* denotes required field

Your Name: *

FIRST NAME

 LAST NAME

Gender: *

Personal Email: *

This will be your username

Password: *

Display Name: *

This will be what others see in social areas of the site.

Address: *

STREET ADDRESS (LINE 1) *

 

STREET ADDRESS (LINE 2)

 

CITY *

STATE *

ZIP *

 

 

Phone Number:

School/University: *

Graduation Date: *

Date of Birth: *

ASDA Membership No:



ABOUT SSL CERTIFICATES

Username

 

Password

Hi returning User! please login with Facebook credentials where Facebook Username is same as THENEXTDDS Username.

Username

 

Password

 
Article
Comments (0)

Treatment of Isolated Recession Defects Using the Lateral Sliding Flap

A Case Series

Root coverage using the lateral sliding-flap technique is a less invasive, time efficient and highly aesthetic treatment option for isolated recession defects.1  By using adjacent tissue, the lateral sliding flap allows for correction of the defect without the discomfort encountered during other grafting techniques associated with palatal donor sites.2, 3 Indications for this procedure include adequate, adjacent, keratinized tissue, narrow recession defects, and recession limited to one or two teeth.  The following case series describes this technique and demonstrates its efficacy in various clinical settings.

 

Case Presentations

Case 1

A 35-year-old female patient presented with a recession defect on tooth #24(31) and associated sensitivity. The recession defect measured 4 mm vertically and 3 mm horizontally and was classified as a Miller Class I defect (Figure 1).

After the patient was anesthetized, all hard and soft tissue deposits were removed from the recipient site via hand and rotary instrumentation. The initial partial-thickness incision was made originating at the papilla between teeth #23(32) and #24 at the height of the cementoenamel junction (CEJ). The incision continued parallel to the sulcus of the recipient tooth #24, extending to the distal surface, apical to the mucogingival junction. The second incision extended 1 mm to 2 mm horizontally at the papilla between teeth #24 and #25(41) and then moved apically to join the first incision well past the mucogingival junction. The sulcular epithelium and overlying epithelial layer between the first two incisions was removed using a 15C blade. The third, oblique full-thickness incision was made between teeth #22(33) and #23, parallel to the first incision and extending apically to the mucogingival junction. A horizontal, sulcular incision was then made connecting the first and third incisions. A full-thickness flap was reflected and laterally displaced to the recipient site. The flap was subsequently sutured using 4-0 vicryl sling and an interrupted suture technique (Figure 2). After suturing, the flap was completely immobilized and stable, and pressure was applied to the tissue for five minutes. At the one year follow up, proper flap adaptation, excellent color match and 100% root coverage were observed (Figure 3). The patient did not report any postoperative discomfort or sensitivity.          


Case 2

A 67-year-old female patient presented with severe recession and compromised aesthetics on the facial surface of tooth #27(43) (Figure 4).

Approximately 5 mm of vertical and 3 mm of horizontal recession were evident. The adjacent, keratinized tissue was found to have a width of 6 mm and a height of 4 mm; the probing depth on the facial aspect of #27 was 2 mm. The recession defect was classified as a Miller Class II defect.3

Following anesthesia delivery, the recipient site underwent scaling and root planing, and the root surface was smoothed. The initial partial-thickness incision was made originating at the papilla between teeth #26(42) and #27 at the height of the CEJ, continuing parallel to the sulcus of the recipient tooth #27, and extending to the distal surface of #27, well beyond the mucogingival junction. The second incision extended 1 mm to 2 mm horizontally at the papilla between #27 and #28(44) and then moved apically to join the first incision well beyond the mucogingival junction. The sulcular epithelium and overlying epithelial layer between the first two incisions was removed using a 15C blade. The third, oblique, full-thickness incision was made between teeth #26 and #27, parallel to the first incision, and extending beyond the mucogingival junction. The fourth incision extended horizontally and submarginally to connect the first and third incisions, leaving approximately 1 mm of the marginal gingiva (Figure 5A). A full-thickness flap was reflected to ensure adequate thickness to the donor tissue, and flap elevation was considered sufficient when it was possible to move the flap laterally above the exposed root surface without encountering resistance. The tissue was then laterally displaced to the recipient site and sutured (Figure 5B). Following suturing, the flap was kept completely immobile and stable, and pressure was applied to the graft for five minutes to promote the formation of a clot and stabilization of the flap. Wound healing following placement of a pedicle flap was dependant upon the ability of the tissue to form a fibrin clot during the adaptation stage of healing.4

