COVERAGE OF DENUDED ROOT SURFACES
- A REPORT OF THREE CASES
Three case reports are presented that demonstrate the use of the Double lateral sliding bridge flap for root coverage of mandibular anterior teeth. The primary concept of the technique is that a connected soft tissue flap is slid over the area of recession after releasing the tension at the vestibular end. The original attached gingiva is used to cover the recession, and the vestibular alveolar mucosa is pushed in place of gingiva. The interproximal sutures maintain the flap but its coronal position must not be dependent on their tension.
Miller's Class I & III gingival defects were treated. Complete root coverage was achieved in two cases with Miller's Class I recession that exhibited no radiographic evidence of bone loss. Partial root coverage was achieved in case 3 with Miller's Class III gingival defect, that exhibited radiographic evidence of bone loss. Although majority of the exposed root surface was covered, about 2 mm of root remained exposed, which seemed to closely correspond to the amount of bone loss that was noted radiographically.
The desire for cosmetic dentistry and improved esthetics has increased tremendously in contemporary society. Cosmetic procedures have become an integral part of periodontal treatment. One of the commonly used esthetic periodontal procedures is coverage of denuded roots.
"Gingival recession" is the exposure of root surface due to apical migration of gingival margin. Many patients seek treatment because of concerns with
esthetic appearance, root sensitivity or fear of early loss of the affected teeth. However, other complications that can arise are root caries and tooth discoloration.
The most common cause for gingival recession is abrasive and traumatic tooth brushing habits. Other causes include, buccally positioned teeth, periodontal inflammation and resultant loss of attachment, frenal and muscle attachments that encroach on marginal gingiva and orthodontic tooth movement through a thin buccal osseous plate.
Recession is not only a common clinical finding, which we encounter in our clinical practice but also a challenging condition to manage. Ever since the first surgery proposed by Grupe and Warren1, several procedures have been proposed to cover gingival recession. Panel et al2 demonstrated a combined technique of sliding flap operation after the use of free gingival graft. Cohen and Ross3 used the papilla of the adjacent teeth to cover denuded root surfaces. Gingival recession coverage was also obtained using a coronally repositioned flap4, by
direct coverage of the denuded root surface with free gingival graft or by combination of free gingival graft and coronally repositioned flap5. Marggraf6 presented a surgical procedure, which is a combined Edlan-Mejchar with a coronally repositioned bridging flap.
This report will focus on the Double Lateral Sliding Bridge Flap for root coverage in three patients with different Miller's Classes of marginal tissue
A 27 year old male patient reported to the Department of Periodontics with a chief complaint of sensitivity and difficulty in practicing oral hygiene procedures in lower anterior region.
The examination revealed Miller's Class I gingival defect in relation to lower right and left central incisors with high frenal attachment(Fig 1a).
Fig - 1a: Pre-op view
There was no more than 2 mm probing depth.
A 30 year old male patient reported to the department with the chief complaint of sensitivity of lower anterior region. We found Miller's Class I gingival defect in lower right central & lateral incisors and left lower central incisor (Fig 2a).
Fig - 2a: Pre-op view
A 45 year old female patient reported with the complaint of lowered gums in lower anterior region and unaesthetic appearance of the same. Clinical and radiographic examination revealed Miller's Class III gingival recession (Fig 3a),
Fig - 3a: Pre-op view
We decided to achieve not only root coverage but also adequate vestibular depth with functioning attached gingiva in all these patients. It was hoped that this would facilitate maintaining the health of mandibular incisors with routine oral hygiene procedures.
Professional plaque removal and oral hygiene instructions were given. Informed consent was obtained from the patients after explaining the procedure.
The first step is to determine the number of teeth to be covered. The incision should extend one tooth on either side of the number of teeth to be covered.
The next step is to measure the amount of recession. The first incision is an arc or semilunar shaped incision. It is placed on the vestibular mucosa/lip at a distance approximately 2 X GR + 2mm.(GR=Gingival Recession). This is necessary in order to produce a sufficiently wide bridging flap ensuring sufficient blood supply.
After the initial incision, a split or partial thickness flap is elevated in coronal direction till the
mucogingival junction is reached.
A full thickness flap is then raised from the gingival margin till it communicates with the partial thickness flap. The patency of the reflection can be checked
with the help of a periosteal elevator or a periodontal probe (Fig - 1b).
Communication of full & partial thickness flap
The root surface should be thoroughly debrided. Root planing was done with the help of the gracey curettes.
The whole bridge flap is coronally repositioned to cover the denuded root surface. The lips are then stretched to check for any muscular tension. The flap should stay in place without any tension while stretching the lips (Fig - 1c).
Bridge flap coronally positioned without tension
The sling suture is then placed with bites taken in the papilla. The purpose of this sling suture is to just hold the flap in place.
The last step is to place the loose alveolar mucosa over the space created by the attached gingiva, which has slid coronally. The flap is pressed to the alveolar bone for at least 3 minutes to avoid hematoma. The vestibular incision has to be left untouched with instructions to the patient not to stretch the lips for next few days. The vestibular incision will heal by secondary intention over the next few days. It is important to note that no sutures have to be placed for the incision at the vestibular end.
Antibiotics and analgesics were prescribed and a chlorhexidine mouth rinse was also given for twice daily use. The patients were checked the next day and was comfortable without any swelling or pain.
Two weeks after surgery, the dressing and sutures were removed. The patient's teeth were leaned and the importance of oral hygiene was emphasized.
