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82
Journal of International Oral Health 2014; 6(6):82-84
Root coverage using double papilla … Samatha P et al
Root Coverage using Double Papilla Preservation Flap: A Case Report
Pallavi Samatha Yalamanchili
1
, Davanapelly Pavithra
2
, Sushma Potluri
2
, P R Arunima
3
Contributors:
1
Reader, Department of Periodontics, Drs Sudha and Nageswara
Rao Siddhartha Institute of Dental Sciences, Gannavaram, Krishna,
Andhra Pradesh, India;
2
Postgraduate Student, Department of
Periodontics, Drs Sudha and Nageswara Rao Siddhartha Institute
of Dental Sciences, Gannavaram, Krishna, Andhra Pradesh, India;
3
Reader, Department of Periodontics, PMS College of Dental
Science and Research, Thiruvananthapuram, Kerala, India.
Correspondence:
Dr. Yalamanchili PS. Drs Sudha and Nageswara Rao Siddhartha
Institute of Dental Sciences, Gannavaram, Krishna, Andhra Pradesh,
India. Phone: +91-9490716163. Email: pallavi_yalamanchili@
yahoo.co.in
How to cite the article:
Yalamanchili PS, Pavithra D, Potluri S, Arunima PR. Root coverage
using double papilla preservation ap: A case report. J Int Oral
Health 2014;6(6):82-4.
Abstract:
Gingival recession can result in an unesthetic appearance,
hypersensitivity, and root caries. The physiological well-being
of the patient is a signicant factor associated with the success of
dental therapy. Esthetics is one of the main concerns of the patient
if recession is present especially in anteriors. Hence, the treatment
of choice for root coverage for the anterior teeth should address
the biological as well as the patient’s aesthetic demands. Numerous
surgical procedures have been implicated for root coverage. Aesthetic
results from using pedicle grafting procedure are superior to the use
of free gingival grafts. The double papilla technique evolved from
treating defects where tissues adjacent or apical to the defect alone
may be inadequate for grafting purpose. This technique can be used
in areas with shallow vestibule and palatal areas. The double papilla
technique combines the esthetic results of pedicle graft with the
predictability and usefulness of free gingival graft and is an eective
and predictable method of obtaining esthetic root coverage.
Key Words: Double papilla technique, esthetics, recession, root
coverage
Introduction
Gingival recession is dened as the location of the gingival
margin apical to the cemento-enamel junction.
1
Most
important factors causing gingival recession are periodontal
disease and improper oral hygiene measures along with
other predisposing factors such as thin gingiva, a prominent
root surface, labially positioned teeth, frenum pull, and
bone dehiscence.
2
Recession of the gingival margin results
in an impaired esthetic appearance and sometimes dental
hypersensitivity. Gingival recessions are treated to increase
the attached gingival width and in some cases for esthetics.
Various techniques are described to achieve root coverage. The
procedures to treat the recession are classied into pedicle soft
tissue grafts or free soft tissue grafts.
3
Pedicle graft procedures, depending on their direction of
transfer may be grouped as: (i) rotational aps (such as lateral
sliding aps or papilla aps) or (ii) advanced aps with or
without rotation or lateral movement.
4
Two important factors which inuence the root coverage
outcome include (i) height of the interdental bone
and (ii) interdental soft tissue adjacent to the defect. The
depth and width of the defect and the amount of avascular tooth
surface in contact with a graft during initial healing period will
also aect the outcome.
The double papilla technique is opted to treat Miller’s Class 1
recession in this case report.
Case Report
A male patient aged 31 years came to the dental oce with
Miller’s Class I recession in relation to buccal aspect of 24.
Patient was in good health and had not received any periodontal
therapy previously. On intraoral examination, the recession was
2 mm in length and 2 mm in width (Figure 1). The attached
gingival width adjacent to the recession was 3 mm and probing
depth of the adjacent tooth was 2 mm on mesial side, 1 mm
on buccal side, 3 mm on distal side, and 2 mm on palatal side.
