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Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): ZD25-ZD27 2525
DOI: 10.7860/JCDR/2014/8367.4606 Case Report
Modified Approach of Double Papillae
Laterally Positioned Flap Technique using
Alloderm® for Root Coverage
Keywords: Alloderm, Cosmetic, Double papilla flap, Gingival recession, Lateral positioned flap, Root coverage
CASE REPORT
A 35-year-old male patient reported to outpatient Department
of Periodontology, with the chief complain of hypersensitivity in
lower anterior tooth region. On clinical examination, class I gingival
recession and lack of attached gingiva was noticed in relation to
mandibular left central incisor [Table/Fig-1] Diagnosis of chronic
localised periodontitis was reached. Other clinical parameters
noticed were probing depth of 1mm, gingival recession is 5mm and
clinical attachment loss is 6mm. The possible aetiology considered
to be incorrect tooth brushing technique. As the adequate amount
of attached gingiva was present in relation to the adjacent tooth
and patient’s unwillingness to underwent surgery for harvesting free
autografts from palate, it was decided to use double papilla lateral
flap with alloderm for root coverage. The patient was explained
about the procedure and written informed consent was taken.
Clinical parameters were assessed at the mid-buccal site of the
tooth using the CEJ as a fixed reference point from which recession
was recorded. All measurements were recorded using an UNC-15
periodontal probe at baseline, 3 months and 6 months after surgery.
Presurgical preparation including oral hygiene instructions, complete
scaling and root planning was done.
After adequate anaesthesia (2% lidocaine with 1:100.000
epinephrine), a v – shaped incision was made to remove a wedge
of gingiva over the exposed root. The full thickness lateral releasing
incisions was made at the mesiofacial and distofacial line angles of
the adjacent teeth on both sides of exposed root. This incision was
extended far enough apically into the mucosa to prevent bunching
of the tissue when the flaps are brought together. The submarginal
horizontal incision is made connecting lateral releasing incision to
recipient site; full thickness flap is elevated on either side of recipient
bed [Table/Fig-2]. The measured piece of rehydrated alloderm was
placed on recipient site involving the adjacent donor areas where
bone is exposed [Table/Fig-3] and sutured into place with sling and
interrupted sutures using 5-0 bioabsorbable suture [Table/Fig-4].
The lateral pedicle tissue is grasped with corn tissue plier and the
suture needle is passed through the outer surface of first papilla
and on through the under surface of another papilla. Coaptation
of double flap is done using 5-0 bioabsorbable suture. Releasing
incisions were sutured by interrupted sutures [Table/Fig-5]. Special
care is taken to ensure that there is no separation of flaps. Digital
pressure was applied for five mintues to aid initial adherence of the
flaps to the underlying bed and prevents formation of a blood clot.
After surgery, patient was instructed to discontinue tooth brushing
at the surgical area for two weeks and to rinse with 0.12%
chlorhexidine solution three times daily for 6-8 weeks. Amoxicillin
(500 mg three times a day for five days) and ibuprofen (three times
a day for five days) were prescribed. Suture removal was done at 15
days [Table/Fig-6]. Patient was recalled once a week for review for
the first month and then at the end of 3rd month [Table/Fig-7] and
6th months [Table/Fig-8] to evaluate stability of the root coverage
achieved. Regular maintenance care by scaling and plaque control
was performed.
The healing of the tissue was uneventful. Coverage of around
4mm was achieved. Shrinkage of the tissue during healing period
resulted in 1mm of the residual defect. The patient maintained good
oral hygiene and the probing depth on the midfacial surface of the
treated tooth was normal (2mm) throughout the six months follow-
up period. The result was found to be stable from 3 to 6 months.
The patient was instructed and trained to use a soft toothbrush and
to eliminate habits related to the aetiology of the recession.
Dentistry Section
ABSTRACT
Cosmetic concern is on increase in dental patients these days resulting in more demand for periodontal plastic surgical procedures. Gingival
recession is one of the common problems which impairs aesthetic and may result in hypersensitivity and increase chances of root caries.
Several plastic procedures are available to correct the defect. Double papilla laterally positioned flap combined with Alloderm has been
used to cover single tooth class I recession site as adequate width of keratinized gingiva is present on adjacent teeth. The technique has
resulted in 80% of root coverage.
