International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 4(16), August, 2012

Pages: 125-130

Date of Publication: 28-Aug-2012


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DOUBLE LATERAL SLIDING BRIDGE FLAP - A LESS TRODDEN PATH FOR THE COVERAGE OF DENUDED ROOTS-A CASE REPORT

Author: R.Vijayalakshmi, B.Ashwath, Rani Chellam, P.K.Saraswathi

Category: Healthcare

Abstract:Root coverage has become an important aspect of periodontal plastic surgery. It is a challenge in the presence of a high frenal pull and inadequate attached gingiva. This article reports a case of gingival recession, which has been treated with double lateral sliding bridge flap. The main advantages of this technique are that it doesn't require a separate frenectomy procedure and it can be used to cover multiple gingival recession defects, without a second surgical site. The treated case demonstrated adequate root coverage and increase in width of the attached gingiva at three months follow-up.

Keywords: Root coverage, bridge flap, gingival recession

Full Text:

INTRODUCTION
“Pink esthetics” is the terminology of concern in periodontal plastic surgery for root coverage. Gingival recession is an intriguing and complex phenomenon that may present numerous therapeutic challenges to the clinician. Patients are also frequently disturbed by recession owing to sensitivity and esthetics. Gingival recession is the exposure of the root surface by an apical shift in the position of the gingiva1. The term “marginal tissue recession” was proposed by Maynard and Wilson in 19792 to indicate exposure of root surface caused by apical migration of the soft tissue margin. The term was widely accepted because the soft tissue margin may not always be composed of gingiva; it may even be formed only by alveolar mucosa in some instances. For many years the presence of an adequate zone of gingiva was considered critical for the maintenance of gingival health and for the prevention of progressive loss of connective tissue attachment. It is generally acknowledged that an inadequate zone of gingiva would facilitate subgingival plaque formation as well as the apical spread of plaque-associated gingival lesions. Bowers in 19633 stated that it is possible to maintain a clinically healthy gingiva despite a narrow zone of attached gingiva i.e. <1mm. Ainamo and Loe in 19664 found that in patients with different degrees of recession, the width of the attached gingiva was more or less the same. Lang and Loe in 19725 showed in a clinical study that in areas with <2mm of keratinized gingiva, inflammation persisted irrespective of effective oral hygiene. They suggested that 2mm of keratinized gingiva were adequate to maintain clinical health. The conclusion drawn from various studies is that gingival health can be maintained independent of its dimensions6.

Important functional points in the treatment of mucogingival problems are to stop the progressive recession process and to facilitate plaque control in the affected area7. Appropriate mucogingival therapy can also result in the creation of adequate vestibular depth in areas where there is a deficiency. If untreated, gingival recession may progress and can compromise the prognosis of the affected tooth. Furthermore, root surface exposure may result in caries or abrasion, both of which may give rise to subsequent pulpal pathology8and9. Aberrant frenal attachment, inadequate vestibular depth, absence of the keratinized gingiva, gingival recession without pocket formation, and plaque accumulation despite effective home care are the indications for a bridge flap to form an adequate zone of attached gingiva. Mucogingival therapy includes increasing the dimensions of the gingival tissues to stop or prevent recession, to facilitate plaque control, and to improve aesthetics and to reduce or eliminate root sensitivity6. The double lateral sliding bridge flap technique was originally proposed by Marggraf in the year 198510 to cover gingival recession and to extend the gingiva in a one-step procedure. This technique utilizes a combination of a coronally advanced flap and the modified Edlan and Mejchar technique. The advantages of this technique are that it doesn’t require a second surgical site as in free soft tissue grafting procedures and a separate frenectomy procedure. This article reports a case treated with this technique.

CASE REPORT
A patient with the complaint of gingival recession and hypersensitivity was examined and various clinical parameters were recorded with a William’s periodontal probe.

  • Probing pocket depth [PPD].
  • Gingival recession [GR], by measuring the distance between the cementoenamel junction [CEJ] and the free gingival margin.
  • Width of the attached gingiva, by measuring the distance from the base of the pocket to the mucogingival junction.

The parameters were recorded before and after surgery. The surgical procedure was explained to the patient and informed consent was obtained.

Clinical Presentation
Intraoral examination of the 21-year old male patient revealed the following: Miller’s class II gingival recession of 4mm was present in relation to 41 and Miller’s class I gingival recession of 2mm was present in relation to 31. A high frenal attachment was present in relation to 31 and 41. The width of the attached gingiva was 1mm in relation to 31 and 41. PPD of 2mm was present in relation to 31 and 41 [ Fig 1].

