Vestibular deepening by periosteal fenestration and its use as a periosteal pedicle flap for root coverage
A 17-year-old girl reported to the Department of Periodontics with the chief complaint of unesthetic appearance of her front lower teeth []. On examination, it was found that 6 mm deep and 4 mm wide class II gingival recession (Miller, 1985) was there on the lower left central incisor [Figures and ]. The tooth was slightly labially placed and patient also gave the history of tooth brush trauma. The vestibular depth and the width of attached gingival were also inadequate in the region. There was no mobility associated with the tooth. For the root coverage, increase in width of attached gingiva and vestibular deepening the periodontal plastic surgery was planned with a single stage fenestration technique and root coverage using the periosteal pedicle graft. The patient was advised for the treatment of the isolated gingival recession defect. The patient was in good systemic health with no contraindications for periodontal surgery. She was explained about the surgery and signed informed consent was taken by the patient. A general assessment of the patient was made through her history, clinical examination and routine laboratory investigations. Before surgery, the patient received phase-I therapy, which included oral hygiene instructions and scaling and root planning with ultrasonic and hand instruments. Two weeks after phase I therapy, the patient was planned for surgical procedures. On the day of surgery, local anesthesia was first administered bilaterally by using a mental nerve block. A horizontal incision was made using a no. 15 surgical blade at the mucogingival junction retaining all of the attached gingiva [Figures and ]. A split thickness flap was reflected sharply, dissecting muscle fibers and tissue from the periosteum. This was then sutured in the depth of the vestibule using resorbable 5-0 sutures []. A strip of periosteum was then removed at the level of the mucogingival junction, causing a periosteal fenestration exposing the bone. The care was taken not to remove the periosteal strip completely and to leave it pedicled to the bone and the rest of the surrounding periosteum at the lateral end [Figures and ]. The recipient site preparation included two horizontal incisions. First, intracrevicular incision and a second incision made parallel and apical to the first incision []. The incisions were followed by split-thickness dissection of the facially located tissue up to the level of the vestibular incision so as to create a tunnel [Figures and ]. The exposed root surface was root planed with curettes to remove bacterial contamination and was biomodified using the tetracycline powder mixed with saline. The pedicled periosteal donor tissue was then moved vertically towards the recession area, passing through the tunnel [Figures -]. At repositioning, the osteoperiosteal portion was closely adapted to the recipient site by pressing for 3 min and then sutured along with the overlying gingival tissue, to the recipient bed, using 5-0 resorbable sutures [Figures and ].\nPeriodontal dressing (Coe-Pak; GC America Inc.) was applied over the operated area covering the exposed bone []. Antibiotic therapy (amoxicillin 500 mg, Thrice daily and analgesic (ibuprofen 400 mg twice daily) was prescribed for 5 days. Tooth-brushing was discontinued for the first 2 weeks at the surgical site and 0.2% chlorhexidine mouth rinse was instructed till 4 weeks after surgery. Coepak was removed 10 days after the surgical procedure and the patient was asked to maintain meticulous oral hygiene. Healing had proceeded uneventfully, with secondary wound closure []. In 3 weeks, healing was nearly complete, with minimal post-operative discomfort to the patient []. At 6 months post-operative, root coverage was nearly 100% of the recipient site, with minimal probing depths, no inflammation, and a favorable esthetic result [].