Surgical technique
Local anesthesia with 2% lidocaine (2% lignox, 1:80,000)
was administered, and two horizontal incisions were made
Received: 11
th
May 2014 Accepted: 15
th
August2014 ConictofInterest:None
SourceofSupport:Nil
Figure 1: Pre-operative incisions given.
Case Report
83
Journal of International Oral Health 2014; 6(6):82-84Root coverage using double papilla … Yalamanchili PS et al
on the interdental papilla, parallel to the cemento-enamel
junction of the tooth to be treated with no. 15 blade. Two
releasing incisions were made obliquely at the line angles of
the adjacent teeth, and these incisions were extended beyond
the mucogingival junction (Figure 2).
Partial thickness ap on the mesial and distal portions was
elevated (Figure 3), and the root surface which was exposed
was planned thoroughly using a curette. Root conditioning was
performed using tetracycline hydrochloride (250 mg, pH 1.8)
for 5 min (Figure 4). De-epithelialization of the ap was done
and rotated to cover tetracycline treated root surface.
The other pedicle ap which was un-deepithelialized was
kept in position to cover the previous flap. Interrupted
suturing (5-0 vicryl) was done across the medial area of the
two papilla aps (Figure 5). Surgical site was protected with
tin foil (Figure 6), and periodontal dressing was given with
coe-pack. The patient was advised to refrain from brushing
at the grafted site for 3 weeks. The patient was instructed to
rinse with 0.2% of chlorhexidine mouthwash twice daily for
3 weeks. Antibiotic (amoxicillin 500 mg, 3 times a day for
5 days) and analgesic (acecloren-p [aceclofenac 100 mg and
paracetamol 500 mg] 3 times a day for 5 days) was prescribed.
The patient was reviewed after a week, 2 weeks, and after a
month. Complete root coverage was observed at 3 months
follow-up (Figure 7).
Discussion
Complete coverage of the root is the main objective to be
achieved when treating gingival recession in patients who have
Figure 2: Oblique releasing.
Figure 3: Partial thickness ap elevated.
Figure 4: Root conditioning done with tetracycline.
Figure 6: Tin foil placed.
Figure 5: Sutures placed.
84
Journal of International Oral Health 2014; 6(6):82-84Root coverage using double papilla … Yalamanchili PS et al
esthetics as their priority. Dierent surgical techniques are
practiced for root coverage which include lateral pedicle aps,
coronally advanced aps, free gingival grafts, free connective
tissue grafts, etc.
The double papilla procedure is technique sensitive
but has good results in treating isolated recessions. The
partial thickness double papilla pedicle graft technique
was first proposed by Cohen and Ross.
5
Hall stated that
double pedicle graft had “very low predictability in most
practitioners’ hands.”
6
The 1989 World Workshop in
clinical Periodontics concluded “the double papilla pedicle
has very limited usefulness.”
7
Its weaknesses are its poor
predictability and the technical skills required to perform
the procedure. Nelson proposed a technique that combines
a free connective tissue graft with a full thickness double
papilla graft.
8
Harris further proposed the use of a partial
thickness double pedicle flap rather than a full thickness
one overlying a free connective tissue graft as partial
thickness flap allows the connective tissue graft to receive
vascular supply both from the recipient bed and from the
flap overlying it.
9
The advantages of this technique include excellent color
matching, good vascular supply, root coverage, and decrease
in hypersensitivity.
10
The greatest advantage of this
procedure is that there is no need for an additional donor
site.
11
Few factors have to be considered when opting for
this technique.
Figure 7: 3 months post-operative.
1. The interdental papilla should be thick next to recession
2. There should be an absolutely healthy periodontium
adjacent to the recession to be treated
3. This technique cannot be practiced to treat multiple
adjacent recessions.
Conclusion
In the past decades, several surgical procedures have been
proposed for treating gingival recession. However, the choice
of mucogingival surgical technique to treat a recession defect
depends on the clinician’s skill and the type of recession. The
double papilla technique had demonstrated good esthetic
results in this case report.
References
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th
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