Healing was unremarkable at the two week follow up, and the four-week postoperative result demonstrated successful flap adaptation with an appropriate color match and gingival contours (Figure 6). The position of the free gingival margin was 1 mm apical to the CEJ, resulting in approximately 85% root coverage. The patient did not report any postoperative sensitivity or discomfort.

Case 3

A 55-year-old male patient presented with a severe recession defect on the facial aspect of tooth #12(24) (Figure 7).  The recession measured 10 mm vertically and 4 mm horizontally, which categorized it as a Miller Class II defect.

The patient was anesthetized prior to scaling and root planing, and the root surface was smoothed. The initial partial-thickness incision was made originating at the papilla between #11(23) and #12(24) at the height of the CEJ, continuing parallel to the sulcus of the recipient tooth #12. This incision extended to the distal surface of #12, well beyond the mucogingival junction. The second incision extended 1 to 2 mm horizontally at the papilla between #12 and #13(25) and then moved apically to join the first incision past the mucogingival junction. The sulcular epithelium and overlying epithelial layer between the first two incisions was removed, as preparation of the recipient site for the donor flap. The third, oblique, full-thickness incision was made between teeth #13 and #14, parallel to the first incision, and extending beyond the mucogingival junction. The fourth incision extended horizontally and submarginally, connecting the first and third incision, and leaving approximately 1 mm of marginal gingiva. A full-thickness flap was reflected, and the tissue was laterally displaced to the recipient site and sutured using 5-0 vicryl sling and interrupted sutures. Following suture placement, the flap was kept completely immobile and stable, and pressure was applied to it for five minutes to promote clot formation and flap stabilization.

At the two week follow up, healing was unremarkable and at the four-week postoperative appointment, the tissue demonstrated successful flap adaptation with proper gingival contours (Figure 8). The patient did not report any postoperative sensitivity or discomfort. The position of the free gingival margin was approximately at the level of the CEJ, resulting in 100% root coverage. A three-year follow-up demonstrated the maintenance of the marginal tissue and long-term success of treatment (Figure 9). Slight recession was noted on the donor on the facial aspects of teeth #12 and #13.

 

Case 4

A 65-year-old female patient presented with recession that measured 3 mm vertically and 3 mm horizontally on the facial aspect of tooth #26 (Figure 10).  Her chief complaint was temperature sensitivity to cold in her first molar.

The initial partial-thickness incision was made originating at the papilla between teeth #25 and #26 at the height of the CEJ, continuing parallel to the sulcus of the recipient tooth #26, and extending to the distal surface well beyond the mucogingival junction. The second incision extended 1 mm to 2 mm horizontally at the papilla between teeth #25 and #26 and then moved apically to join the first incision apical to the mucogingival junction. The sulcular epithelium and overlying epithelial layer between the first two incisions was removed using a 15C blade. The third, oblique full-thickness incision was made between teeth #26 and #27 parallel to the first incision extending apical to the mucogingival junction. A horizontal, submarginal incision was then made to connect the first and third. A full-thickness flap was reflected and laterally displaced to the recipient site. A cutback incision was made at the distal-apical extent of the flap to ensure passive movement of flap laterally and occlusally to the exposed root surface. The flap was subsequently sutured using 5-0 vicryl sling and interrupted sutures. After suturing, the flap was completely immobilized and stable, and pressure was applied to the tissue for five minutes.           