Preparatory Phase
Preparation of the patient included scaling and root planing of the entire dentition and oral hygiene instructions.

Surgical Technique11
The bridge flap technique is a combination of the coronally repositioned flap and a modified vestibuloplasty procedure by Edlan and Mejchar (1965)12.

  • Prior to starting the procedure, local anaesthesia was administered by infiltration technique from 33-43 region and on the labial mucosa with 2% lignocaine. The first incision is arch shaped with a distance to the vestibule of approximately 2 x GR + 2mm. This is necessary in order to produce a sufficiently wide bridging flap ensuring a sufficient blood supply.
  •  A split thickness flap is elevated in a coronal direction and an incision into the periosteum is placed at its base.
  • This flap is elevated in a corono-apical direction after a sulcular incision.
  • The whole bridge flap is coronally repositioned to cover the denuded root surface and pressed to the alveolar bone for at least 3 minutes to avoid hematoma.

The patient was given antibiotic (Amoxycillin 500 mg every 8 hours for 5 days) and analgesics (Ibuprofen 400mg and paracetamol 500mg combination for 3 days) and post-operative instructions were given. Antibiotics were prescribed to control any post-operative infections. 0.2% chlorhexidine mouthrinse was prescribed for 4 weeks after surgery. A periodontal pack was placed in the operative site. The donor area was left to granulate and heal by secondary intention after the flap was coronally positioned [Fig 2-5]. Healing The sutures were removed 10 days after the procedure. The surgical site was examined for uneventful healing. There was no post – operative complication and healing was satisfactory[Fig 6]. The patient did not have any post-operative morbidity. The patient was recalled for post-operative examination on the 90th day. Complete root coverage was achieved. The width of the attached gingiva increased from 1mm to 5mm in relation to 31 and 41. PPD of 2mm was present in relation to 31 and 41. The patient was instructed to use a soft toothbrush for mechanical plaque control in the surgical area by a coronally directed roll technique.

DISCUSSION
Root hypersensitivity, predisposition to root caries and patient’s intense esthetic concern has broadened the scope of root coverage therapy. Several procedures have been proposed to cover gingival recessions. Marggraf in 198510 presented a surgical procedure namely, the double lateral sliding bridge flap technique, which is a combined Edlan-Mejchar technique with a coronally repositioned bridging flap. In the original Edlan-Mejchar technique12, which was developed to deepen the vestibule and not to cover gingival recessions, there was alveolar bone exposure. But in this modification there is no alveolar bone exposure. This could explain the uncomplicated and rapid healing in most cases. Also, in this technique, a coronally repositioned flap [CRF] could be used for root coverage even in the presence of an attached gingival width of less than 3mm10. Scientific data obtained from well-controlled clinical and experimental studies have unequivocally demonstrated that the apicocoronal width of the gingiva and the presence of an attached portion of gingiva are not of decisive importance for the maintenance of gingival health and height of the periodontal tissues. Consequently, the presence of a narrow zone of gingiva per se cannot justify surgical intervention15and16. Although increasing the band of attached gingiva is not the main aim of this technique, this was also achieved in the due course of the treatment. In this case, complete root coverage as defined by Miller in 198715 was achieved. Miller in 198715 defined complete root coverage in clinical terms as location of soft tissue margin at the CEJ, presence of clinical attachment to the root, a sulcus depth of 2mm or less and absence of bleeding on probing. The other advantages of this technique are that by releasing the periosteal fibers, the frenal pull also can be relieved, as seen in this case-report. There is no necessity for a separate frenectomy procedure. Also, as seen in this case, this technique can be used to cover multiple recessions. Even in the presence of a narrow width of attached gingiva, a high level of root coverage was achieved. This was in accordance with the study done by Romanos and Bernimoulin, 199311. In this case, neither the quantity of gingival recession, nor the quality of the supporting tissues affected the success of this technique. This observation is supported by two human studies which showed that the absence of a narrow band of keratinized gingiva did not interfere with gingivectomy / flap surgery results17. Also, some of the technical aspects described during the bridge flap procedure were key to its success. The initial semilunar incision was at least 2GR+2mm apical to the gingival recession and this provided a wide flap11. The results of our case reports are consistent with the previous studies done by Romanos et al 1993, Margraff et al 1985 who found 70% coverage even after a follow-up period of 5 – 8 years. This technique resulted in the development of keratinized epithelium of the transposed alveolar mucosa13and14. The possible sources of induction of keratinization of the underlying tissues according to the study done by Ivan Bokan et al, 199717 would be the remnants of the attached gingiva left on the flap margin after the paramarginal incision, the retained deepithelialized gingival tissue and the periodontal ligament. In the treated case, the double lateral sliding bridge flap technique has been successful in treating gingival recession in the presence of high frenal pull and shallow vestibule and the outcome was dependent on the careful performance of the operation. However, future long term studies are needed for evidence about the procedure. We assume that this case report will be useful in the future meta-analysis about this procedure.

ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

 

References:

1. In the treated case, the double lateral sliding bridge flap technique had been successful in treating gingival recession in the presence of high frenal pull and shallow vestibule and the outcome was dependent on the careful performance of the operation. Carranza, Newman, Klokkevold, Takei. Clinical features of gingivitis: In: Clinical Periodontology 2006;10:369.Bowers G.M. A study of the width of attached gingiva. J Periodontol 1963; 34: 201 – 209.

2. Maynard and Wilson. Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol 1979;50:170-174.

3. Bowers G.M. A study of the width of attached gingiva. J Periodontol 1963; 34: 201 – 209.

4. Ainamo J and Löe H. Anatomical Characteristics of gingiva. A clinical and microscopic study of the free and attached gingiva. J Periodontol 1966; 37: 5 – 13.

5. Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol 43: 623-627, 1972.

6. Jan Lindhe, Thorkild Karring, Niklaus P Lang. Mucogingival therapy – Periodontal plastic surgery.In: Clinical Periodontology and Implant dentistry. 2003;4:579.

7. Smith RG. Gingival recession: reappraisal of an enigma condition and a new index for monitoring. J Clin Periodontol 24: 201- 205,1997.

8. Grupe H, Watten R. Repair of gingival defects by a sliding flap operation. J Periodontol 27: 92-95, 1956.

9. Lindhe J, Nyman S. Alterations of the position of the marginal soft tissue following periodontal surgery. J Clin Periodontol 7: 525-530, 1980.

10. Marggraf E. A direct technique with a double lateral bridging flap for coverage of denuded root surface and gingival extension. Clinical evaluation after 2 years. J Clin Periodontol 1985; 12: 69 – 76.

11. Romanos GE, Bernimoulin JP, Marggraf E. The double lateral bridging flap for coverage of denuded root surface. Longitudinal study and clinical evaluation after 5-8 years. J Periodontol 1993;64:683-688.

12. Edlan A and Mejchar B. Plastic surgery of the vestibule in periodontal therapy. Int Dent Journal 1963;13:593-597.

13. Karring T, Lang NP, Loe H. The role of gingival connective tissue in determining epithelial differentiation. J Dent Res 1972;51:1303-1304.18

14. Niklaus P.Lang and Thorkild Karring. Proceedings of the first European Workshop on Periodontology 1994.In: Mucogingival surgery; 193-209.19

15. Miller PD, Jr – Root coverage with free gingival graft: J Periodontol 1987; 58:674 – 681.20

16. Wennström JL. Lack of association between width of attached gingiva and development of soft tissue recession. A 5-year longitudinal study. J Clin Periodontol 1987; 14: 181 – 184.21

17. Ivan Bokan. Potential of gingival connective tissue to induce keratinization of an alveolar mucosal flap: A long-term histologic and clinical assessment. Case report. Quintessence International 1997; 28: 731- 736.22

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Awards, Research and Publication incentive Schemes by IJCRR

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

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A study by Shafaque M. et al. entitled \"A Case-Control Study Performed in Karachi on Inflammatory Markers by Ciprofloxacin and CoAmoxicillin in Patients with Chronic Suppurative Otitis Media\" is awarded Best Article of Vol 14 issue 17
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A Study by Humaira Tahir et al. entitled "Comparison of First Analgesic Demand after Major Surgeries of Obstetrics and Gynecology between Pre-Emptive Versus Intra-Operative Groups by Using Intravenous Paracetamol: A Cross-Sectional Study" is awarded Best Article for Vol 14 issue 14
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A Study by Manoj KP et al. entitled "A Randomized Comparative Clinical Trial to Know the Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block Against Multimodal Analgesia for Postoperative Analgesia Following Caesarean Section" is awarded Best Article Award of Vol 13 issue 23
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A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
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A Study by Kumar S. et al. entitled "A Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India" is awarded Best Article for Vol 13 issue 09
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A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
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A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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Disclaimer: International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal.



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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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