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International Journal of Medical Science and Current Research (IJMSCR) Available online at: www.ijmscr.com Volume1, Issue 1, Page No: 158-162 May-June 2018

Treatment of Two Adjacent Gingival Recessions by Bilateral Pedicle Flap and Tunnel Connective Tissue Graft Technique Dr. Awadhesh Kumar Singh* Dhananjay Kumar Mali *MDS Periodontology Professor, Department of Periodontology, Chandra Dental College & Hospital, Barabanki, Uttar Pradesh, India. Junior resident, Department of Periodontology, Chandra Dental College & Hospital, Barabanki, Uttar Pradesh, India

Corresponding Author: Dr. Awadhesh Kumar Singh Professor, Department of Periodontology, Chandra Dental College & Hospital, Barabanki, Uttar Pradesh, India

Type of Publication: Original Research Paper Conflicts of Interest: Nil ABSTRACT Now-a-days, esthetic is more important in human beings. Patient is more concerned about exposure of tooth root surface. Different surgical approaches used for treatment of gingival recessions are pedicle flap, free gingival graft, free connective tissue graft and combination of them. In the bilateral pedicle flap and tunnel connective tissue graft technique, bilateral pedicle flap and free connective tissue graft combined with tunnel technique is described for the treatment of two adjacent gingival recessions. The tunnel is prepared in the interdental papilla. The bilateral pedicle flap and tunnel connective tissue graft technique is indicated in class II or III two adjacent gingival recessions of deep and wide type. The bilateral pedicle flap and tunnel connective tissue graft technique is contraindicated in cases where the interdental papilla is too narrow. The bilateral pedicle flap and tunnel connective tissue graft technique offers advantages of increased blood supply, better adaptation and stability, complete coverage of connective tissue graft, prevention of apical retraction of overlying flap, less surgical trauma and more rapid healing. . Keywords: Connective tissue graft, gingival recession, pedicle flap, tunnel technique

An adequate mucogingival complex is always essential in which the mucogingival tissues can sustain their biomorphological integrity and maintain an enduring attachment to the teeth and the underlying soft tissue. When a mucogingival problem occurs, there are basically two ways in which it presents itself. First, as a close disruption of the mucogingival complex resulting in pocket formation. Second, as an open disruption of the mucogingival complex resulting in gingival clefts and gingival recession [1]. Gingival recession is defined as the exposure of root surface in the oral cavity, resulting from the detachment and migration of junctional epithelium toward the apex of the root [2]. Gingival recession may be treated by different surgical techniques. Each technique has its own indications, contraindications, advantages, disadvantages, and

success rates. Connective tissue graft (CTG) is considered as the gold standard. A number of studies have described various tunnel approaches with CTGs or allografts that maintain papillary integrity and avoid vertical releasing incisions [3-6]. The current tunnel preparation techniques primarily use an intrasulcular approach to create either a sub- or supra- periosteal space to extend beyond the mucogingival junction, allowing graft tissue to be inserted under the gingival collar. The limitations of this tunnel access technique include the technically challenging nature of intrasulcular tunneling because of the need to obtain access through a small sulcular access point and the increased risk of traumatizing and perforating the sulcular tissues, yielding possible unfavorable healing outcomes. To avoid these risks, tunnel is prepared in the interdental papilla. The

International Journal of Medical Science and Current Research | May-June 2018 | Vol 1 | Issue 1

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INTRODUCTION

Dr. Awadhesh Kumar Singh et.al. International Journal of Medical Science and Current Research (IJMSCR)

A 35-year-old female patient reported in the department of Periodontology with the chief complaint of exposed root surface in lower front tooth region. On intraoral examination, two adjacent Miller class III labial gingival recessions were present at lower right and left central incisors (tooth no # 41 and #31) [Figure 1]. Lower central incisors had open contact between them. The depth of gingival recessions were 5.0 mm and 4.0 mm in lower right and left central incisors, respectively when measured from cementoenamel junction to the gingival margin by PCP UNC15 probe (HUFRIEDY, USA). Probing depths were 2.0 mm in both receded tooth roots. Widths of keratinized gingiva were 00 mm in both lower right and left central incisors. The patient underwent periodontal treatment of phase I therapy including scaling, root planing, polishing and instructions for proper oral hygiene measures. Surgical treatment of recession was not scheduled until the patient could able to maintain full mouth and local plaque score less than 20% and full mouth and local bleeding score of less than 15% according to index proposed by O’ Leary et al. [7]. Before treatment, surgical procedure was briefed to patient and asked to sign written consent form including permission or no objection of photographs for publication in any journal. Patient was instructed to do presurgical rinse by 0.2% chlorhexidine solution. The perioral skin was cleaned with spirit and scrubbed by 7.5% povidone iodine solution. Intraoral surgical site was painted with 5% povidone iodine solution [8]. After presurgical rinse and part preparation for surgery, 2% lignocaine hydrochloride with 1:80,000 adrenaline was administered to anesthetize right and left mental nerves. An internal bevel incision was made around the receded gingival margin to remove infected gingival tissue. Two horizontal incisions were placed at the level of cementoenamel junction, each one distal to receded tooth. Two vertical incisions were placed at the end of the horizontal Volume 1, Issue 1; May-June 2018; Page No. 158-162 © 2018 IJMSCR. All Rights Reserved

