Root coverage with bridge flap
A female patient aged 42 years reported in the Faculty of Dental Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India, with a chief complaint of receding gums in multiple lower anterior teeth. Clinical examination revealed an inadequate zone of attached gingiva (tension test-positive) with shallow vestibule appearing. The recession was Grade II, according to Miller's classification, in 32, 31, 41 teeth[] []. The recession was uniform of about 4 mm in all the lower anteriors and the width of attached gingiva was 2 mm. Intraoral periapical radiograph in relation to 32, 31, 41 revealed adequate bone support in interdental areas. Clinical parameters were recorded using UNC-15 periodontal probe. Clinical parameters included Probing Pocket Depth (distance from gingival margin to base of pocket), Gingival Recession (distance from cemento-enamel junction to gingival margin), width of attached gingiva (distance from base of pocket to mucogingival junction), and Clinical Attachment Level (distance from cemento-enamel junction to base of pocket).[] The procedure was well explained to the patient and informed consent was obtained for surgery. The patient was medically sound and fit, so a surgical procedure was planned. Scaling and root planing was done prior to surgery.\nAfter administering local anesthesia (2% lignocaine hydrochloride with 1:80,000 epinephrine), an incision was made in the vestibule from 33 to 43 [] into the periosteum at its base and the bone was exposed so that scar formation could occur. This procedure deepens the vestibule with fenestration technique to increase the width of attached gingiva. The surgical procedure included the bridge flap technique as introduced by Marggraf[] and later on modified by Romanos.[] A spilt-thickness flap was elevated in the apicocoronal direction by making a sulcular incision, connecting it with the first incision so that the whole bridge flap could be elevated and repositioned coronally to cover the denuded root surfaces from 33 to 43 []. No vertical incisions were given. This forms a bridge from coronal aspect to the vestibule as shown in . Thereafter, root conditioning was done with tetracycline HCl. Then, the flap was repositioned coronally with interrupted stabilization sutures [] and, in the vestibule, the epithelium was sutured with the periosteum []. Sutures were resorbable in nature. After suturing, periodontal dressing was given []. Patient was discharged with all post-surgical instructions and medications for 5 days to avoid postoperative pain and swelling. Patient was recalled after 7 days for suture removal. The surgical site was examined for uneventful healing. There were no postoperative complications and healing was satisfactory with significant root coverage and significant gain in attached gingiva and clinical attachment was 5 mm []. Postoperative recession at 1 month follow-up was about 1 mm. Patient was instructed to use soft toothbrush for mechanical plaque control in surgical area. Patient was monitored on weekly schedule postoperatively, to ensure good oral hygiene in the surgerized area. Supportive periodontal maintenance at 3 months was prescribed to maintain periodontal health and to re-evaluate this area; 9 months follow-up showed no recurrence.