Clinical Advances in Periodontics Vol. 7, No. 4, November 2017 : Page-195

CASE REPORT Minimally Invasive Treatment of Mandibular Anterior Lingual Defects by Vestibular Incision Subperiosteal Tunnel Access Technique and Connective Tissue Graft: A Case Report Kriti Mehrotra Vijay,* M. Gowda Triveni,* A.B. Tarun Kumar,* and Dhoom Singh Mehta* Introduction: Treatment of recession defects on the lingual surface of mandibular anterior teeth is challenging owing to site-specific anatomic features of this region. Surgical approaches based on use of subepithelial connective tissue grafts (SCTGs) are considered the “ gold standard ” for treatment of multiple recession defects. To the best of the authors ’ knowl-edge, this is believed to be the first case report of an attempt to correct lingual recession by SCTG with the minimally invasive vestibular incision subperiosteal tunnel access technique. Case Presentation: A non-smoking 55-year-old male patient presented with hypersensitivity in his mandibular an-terior teeth in August 2016. Multiple lingual recession defects were treated by placing a SCTG harvested from the palate underneath the subperiosteal tunnel using a midline access incision. Six months after treatment, a significant increase of root coverage (88.17%), gain in gingival thickness (1.29 mm), and width of keratinized gingiva (1.41 mm) led to a promising outcome and high patient satisfaction. Conclusion: A minimally invasive surgical technique has been presented that can restore the functional properties of lingual gingiva of the mandibular anterior teeth by repairing gingival defects and reestablishing integrity of the zone of kerati-nized gingiva. Clin Adv Periodontics 2017;7:195-200. Key Words : Connective tissue; gingival recession; mandible; personal satisfaction; sutures; treatment outcome. Background Gingival recession (GR) is a widespread clinical manifes-tation affecting single or multiple teeth of all tooth types and all tooth surfaces. 1 Over the years, several root cov-erage (RC) techniques have been proposed with pre-dictable treatment outcomes. 2 However, challenges for clinicians arise when patients present with lingual mucogingival concerns as empirical evidence to make decisions regarding appropriate care in such cases is lacking. A recent consensus report highlights that RC on * Department of Periodontics, Bapuji Dental College and Hospital, Davangere, India. Submitted April 1, 2017; accepted for publication June 13, 2017 doi: 10.1902/cap.2017.170020 the lingual aspect of teeth is possible, but evidence on predictability is insufficient. 2 GR at the lingual surfaces of mandibular anterior teeth shows a strong association with the presence of supragingi-val and subgingival calculus. 3 A few case reports list it as a complication of tongue piercings. 4,5 The goal of treatment for GR should not be merely limited to re-creation of es-thetics but must equally focus on restoration of the protec-tive functional morphology of the mucogingival complex and regeneration of the lost attachment apparatus. 6 A coronally advanced flap (CAF) with autogenous sub-epithelial connective tissue graft (SCTG)-based RC proce-dure shows the best clinical outcomes for both recession reduction and complete root coverage. 6 This case report introduces an approach of combining a vestibular incision subperiosteal tunnel access (VISTA) technique with a SCTG and demonstrates its successful use in lingual RC. Clinical Advances in Periodontics, Vol. 7, No. 4, November 2017 195

Minimally Invasive Treatment Of Mandibular Anterior Lingual Defects By Vestibular Incision Subperiosteal Tunnel Access Technique And Connective Tissue Graft: A Case Report

Kriti Mehrotra Vijay, M. Gowda Triveni, A.B. Tarun Kumar, and Dhoom Singh Mehta

Introduction: Treatment of recession defects on the lingual surface of mandibular anterior teeth is challenging owing to site-specific anatomic features of this region. Surgical approaches based on use of subepithelial connective tissue grafts (SCTGs) are considered the “gold standard” for treatment of multiple recession defects. To the best of the authors’ knowledge, this is believed to be the first case report of an attempt to correct lingual recession by SCTG with the minimally invasive vestibular incision subperiosteal tunnel access technique.