Antibiotic (amoxicillin 500 mg, 1 tab every 8 hours, for 7 days) and analgesic (nimesulide 100 mg, 1 tab every 12 hours, for 3 days) were prescribed. Toothbrushing and chewing were discontinued on the operated area for 2 weeks. After this period patient was advised to manual toothbrushing for cleaning of the operated area using an extra soft toothbrush by modified Stillman’s technique. Plaque control was obtained by o.2 % chlorhexidine rinse, twice daily for one minute during the first two weeks [10] and then application of 0.2 % chlorhexidine gel onto the operated area two times in a day for another two weeks after meal. The patient was followed up every week during the first month and monthly thereafter upto 12 months. At the recalled visits, ultrasonic and manual tooth cleaning and evaluation of oral hygiene measures were done.

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CASE REPORT

incisions and extended into base of vestibule. A sharp dissection was made to prepare recipient bed and split thickness lateral pedicle flap without disturbing the interdental papilla at the midline [Figure 2]. The interdental papilla at the midline was undermined by sharp dissection to prepare a tunnel with the help of Orban’s interdental knife [Figure 3]. Care was taken in performing this sharp dissection to avoid tear of the tip of the interdental papilla. The connective tissue graft was obtained from the right side of premolar region of the palate by the “trap-door” technique [9]. The connective tissue graft was drawn underneath the papilla in the tunnel, placed on recipient bed and receded root surfaces [Figure 4]. The connective tissue graft was sutured by interrupted suturing technique laterally and sling suturing technique around the neck of tooth coronally with 5-0 black silk suture. The lateral pedicle flaps were rotated mesially over the connective tissue graft and sutured by sling suturing technique around the neck of tooth coronally with 5-0 black silk suture. The mesial borders of lateral pedicle flaps were sutured to the interdental papilla by interrupted suturing technique with 5-0 black silk suture [Figure 5]. After completion of the tunnel connective tissue graft and bilateral pedicle flaps suturing, no area of exposed root and recipient bed were seen. Finger pressure through a moist gauze piece was applied at the surgical site for about 10 minutes in order to close adaptation of tissue and to reduce the incidence of bleeding, microhematoma or dead space.

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present study was envisaged to design the treatment of two adjacent gingival recessions by combination of pedicle flap, connective tissue graft and tunnel technique in which tunnel was prepared in interdental papilla.

Dr. Awadhesh Kumar Singh et.al. International Journal of Medical Science and Current Research (IJMSCR)

The ultimate goal in the treatment of the soft tissue marginal recession is the complete coverage of the denuded root, resulting in an esthetic and natural appearance of the newly gained tissue [11]. The technique described in this article is a modification of the supraperiosteal pouch technique to provide a greater blood supply to the graft and thus more predictable root coverage. This modification includes the use of two lateral pedicle flaps distal to the adjacent recessions. This alteration in the technique provides blood supply to the entire surface of the graft; the original supraperiosteal pouch technique provides double blood supply in the apical portion of the graft, but no blood supply for the exposed portion of the graft overlying the root surface. The present article presents a combined bilateral pedicle flaps and tunnel connective tissue graft technique that has resulted in 89% mean root coverage after one year. In our case we did not leave the epithelium on CTG because some authors have hypothesized that when covering the epithelium with the graft, there is a possibility of cyst formation [12]. On the other hand, Bouchard and Etienne studied the effect of leaving the epithelium exposed compared to removing the epithelium and covering the entire graft with the pedicle flap. They found better esthetic results with the latter approach, although more keratinized tissue was gained by leaving the epithelium exposed [13]. Since there is no evidence-based data on the esthetic and histologic impact of this epithelium remnant on the final outcome of the grafting procedure, it is the opinion of the authors that the elimination of the epithelium is a necessary surgical step. Volume 1, Issue 1; May-June 2018; Page No. 158-162 © 2018 IJMSCR. All Rights Reserved

The finding of the bilateral pedicle flap and tunnel connective tissue graft technique was comparable to other techniques in which tunnel connective tissue graft used with or without bilateral pedicle flap for treatment of two adjacent gingival recessions. Blanes and Allen by bilateral pedicle flap- tunnel technique found predictable root coverage in shallow, narrow two adjacent gingival recessions with 97% mean root coverage [15]. Khuller by using tunnel connective tissue graft technique for coverage of two adjacent gingival recessions obtained totally root coverage with a beautiful aesthetic [16]. The indications for the use of the bilateral pedicle flap and tunnel connective tissue graft technique are Class I and II deep and wide adjacent soft tissue marginal recession with shallow vestibular depth; Class I and II deep and wide adjacent soft tissue marginal recession with a narrow interproximal papilla and Class III adjacent soft tissue marginal recession where some gain in papillary height may be attempted. This gain in papillary height is accomplished by undermining the interproximal tissue and raising it with a sling suture. The bilateral pedicle flap tunnel connective tissue graft technique is contraindicated in cases where the interproximal papilla is too narrow. In these clinical situations the creation of the mesial pedicle flaps may leave the flaps more slender, which may complicate suturing and jeopardize their blood supply [15]. This approach to cover two adjacent gingival recessions by tunnel connective tissue graft and bilateral pedicle flap technique offers the advantages of increased blood supply to the connective tissue graft by covering the graft completely with bilateral pedicle flaps, better adaptation and stability of the graft to the recipient site as a result of the compressing effect of the tunneled interproximal papilla, complete coverage of the graft when the coronally positioned flap is contraindicated, such as in a shallow vestibule, prevention of apical retraction of the overlying flap, as is commonly seen in the mandibular incisor region and other sites with a shallow vestibule and less surgical trauma and more rapid healing by preserving the interproximal papilla