CHITRA AGARWAL1, PRAGYA PUROHIT2, SURESH KUMAR SHARMA3, AASHISH SHARMA4
[Table/Fig-1]: Pre-operative photograph showing gingival recession
[Table/Fig-2]: Double papilla pedicle flap elevated from adjacent teeth
[Table/Fig-3]: Alloderm® graft placed at the site
Chitra Agarwal et al., Root Coverage using Double Papilla Flap and Alloderm® www.jcdr.net
Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): ZD25-ZD27
2626
technique was combined with alloderm®. This technique not only
results in root coverage but also results in increase in keratinised
attached gingiva. Double papillae laterally positioned flap technique
has been considered to be a reliable and predictable method for
treating localised gingival recession. The advantages of laterally
repositioned over other procedures are the presence of its own
blood supply after the transfer of the graft and a high survival rate.
It results in reduced hypersensitivity, aesthetic color matching, high
mean percentage of root coverage [4]. Studies have shown that
these procedures are associated with significant clinical attachment
gain with reduction in probing pocket depth along with root coverage
outcomes. The root coverage was obtained with no change in the
position of the gingival margin lateral to the defect [5]. Studies have
shown that laterally positioned flap results in 93% of root coverage
and 62.5% of the recipient sites with complete root coverage. This
technique have also resulted in gain in keratinised gingiva (more in
maxilla than mandible) [7].
Double laterally rotated bilayer flap, another modification of double
papillae flap had also resulted in complete coverage of root [8]. In
one of the study, lateral positioned flap showed results similar to
that of connective tissue graft for recession coverage with regard to
mean recession change ((LPF 2.47 mm versus CTG 2.64 mm) [9].
In the present case report, alloderm® has been used underneath
the flap to increase the predictability of the procedure. In a study,
alloderm® has been used with coronally advanced flap procedure,
mean gingival recession decreased from 4.20 to 0.25 mm when
basement side of the graft was toward the site and it decreased
from 3.70 to 0.15 mm when connective tissue side was toward the
site [6]. When double papilla flap combined with GTR was compared
with coronally advanced flap combined with GTR, the study had
shown that there was significant decrease in recession in both the
cases and no significant difference between the groups [10]. Double
papillae flap in combination with subepithelial connective tissue
graft had shown to have better result than free gingival graft alone
[11,12].
The present technique avoids discomfort and morbidity of patients
encountered with other grafting techniques which are associated
with palatal donor sites. This procedure is a time efficient, less
invasive, and highly aesthetic treatment option for managing isolated
recession defects [13].
CONCLUSION
Combining double papilla lateral sliding flap with Alloderm® for
root coverage presents a new technique which possesses many
potential benefits to patients with localised recession defects. Thus,
it can be considered as a predictable method for root coverage.
REFERENCES
[1] Camargo PM, Melnick PR and Kenney EB. The use of free gingival grafts for
aesthetic purposes. Periodontol. 2000. 2001; 27: 72-96.
[2] Cohen ES. Atlas of cosmetic & reconstructive periodontal surgery. Philadelphia,
Williams & Wilkins, 2nd Ed; 65-135.
[3]
Sato N. Periodontal Surgery. A clinical Atlas. Quintessence Publishing. Co. 336-55.
[4] Ramjford S. The lateral sliding flap with free gingival grafts. The University of
Michigan, School Of Dentistry. 1971.