Case Presentation: A non-smoking 55-year-old male patient presented with hypersensitivity in his mandibular anterior teeth in August 2016. Multiple lingual recession defects were treated by placing a SCTG harvested from the palate underneath the subperiosteal tunnel using a midline access incision. Six months after treatment, a significant increase of root coverage (88.17%), gain in gingival thickness (1.29 mm), and width of keratinized gingiva (1.41 mm) led to a promising outcome and high patient satisfaction.

Conclusion: A minimally invasive surgical technique has been presented that can restore the functional properties of lingual gingiva of the mandibular anterior teeth by repairing gingival defects and reestablishing integrity of the zone of keratinized gingiva. Clin Adv Periodontics 2017;7:195-200.

Key Words: Connective tissue; gingival recession; mandible; personal satisfaction; sutures; treatment outcome.

Background

Gingival recession (GR) is a widespread clinical manifestation affecting single or multiple teeth of all tooth types and all tooth surfaces.1 Over the years, several root coverage (RC) techniques have been proposed with predictable treatment outcomes.2 However, challenges for clinicians arise when patients present with lingual mucogingival concerns as empirical evidence to make decisions regarding appropriate care in such cases is lacking. A recent consensus report highlights that RC on the lingual aspect of teeth is possible, but evidence on predictability is insufficient.2

GR at the lingual surfaces of mandibular anterior teeth shows a strong association with the presence of supragingival and subgingival calculus.3 A few case reports list it as a complication of tongue piercings.4,5 The goal of treatment for GR should not be merely limited to re-creation of esthetics but must equally focus on restoration of the protective functional morphology of the mucogingival complex and regeneration of the lost attachment apparatus.6

A coronally advanced flap (CAF) with autogenous subepithelial connective tissue graft (SCTG)-based RC procedure shows the best clinical outcomes for both recession reduction and complete root coverage.6 This case report introduces an approach of combining a vestibular incision subperiosteal tunnel access (VISTA) technique with a SCTG and demonstrates its successful use in lingual RC.

Clinical Presentation

A non-smoking 55-year-old male presented to the Department of Periodontics, Bapuji Dental College and Hospital, Davangere, India in August 2016 with hypersensitivity in his mandibular anterior teeth. Clinical examination showed lingual recession defects in teeth #22, #23, #24, #25, #26, and #27 with recession depths varying between 0.5 and 2.5 mm, probing depth of 1.5 mm uniformly, mild plaque accumulation, and minimal bleeding on probing (Fig. 1). The patient presented a thin gingival biotype7 measured as 1 mm using a digital vernier caliper, and width of attached gingiva ranged from 2 to 3mm. Radiographically, only periodontal ligament space widening was observed with respect to teeth #24, #25, and #26 (Fig. 2). After discussing findings, treatment options, and risks with the patient, oral and written consent was obtained to treat this site using a SCTG.

Case Management

Initial preparation of recipient teeth included thorough scaling, root planing, and minor occlusal correction. After administration of local anesthesia (2% lignocaine with 1:80,000 adrenaline†), a vertical midline access incision was made, allowing creation of a subperiosteal tunnel using VISTA #1 and #5 instruments‡ only, inserted between the periosteum and bone, exposing the lingual osseous plate. The tunnel elevation was extended beyond the mucogingival margin as well as through the gingival sulcus of £1 tooth beyond the teeth requiring RC to mobilize gingival margins and facilitate low-tension coronal repositioning (Fig. 3). Additionally, the subperiosteal tunnel was extended interproximally as far as the embrasure space permitted while maintaining the papillary integrity. A SCTG was harvested using a single-incision technique described by Hu¨ rzeler and Weng8 and guided using a lasso suture within the tunnel by 4-0 polyglactin suturesx (Fig. 4). Once the SCTG was correctly positioned, the entire mucogingival complex was advanced in the new position using coronally advanced suturing. This entails placing a horizontal mattress suture atz2 to 3mmapical to the lingual gingival margin of each involved tooth and placing the knot at the midcoronal point of the lingual aspect, securing it with the help of composite resin║ (Fig. 5). This horizontal mattress suture again attempted to engage the SCTG inside the tunnel, decreasing the possibility of apical displacement of the autogenous graft. The vertical incision was approximated and sutured. The patient was prescribed analgesics as required and was advised to use chlorhexidine mouthrinse daily for 3 weeks. Sutures at the access incision were removed after 1 week, and coronally anchored bonded sutures were removed at the 3-week postoperative visit.