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DISCUSSION

A split thickness dissection of the recipient site was used in this case because it was considered to offer a better blood supply and therefore faster revascularization of the connective tissue graft [14].

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Periodontal dressing and sutures were removed one week after surgery. Healing was uneventful. Patient was happy to see the presence of gum on the receded roots surface. During progression of time, tissue maturity, color blending with surrounding of surgical site and stability were obtained. After one year, 4.5 mm, that is, 90% and 3.5 mm that is, 87.5% root coverage in lower right and left central incisors were obtained, respectively [Figure 6]. Probing depths were 1.0 mm in each. Widths of keratinized gingiva of 4.5 mm and 3.5 mm in lower right and left central incisors were obtained, respectively.

Dr. Awadhesh Kumar Singh et.al. International Journal of Medical Science and Current Research (IJMSCR)

[15]. The only disadvantage is the chance of tear of tip of interdental papilla during tunnel preparation. This problem can be overcome by careful dissection of interdental papilla during tunnel preparation. CONCLUSION The bilateral pedicle flap and tunnel connective tissue graft technique for coverage of two adjacent gingival recessions offers a better blood supply to the connective tissue graft which may enhance predictability of treating class III gingival recession of deep and wide type. REFERENCES

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1. Khosya B, Devaraj CG. Etiology and severity of different grades of gingival recession in adult population. Nat J Med Res 2014;4:189-92. 2. Singh AK, Gautam A. Platelet-rich fibrinreinforced periosteal pedicle graft with vestibular incision subperiosteal tunnel access technique for the coverage of exposed root surface. J Interdiscip Dentistry 2016;6:33-8. 3. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: A clinical report. Int J Periodontics Restorative Dent 1999;19:199‑206. 4. Raetzke PB. Covering localized areas of root exposure employing the “envelope” technique. J Periodontol 1985;56:397‑402. 5. Tözüm TF, Dini FM. Treatment of adjacent gingival recessions with subepithelial connective tissue grafts and the modified tunnel technique. Quintessence Int 2003;34:7‑13. 6. Ribeiro FS, Zandim DL, Pontes AE, Mantovani RV, Sampaio JE, Marcantonio E. Tunnel technique with a surgical maneuver to increase the graft extension:

Case report with a 3- year follow-up. J Periodontol 2008;79:753‑8. 7. O’ Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38. 8. Singh AK, Kiran P. The periosteum eversion technique for coverage of denuded root surface. J Indian Soc Periodontol 2015;19:458-61. 9. Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95102. 10. Singh AK, Saxena A. Treatment of periradicular bone defect by periosteal pedicle graft as a barrier membrane and demineralized freeze-dried bone allograft. J Clin Diagn Res 2017;11:12-4. 11. Miller PD. Root coverage grafting for regeneration and esthetics. Periodontol 2000 1993;2:118-27. 12. Breault L, Billman MA. Report of a gingivai surgical cyst developing secondarily to a subepitheiial connective tissue graft J Periodontol 1997;68:392-5. 13. Bouohard P, Etienne D. Subepitheiial connective tissue grafts in the treatment of gingival recessions. A comparative study of two procedures. J Periodontol 1994;65:929-36. 14. Langer B, Calagna L. The subepithelial conneotive tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent 1962;2:22-34. 15. Blanes RJ, Allen EP. The bilateral pedicle flap-tunnel technique: A new approach to cover connective tissue grafts. Int J Periodont Res Dent 1999;9:471-9. 16. Khuller N. Coverage of gingival recession using tunnel connective tissue graft technique. J Ind Soc Periodontol 2009;13:101-5

Volume 1, Issue 1; May-June 2018; Page No. 158-162 © 2018 IJMSCR. All Rights Reserved

Dr. Awadhesh Kumar Singh et.al. International Journal of Medical Science and Current Research (IJMSCR)

FIGURE LEGENDS Figure 1: Two adjacent gingival recessions in #41 and #31. Figure 2: Bilateral pedicle flap. Figure 3: Tunnel preparation. Figure 4: Connective tissue graft placed in tunnel. Figure 5: Connective tissue graft and bilateral pedicle flap sutured. Figure 6: After one year, predictable root coverage.

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Volume 1, Issue 1; May-June 2018; Page No. 158-162 © 2018 IJMSCR. All Rights Reserved

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Figure 1