootcoverage procedures. J Periodontol 2009; 80 (1), 41-47.  Back to cited text no. 13
    
14.
Maynard JG Jr, Wilson RDK. Physiological dimensions of the periodontium significant to the restorative dentist. J Periodontol 1979; 50; 170-177.  Back to cited text no. 14
    
15.
Jagannathachary S, Prakash S. Coronally positioned flap with or without acellular dermal matrix graft in the treatment of class II gingival recession defects: A randomized controlled clinical study. Contemp Clin Dent 2010;1:73-78.  Back to cited text no. 15
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16.
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 : 1734-1741  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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