Laterally positioned flap-revised technique along with platelet rich fibrin in the management of Miller class II gingival recession
A 36-year-old male patient came to Department of Periodontia, Government Dental College and Hospital, Patiala with chief complaint of receding gums and sensitivity of lower teeth. On clinical examination a Miller class-II recession defect was present in 41 on buccal aspect along with shallow vestibule. There was clinical attachment loss of 7 mm. The distance between the cemento-enamel junction and gingival margin was 5 mm and the distance between the gingival margin and the base of the pocket was 2 mm. Base of the pocket was extending above the mucogingival junction [].\nA two stage treatment modality was contemplated. In the first stage, to increase the vestibular depth a vestibular extension (Fenestration technique)[] was planned. In the second stage, laterally positioned flap-revised technique[] along with PRF membrane was speculated to cover gingival recession.\nA general assessment of patient was made through history and routine laboratory investigations. The surgical procedure was explained to the patient and the informed consent obtained. Preparation of the patient included scaling and root planing and oral hygiene instructions. Modified Stillman's brushing technique was prescribed to the patient.\nParameters were assessed with UNC-15 periodontal probe. Following parameters were assessed at baseline and 6 months after the surgical procedure.\nClinical recession depth (RD) - distance between cemento-enamel junctions to the most apical point of gingival margin.\nPocket depth (PD) - distance between the gingival margin and the bottom of the gingival sulcus.\nClinical attachment level (CAL) - measured from the cemento enamel junction to the bottom of the pocket.\nStep 1: Vestibular extension procedure. After proper isolation of the surgical field, the operative sites were anesthetized using 2% xylocaine hydrochloride with adrenaline (1:200000). A horizontal incision was made using a #15 blade at the mucogingival junction retaining all of the attached gingiva. Flap was reflected sharply, dissecting muscle fibers. A rectangular periosteal strip measuring 2-3 mm width was then bluntly dissected at the level of mucogingival junction along the length of operative field, causing a periosteal fenestration []. Periodontal dressing (Coe pak) was placed over the wound. Post-operative instructions were given to the patient. Periodontal dressing was removed after 7 days. Patient was re-evaluated after 3 months [].\nStep 2: After 3 months, laterally positioned pedicle flap-revised technique along with PRF was done. After proper isolation of the surgical field, the operative sites were anesthetized using 2% xylocaine hydrochloride with adrenaline (1:200000). A collar of tissue was removed around the recession by two vertical incisions, which joined at one point apical to the base of the recession []. Then the donor site (right canine) was prepared by giving a vertical incision extending from gingival margin to the oral mucosa up to the level of the base of central incisor with a #15 blade. After that, thorough scaling and root planning was performed. The sliding flap detached as follows: First, the one-half of the flap away from the recession was reflected as a split thickness flap by giving sharp dissection using #15 blade, and then one half of the flap close to the recession was reflected as full thickness flap by giving blunt dissection using periosteal elevator [Figures and ]. The entire flap was finally released by performing an undermining incision through the periosteum at its apical base.\nThe 5 ml of blood was drawn in 10 ml test tube without an anticoagulant and centrifuged immediately. Blood was centrifuged in single step using a Bench top centrifuge (REMY Laboratories, Goregaon, Mumbai, India) for 10 min at 3000 rpm.[] The resultant product consisted of the following three layers: Top layer consisting of acellular platelet poor plasma, PRF clot in the middle, RBC's at the bottom []. The PRF membrane was obtained by squeezing out the fluids from the fibrin clot.[] The PRF membrane was placed over the denuded roots and stabilized []. The flap was then slided to completely cover the membrane and secured using sling sutures []. Periodontal dressing (Coe-pak) was used over the surgical site.\nAmoxicillin 500 mg thrice a day was prescribed for 5 days. Ibuprofen 400 mg thrice daily and vitamin-B complex, 1 capsule daily were also prescribed for 5 days. Patient was recommended to follow all the normal oral post-operative hygiene instructions. Patient should rinse the oral cavity with 0.12% chlorhexidine digluconate mouth rinse for two weeks. Patient was advised to avoid pulling on their lips to observe the surgical site. Both dressings and sutures were removed 12 days after surgery []. Post-operative follow-up was done for 6 months []. In this case, there was no post-operative complication and healing was satisfactory. The patients did not have any post-operative morbidity.