Healing was unremarkable at the two week follow up, and at the three-week postoperative visit, the tissues demonstrated successful flap adaptation with 100% root coverage (Figure 11). An 18-month follow-up visit demonstrated the successful results of the procedure and excellent color and contour of the pedicle flap (Figure 12).

Discussion

The lateral sliding flap is a valuable procedure in cases of localized gingival recession.1 The clinician’s ability to work with one surgical site decreases patient discomfort and also preserves the vascularity of the pedicle flap, increasing the probability of graft survival and root coverage.5 The technique is limited by the width and thickness of the adjacent keratinized tissue and can only be used for isolated defects. This method is contraindicated in the presence of deep interproximal pockets, excessive root prominences, when multiple teeth are involved, when a shallow vestibule is present, and if a significant loss of interproximal bone height is present (Table 2).

 

*Periodontal resident, University of Detroit Mercy School of Dentistry, Detroit, Michigan.

†Assistant Clinical Professor, University of Detroit Mercy, Detroit, Michigan; private practice, Troy, Michigan.

‡Director of Post-Graduate Periodontics, Co-Director of Implant Dentistry, University of Detroit Mercy, Detroit, Michigan; private practice, Waterford, Michigan.

References:

  1. Grupe HE, Warren RF. Repair of gingival defects by a sliding flap operation. J Periodontol 1956; 27:92-95.
  2. Corn H. Edentulous area pedicle grafts in mucogingival surgery. Periodontics 1964;2:229.
  3. Miller PD Jr. A classification of marginal tissue recession. Int J Periodont Rest Dent 1985;5(2):8-13.
  4. Wilderman MN, Pennel BM, King K, Barron JM. Histogenesis of repair following osseous surgery. J Periodontol 1970;41(10):551-565.
  5. Espinel MC, Caffesse RG. Comparison of the results obtained with the laterally positioned pedicle sliding flap–Revised technique and the laterally sliding flap with a free gingival graft technique in the treatment of localized gingival recessions. Int J Periodont Rest Dent 1981;1(6):30-37.

Tables

Table 1: Advantages and Disadvantages to Lateral Sliding Flap Protocol


Advantages

Disadvantages

1. Single surgical site (no donor site)

1. Limited by the amount of adjacent keratinized attached gingiva

2. Acceptable pedicle flap vascularity

2. Possibility of recession at donor site

3. Postoperative color match is consistent with surrounding tissues

3. Limited to one or two teeth with recession defects

4. Time efficient procedure

4. Dehiscence or fenestration at donor site

Table 2: Indications and Contraindications of Lateral Sliding Flap Protocol

 

Indications

Contraindications

1. Adequate length, width, and thickness of keratinized tissue adjacent to recession defect

1. Insufficient width and thickness of keratinized tissue adjacent to recession defect

2. Recession is limited to one or two teeth

2. Presence of deep interproximal pockets

3. Best results with narrow recession defects

3. Excessive root prominence

 

4. Multiple teeth involved

 

5. Deep or extensive root abrasion or erosion

 

6. Shallow oral vestibule

 

7. Significant loss of interproximal bone height

Table 3: Clinical Studies on the Use of Lateral Sliding Flaps for Root Coverage

 

Author/ Date of Publication

Length of Study (months)

Pre-treatment recession, Mean (mm)

Exposed Root Coverage, Mean (%)

 

Number of patients/ Teeth

Complete Root Coverage (% teeth)

Espinel & Caffesse, 198116

6

3.5

74

14/14

----

Guinard & Caffesse, 19788

6

3.3

69

14/14

----

Smuckler, 197612

9

3.5

72

15/21

----

Oles et al. 1985

3

3.6

74

10/10

40-50

Caffesse et al. 1987

6

4.2

56

14/14

----

Adapted from Wennstrom JL. Mucogingival therapy. Ann Periodontol 1996;1(1):671-701.

Sorry, your current access level does not permit you to view this page.