|Year : 2019 | Volume
| Issue : 3 | Page : 150-153
Laterally positioned flap with chorion membrane for coverage of isolated gingival miller class III recession
Deepak Sharma1, Pravesh Kumar Jhingta1, Arun Singh Thakur2, Ashish Justa3
1 Department of Periodontology, HP Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Public Health Dentistry, HP Government Dental College, Shimla, Himachal Pradesh, India
3 Department of Paedodontics, HP Government Dental College, Shimla, Himachal Pradesh, India
|Date of Web Publication||3-Jul-2019|
HP Government Dental College, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
The treatment of gingival recession (GR) defects is indicated for esthetic reasons, to reduce root sensitivity, to remove muscle pull, and to create or augment keratinized tissue. Various root coverage procedures have been used to cover localized GRs, such as laterally repositioned flaps (LPF), coronally advanced flaps, free gingival grafts, connective tissue pedicle flaps with a free gingival graft, subepithelial connective tissue grafts, acellular dermal matrix allografts, and guided tissue regeneration. The predictability of these perioplastic surgery procedures may be associated with different conditions, especially the initial recession classification. This report discusses Miller Class III isolated GR case with interproximal bone loss and wide and deep defects treated with a combination procedure of an LPF and chorion membrane.
Keywords: Chorion membrane, clinical attachment level, isolated gingival recession, lateral positioned flap, recession depth, recession height
|How to cite this article:|
Sharma D, Jhingta PK, Thakur AS, Justa A. Laterally positioned flap with chorion membrane for coverage of isolated gingival miller class III recession. Indian J Dent Sci 2019;11:150-3
|How to cite this URL:|
Sharma D, Jhingta PK, Thakur AS, Justa A. Laterally positioned flap with chorion membrane for coverage of isolated gingival miller class III recession. Indian J Dent Sci [serial online] 2019 [cited 2019 Sep 17];11:150-3. Available from: http://www.ijds.in/text.asp?2019/11/3/150/261940
| Introduction|| |
Gingival recession (GR) causes exposure of root surfaces leading to deterioration in the esthetic appearance and in some cases, dental hypersensitivity to tactile and thermal stimuli. Such potential complications stimulate patients to seek appropriate therapy.
The most predictable periodontal plastic procedure is coronally advanced flap (CAF) with subepithelial connective tissue graft (SCTG), which remains the “gold standard” of periodontal plastic surgery. It provides excellent predictability and improved long-term root coverage, but it is limited in supply and significantly increases the patient morbidity. CAF is contraindicated with local anatomic conditions such as (1) the absence of keratinized tissue apical to the recession defect, (2) the presence of gingival (“Stillman”) cleft extending in alveolar mucosa, (3) the marginal insertion of frenuli, (4) the presence of deep root structure loss, and (5) the presence of a very shallow vestibulum. In these situations, the clinician should take the soft tissues located laterally to the recession defect into consideration.
Laterally positioned flap (LPF) first described by Grupe and Warren is indicated to cover GRs of one or more teeth, allowing better esthetic, increasing attached gingiva, and decreasing both hypersensitivity and cervical caries.
Fetal membranes are comprised of amniotic and chorion tissues. The chorion forms the outer limits of the sac that encloses the fetus and is composed of different types of collagen and cell-adhesion bioactive factors. These are known to aid in the formation of granulation tissue by stimulating fibroblast growth and neovascularization. These properties suggest that a chorion membrane (CM) may have a considerable potential for regeneration.
| Case Report|| |
Healthy, nonsmoker female patient presented with a complaint of displeasing receding gums and sensitivity to cold food and beverages in the lower left canine. On clinical examination, Miller Class III recession was seen in the left mandibular canine with mild soft tissue and bone loss [Figure 1] and [Figure 2].
|Figure 2: Preoperative intraoral periapical view of Miller Class III gingival recession|
Click here to view
The following clinical measurements were taken 1 month after periodontal Phase I therapy and at 1-year follow-up: (1) recession depth (RD) – measured from the cementoenamel junction (CEJ) to the most apical extension of the gingival margin, (2) recession width (RW) – measured at the level of the CEJ, (3) probing depth (PD) at the treated and donor (PD donor) teeth – measured from the gingival margin to the bottom of the gingival sulcus, (4) clinical attachment level (CAL) – measured from the CEJ to the bottom of the gingival sulcus of the treated tooth, and (5) keratinized tissue height at the treated tooth – measured from the most apical extension of gingival margin to the mucogingival junction (MGJ) line [Table 1].
|Table 1: Comparison of pre- and post- parameters with laterally positioned flap and chorion membrane surgical treatment|
Click here to view
A single investigator performed the clinical measurements at baseline and at 1 year. All measurements were performed using a manual probe (UNC-15 periodontal probe, Hu-Friedy, Chicago, IL, USA) and were rounded up to the nearest millimeter. A laterally positioned pedicle flap with CM as a bilaminar technique was planned considering the absence of keratinized tissue apical to the recession defect and good periodontal conditions of the neighboring area with adequate keratinized gingiva and good vestibule depth.