In Case 1, (Millers Class I gingival defects with high frenal attachment) complete root coverage and frenal relief was achieved six months post operatively (Fig -1f).
vestibular mucosa / lip had an uneventful secondary healing.
In Case 2, (Miller's Class I gingival defect) complete root coverage was achieved. (six months
postoperative : Fig - 2d)
Six months post-op view
Three months post-op view
Root coverage can be performed to alleviate a patient's concerns regarding unsatisfactory esthetics and root hypersensitivity. Certainly of equal importance is restoration of the functional properties of zone of keratinized gingiva. Gingival recession, provides a nidus for microbial plaque and calculus accumulation and can be difficult to maintain with normal oral hygiene measures. When the recession is accompanied by an absence of attachment, that
area becomes especially vulnerable to inflammation8. Additionally, there is the potential for root caries to develop on the denuded root surfaces9.
The success and predictability of any surgical procedure for treating gingival recession is based on the amount of complete root coverage, with sulcus depth of 2 mm or less and absence of bleeding on probing10.
In this series of case reports, we have performed double lateral sliding bridge flap which is a pedicle flap from the vestibular mucosa / lip for the coverage of denuded roots.
Various schools of thought regarding the keratinization of the transposed alveolar mucosa were put forward. Ivan Bokass11 in 1997 in his study explained the development of keratinized epithelium. The transformation of an alveolar mucosal epithelium into a keratinized epithelium could have occurred as a consequence of the inductive influence of the underlying gingival connective tissue or as a result of the granulation tissue formation originating from the periodontal ligament tissue.
Also, Karring et al12 emonstrated that the underlying connective tissue had a direct bearing on the type of epithelium that is uperimposed upon it. This principle also explains the keratinization of alveolar mucosa, thus attaining significant increase in attached gingiva.
Achievement of adequate vestibular depth with functional widening of attached gingiva can be quoted as merits of bridge lap technique. Moreover, this is a single step procedure where recession coverage and frenal relief are obtained in the same procedure. Multiple teeth coverage is also possible with this procedure.
According to previously published data, 54.5% showed complete coverage 2 years post operatively and 30% showed a complete coverage after 5 years
using the lateral bridging flap13
In our report, three cases have been presented to demonstrate the use of double lateral sliding bridge flap in repairing gingival defects and re-establishing the integrity and continuity of the zone of keratinized gingiva. Case 1 & 2 with Miller's Class I gingival defects achieved 100% root coverage (six months postoperative) and Case 3 which was treated for Miller's Class III gingival defect achieved 80% of root coverage (three months postoperative) which was found to be satisfactory.
It would be tempting to speculate to perform this technique in Miller's Class I, II & also III marginal
tissue recession, with the abovementioned advantages. But since this is a case report, we need
more relevant studies to be done with large sample size and long term follow up to predict the success
Obtaining predictable and esthetic root coverage is the goal of periodontal plastic surgery. In this report, double lateral sliding bridge flap found to have satisfactory results. It also appears that neither the quantity of gingival recession nor the qualities of the supporting tissues are prerequisites for the success of this technique. The main advantage of this technique is that it is a one-step procedure, which enables us to cover the gingival recession and also extend the keratinized gingiva. The quality of the flap can be improved by the placement of a submerged connective tissue graft which may increase the probability of a stable result.
1. Grupe HE Warren RH. Repair of gingival defects by a sliding flap operation. J. Periodontal 956; 27: 92-95
2. Pennel BM, Tabox JC, Kerig KD, Towner FD, Fritz BD. Free masticatory mucosal graft. J. Periodontal 1969; 40: 162-166
3. Bjorn H. Coverage of denuded root surfaces with a lateral sliding flap use of free gingival grafts. Odont Revef 1971; -44.
4. Cohen EW, Ross SE. The double papillae repositioned flap periodontal therapy. J. Periodontal 1968; 39: 65-70
5. Hawley CE, Staffileno H. Clinical evaluation of free gingival grafts in periodontal surgery. J. Periodontal 1970, 41: 105-112.
6. Marggraf E. A direct technique with a double lateral grading flap fixes coverage of denuded root surface and gingiva extension. Clinical evaluation after 2 years. J. Clin. Periodontal 1985; 12; 69-76.
7. Miller PD Jr. A Classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985; 5: 8-13.
8. Lang NP, Loe H. The relationship between the width of keratinized gingival and gingival health. J Periodontol 1972;43:623-627.
9. Jordan HV, Sumney DL. Root surface caries: Review of literatutre and significance of the problem. J Periodontol 1973;44:158-163.
10. Miller PD - Root coverage with free gingival graft. J Periodontol 1987;58:674-681.
11. Juan Bokass. Potential of gingival connective tissue to induce keratinization of an alveolar mucosal flap; A long term histologic and clinical assessment - Case Report. Quintessence Int 1997; 28: 731-736.
12. Karring T, Lang NP, Loe H. The role of gingival connective tissue in determining epithelial differentiation. J Dent Res 1972; 51: 1303- 1304.
13. Romanos G E,Bernimoulin,E Maggraf.The double lateral bridging flap for coverage of denuded root surface: Longitudinal study and clinical evaluation after 5 to 8 years. J. Periodontol 1993;64:683-688.
* Lecturer ** Assosiate Professor *** Reader **** Professor & Vice Principal
Dept of Periodontics,