DISCUSSION
Gingival recession is the displacement of the gingival margin
apical to the cemento-enamel junction with oral exposure of the
root surface. Gingival recession when causes hypersensitivity or
aesthetic problems necessitate the coverage of root [1,2]. Various
techniques such as free gingival graft, free connective tissue
grafts, pedicle flaps, allografts, guided tissue regeneration have
been proposed for root coverage. The selection of the procedure
depends on degree of recession, width of attached gingiva, no. of
teeth involved and postoperative color harmony. Each technique
has its own indications and limitations. Free autogenous grafts
result in good coverage but associated with second surgical site
and postoperative patient discomfort. On the other hand, Lateral
pedicle flaps have advantage of good blood supply and avoidance
of second surgical site, thus decreasing patient morbidity. They are
preferred at recession sites with narrow mesiodistal dimension on
single tooth, sufficient width, and thickness of keratinized gingiva
on adjacent tooth [3] Double papillae laterally positioned flap is the
type of lateral pedicle flap in which the adjacent papillae from either
[Table/Fig-4]: Alloderm® sutured and stabilized at the site
[Table/Fig-5]: Double papilla pedicle flap sutured over alloderm and stabilized
[Table/Fig-6]: Fifteen days post operative photograph
[Table/Fig-7]: Three months post operative photograph
[Table/Fig-8]: Six Months post operative photograph
side is mobilised into recession defect. Sometimes, pedicle flaps are
combined with free autografts to increase the predictability of the
procedure [4,5]. Alloderm® has been introduced as an alternative
to autografts and has also been combined with coronally positioned
flaps for root coverage in studies [6].
This case report describes the root coverage procedure using
newer technique in which Double papillae laterally positioned flap
www.jcdr.net Chitra Agarwal et al., Root Coverage using Double Papilla Flap and Alloderm®
Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): ZD25-ZD27 2727
PARTICULARS OF CONTRIBUTORS:
1. Senior Lecturer, Department of Periodontology, Jodhpur Dental College General Hospital, Jodhpur, India.
2. Senior Resident, Department of Oral Surgery, Mathura Das Mathur Medical College, Jodhpur, India.
3. Private Practitioner, Shree Balaji Dental Hospital, Nagori Gate Circle, Fort Road, Jodhpur-342001, India.
4. Senior Lecturer, Department of Public Health Dentistry, Jodhpur Dental College General Hospital, Jodhpur, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Chitra Agarwal,
Shree Balaji Dental Hospital, Near Electricity Office, Nagori Gate Circle, Fort Road, Jodhpur-342001, India.
Phone: 09414408077, E-mail: chitra_090282@yahoo.com
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Jan 03, 2014
Date of Peer Review: Feb 21, 2014
Date of Acceptance: May 30, 2014
Date of Publishing: Jul 20, 2014
[5]
Smukler H. A laterally positioned mucoperiosteal pedicle grafts in the treatment of
denuded roots. A clinical and statistical study. J Periodontol. 1976; 47(10): 590-95.
[6] Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW, Mehlbauer
MJ, et al. Predictable multiple site root coverage using an acellular dermal matrix
allograft. J Periodontol. 2001; 72 (5):571- 82.
[7] Chambrone LA, Chambrone L. Treatment of Miller Class I and II localized
recession defects using laterally positioned flaps: a 24-month study. Am J Dent.
2009; 22 (6): 339-44.
[8] Anita V, Vijayalakshmi R, Bhavna J, Ramakrishnan T, Arvindkumar, Bali V. Double
laterally rotated bilayer flap operation for treatment of gingival recession: A report
of two cases. J Indian Soc Periodontol. 2008; 12 (2): 51-54.
[9] Ricci G, Silvestri M, Rasperini G, Cattaneo V. Root coverage: a clinical / statistical
comparison between subpedicle connective tissue graft and laterally positioned
full thickness flaps. J Esthet Dent. 1996; 8 (2):66–73.
[10] Matarasso S, Cafiero C, Coraggio F, Vaia E, de Paoli S. Guided tissue regeneration
versus coronally repositioned flap in the treatment of recession with double
papillae. Int J Periodontics Restorative Dent. 1998; 18 (5):444-53.
[11] Chambrone L, Sukekava F, Araujo MG, Pustiglioni FE, Chambrone LA, Lima LA.
Root-Coverage procedures for the treatment of localized recession-type defects:
A Cochrane systematic review. J Periodontol. 2010; 81(4):452-78.
[12] Paolantonio M, di Murro C, Cattabriga A, Cattabriga M. Subpedicle connective
tissue graft versus free gingival graft in the coverage of exposed root surfaces. A
5-year clinical study. J Clin Periodontol. 1997; 24 (1):51-6.
[13] Isler MS, Kolhatkar S, Bhola M. Treatment of isolated recession defects using the
lateral sliding flap: a case series. Pract Proced Aesthet Dent. 2008; 20 (7): 437-
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