After local anesthesia (2% lignocaine hydrochloride with 1:80,000 epinephrine), first, a “V”-shaped incision was made in the GR area making a wide external bevel incision on mesial aspect and internal bevel on distal aspect. Then, the V-shaped gingiva was removed and beveled for flap adaptation. Root convexity was reduced with manual curettes (Gracey curettes, Hu-Friedy) to decrease the avascular area. The adjacent partial-thickness pedicle flap was reflected from the donor area, leaving about 3 mm of marginal gingiva intact, the width of which was ≥1½ times the area of GR. Muscle insertions were eliminated to facilitate easy mobilization of the pedicle graft. CM (Tissue bank, Tata Memorial Hospital, Mumbai, Maharashtra, India) was trimmed in a size to approximately cover the recession defect and was adapted without sutures as shown in [Figure 3]. The pedicle flap was then laterally and coronally moved to cover the recipient site, and finger pressure was applied with a gauze piece until the graft was firmly seated. It was then carefully secured with 3-0 nonresorbable sling sutures without tension [Figure 4]. The periodontal dressing was given thereafter. Sutures were removed after 10 days [Figure 5].
|Figure 3: Intraoperative view of chorion membrane adapted over isolated recession defect|
Click here to view
|Figure 4: Intraoperative view of suture of laterally repositioned flap over recipient site|
Click here to view
Nonsteroidal anti-inflammatory medication ibuprofen was prescribed for the pain as and when the patient feels postoperative pain or discomfort. Plaque control in the surgically treated area was maintained by 0.2% chlorhexidine rinsing for an additional 2 weeks. After this period, the patients were again instructed in mechanical tooth cleaning of the treated tooth region using a soft toothbrush and a roll technique. The patient was recalled every 3 months until the final examination (12 months) [Figure 6], [Figure 7], [Figure 8].
[Table 1] shows a comparison of pre- and post-treatment parameters with LPF and CM surgical treatment. It is observed that there was reduction of RD by 7 mm and RW by 3 mm. There was 63.5% root coverage. CAL and keratinized tissue height increased significantly by 8 and 5 mm, respectively. Patient-centered outcomes observed as a reduction in hypersensitivity and esthetic evaluation showed that this technique alleviated the symptoms of sensitivity and additionally improved esthetics with significant root coverage, color, contour, and texture blending with surrounding gingiva.
| Discussion|| |
In this case, we selected the technique of laterally positioned pedicle flap because of the good periodontal conditions of the neighboring area showing a large keratinized gingiva and vestibule depth. LPF technique is more advantageous than other root coverage techniques, for example, coronally positioned flap, which would depend on previous creation of apical keratinized gingiva for performing root coverage and would require two surgical procedures.
The therapeutic effect of CAF combined with SCTG procedure on advanced cases, such as Miller Class III GR with a wide and deep defect, is still inconclusive. LPF appears to be a superior option to CAF in these advanced GR cases. LPF can ensure that the CM is covered by a gingival flap, which provides a sufficient blood supply laterally to increase the plasmatic circulation during the initial healing.
The studies done by Zucchelli et al. and  Santana et al. show the mean root coverage with LPF procedure ranging from 74% to 97%. The combined technique of LPF and CM provided a predictable approach to manage Miller Class III recession. There was a significant improvement in RD (7 mm) and width (3 mm). The root coverage was 63.5%. The other periodontal parameters also showed marked improvement such as patient-related outcomes and esthetic score. Root coverage esthetic score  evaluates the esthetic outcome of the treatment of GR; a score of 7 was assigned as there was partial root coverage, proper marginal contour following CEJ, absence of scar, MGJ aligned with MGJ on adjacent teeth, and normal color and integration with the adjacent soft tissues. Donor site also healed uneventfully without any mucogingival complication.
| Conclusions|| |
Laterally positioned flap surgical technique with CM was very effective in treating isolated GR Miller Class III recession. It combined the esthetic and root coverage advantages of the CAF and SCTG with the increase in CAL, gingival thickness, and keratinized tissue associated with the laterally moved flap. The ideal gingival conditions must be present lateral to an isolated recession defect to render the proposed surgical technique – a highly effective and predictable root coverage surgical procedure.
Authors would like to thank Dr. Astrid Lobo Gajiwala, Officer in-Charge, Tissue Bank, Tata Memorial Hospital, Mumbai, India, for the CM and granting permission to perform the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chambrone L, Chambrone LA. Gingival recessions caused by lip piercing: Case report. J Can Dent Assoc 2003;69:505-8.
Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of miller class I and II recession-type defects? J Dent 2008;36:659-71.
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;75:1734-41.
Staffileno H. Management of gingival recession and root exposure problems associated with periodontal disease. Dent Clin North Am 1964;3:111-20.
Suresh DK, Gupta A. Gingival biotype enhancement and root coverage using human placental chorion membrane. Clin Adv Periodontics 2013;3:237-42.
Martins TM, Bosco AF, Gazoni GG, Garcia SF. Laterally positioned flap associated with subepithelial connective tissue graft for coverage of isolated gingival recession. Rev Sul Brasil Odontol 2011;8:464-8.
Cairo F, Cortellini P, Tonetti M, Nieri M, Mervelt J, Cincinelli S, et al.
Coronally advanced flap with and without connective tissue graft for the treatment of single maxillary gingival recession with loss of inter-dental attachment. A randomized controlled clinical trial. J Clin Periodontol 2012;39:760-8.
Santana RB, Furtado MB, Mattos CM, de Mello Fonseca E, Dibart S. Clinical evaluation of single-stage advanced versus rotated flaps in the treatment of gingival recessions. J Periodontol 2010;81:485-92.
Cairo F, Rotundo R, Miller PD, Pini Prato GP. Root coverage esthetic score: A system to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases. J Periodontol 2009;80:705-10.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]