J Periodontal Implant Sci.  2014 Dec;44(6):300-306. 10.5051/jpis.2014.44.6.300.

Root coverage with a modified laterally positioned flap combined with a subepithelial connective tissue graft in advanced recession

• Lee CT
• Chang PC
• Touchan N
• Royzman D

• KMID: 1820403
• DOI: http://doi.org/10.5051/jpis.2014.44.6.300

Abstract

PURPOSE
A laterally positioned flap (LPF) combined with a subepithelial connective tissue graft (SCTG) is one of the conventional approaches for resolving gingival recession defects, with the advantages of flap flexibility and extended coverage of the tissue graft. However, thus far, evidence is lacking for the use of this technique for the treatment of advanced gingival recession defects. This report discusses three Miller class III cases with interproximal bone loss and wide and deep defects treated with a combination procedure of a modified laterally positioned flap (mLPF) and SCTG.
METHODS
mLPF combined with SCTG was performed for each case. The defect size and the degree of hypersensitivity at baseline and the final appointment in each case were documented.
RESULTS
The three cases had a mean initial defect of 7.7+/-1.5 mm and a mean residual defect of 1.7+/-1 mm at the 6-, 3-, and 36-month follow-up, respectively, after the root coverage surgery. The symptom of hypersensitivity was improved, and the patients were satisfied with the clinical outcomes.
CONCLUSIONS
The results demonstrated that the combination of mLPF with SCTG is promising for treating these advanced cases with respect to obtaining the expected root coverage with the gingival tissue.

Keyword

Case reports; Gingival recession; Periodontics

MeSH Terms

Connective Tissue*
Follow-Up Studies
Gingival Recession
Humans
Hypersensitivity
Periodontics
Pliability
Transplants*

Figure

• 

  Figure 1 Surgical technique of modified laterally positioned flap combined with subepithelial connective tissue graft placement. (A) Use the instrument (e.g., Dr. Allen intrasulcular knife) to partially elevate the interproximal gingiva without opening the flap. The partially elevated area should be larger than the area where the tissue graft will be placed. (B) Incise and elevate the modified laterally positioned flap. The incision starts 2 mm below the zenith of the interproximal papilla and should cross the mucogingival junction in vertical and oblique directions to increase the flexibility. The flap is split in thickness, and the periosteum underneath the gingiva is intact. (C) Insert the subepithelial connective tissue graft underneath the partially and fully elevated gingiva. The upper border of the graft is positioned about 2-3 mm above the interproximal crestal bone level. (D) The flap is laterally positioned and sutured. The flap with sufficient flexibility should be positioned about 1-2 mm above the expected level of the future gingival margin.

• 

  Figure 2 Case 1 clinical photographs. (A) The radiographic image of tooth #43; Tooth #43 had severe root resorption and significant interproximal bone loss. (B) The patient had generalized gingival recession and an open bite. Tooth #43 had a Miller class III gingival recession defect which was wide and deep (length: 8-9 mm). (C) A modified laterally positioned flap was made at the mesial interproximal gingiva with vertical and oblique incision. (D) The buccal alveolar bone of tooth #43 was missing and the resorption of the root apex was significant. (E) A clinical photograph on the date of completing surgery. (F) A clinical photograph at the six-month follow-up.

• 

  Figure 3 Case 2 clinical photographs. (A) Tooth #41 had a Miller class III gingival recession defect (length: 7-8 mm) and 0.5-1 mm wide buccal keratinized gingiva. (B) Tooth #41 had 1-2 mm of interproximal bone loss. (C) Modified laterally positioned flap was sutured and most of the subepithelial tissue graft was covered underneath the flap. (D) A clinical photograph at the three-month follow-up.

• 

  Figure 4 Case 3 clinical photograhs. (A) Periapical radiograph at the initial visit. (B) Bitewing radiograph at the initial visit. (C) Tooth #43 had a Miller class III gingival recession defect and the interproximal soft tissue had mild loss. (D) The flap was rotated mesially to assess the flexibility. (E) The subepithelial tissue graft was placed and sutured with Vicryl 5-0. (F) A clinical photograph on the date of completing surgery. (G) A clinical photograph at the six-month follow-up. (H) A clinical photograph of case 3 at the three-year follow-up.

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