Clinical Outcomes

At 1 month, the wound was completely healed, and results were stable and satisfactory at 6 months (Fig. 6). The patient expressed great satisfaction as dental hypersensitivity was no longer reported. The improved gingival thickness and width of keratinized gingiva helped to attain a functionally promising result (Table 1).

Discussion

Frequently, narrow, cleft-like defects develop on the lingual aspect of the mandibular incisors, with recession depths of 2 to 3 mm or more often extending beyond the mucogingival junction.5 Indications for when lingual RC is desirable include to decrease sensitivity, treat or prevent root caries, eliminate a plaque trap, or reestablish a normal gingival contour. Lack of literature, barring a few case reports of lingual recession defect coverage,4,5-10 could be due to lack of esthetic concerns in this region, which probably limits efforts toward its correction. In addition, other technical factors, including difficult surgical access, reduced possibility of coronal or lateral tissue displacement, and less predictable protection of the area from trauma during the healing period compared with buccal recession defects make lingual recession coverage a challenging task. Great care must be taken in the preparation of lingual mucoperiosteal flaps, attempting to avoid any laceration during flap elevation as the central mandibular and parasymphyseal lingual regions are supplied through a very rich vascular plexus, whose violation during surgical procedures may have critical consequences.11 Procedural accidents may lead to accumulation of blood in the floor of the oral cavity, swelling of the tongue due to congestion, and airway obstruction.12

Use of SCTG þ CAF in the mandibular arch may not reach the same extent of success as when it is applied to the maxillary arch due to the depth of the vestibular fornix, flap tensions, and flap thickness found in the maxilla versus the mandible.6 However, the recently introduced VISTA technique used in this case uses the inherent ease of subperiosteal tunnel preparation while maintaining crucial papillary integrity using a specialized set of instruments— VISTA #1 and #5 — whose shape and size allow easy maneuverability in the anterior lingual region.13 The vertical incision facilitates direct visualization of the cortical plate to rule out dehiscence and allows broader access for graft insertion. The coronally anchored suturing technique facilitates stabilization of the coronally advanced gingival marginal tissue. Also, this vertical incision is less likely to disrupt blood supply as the sublingual and submental arteries in the region travel from the vicinity of the mylohyoid muscle attachment along the bone surface in an anterosuperior direction.12

A thin gingival biotype seems to serve as a locus minoris resistentia for further development of GR defects.14 The SCTG provides the most stable, long-term outcomes due to the improvements in width of keratinized gingiva and biotype2 that were attained in the present case. The SCTG was sandwiched between the periosteal lining of the overlying tunnel flap and the underlying lingual cortical plate (Fig. 7). The lingual side of the parasymphyseal region of the mandible has a rich blood supply, with the vascular source in the interforaminal lingual cortical plate.15 Hence, this allowed rapid capillary outgrowth and granulation tissue formation for vascularization of the graft. Gains in keratinized gingiva width and thickness promoted by the proposed RC therapy seem to be key factors for the stability of the results, which are clinically significant. Treatment of lingual GR is technically challenging and has not been routinely reported or is not performed. In its research, the Consensus Report of the American Academy of Periodontology Regeneration Workshop highlighted the need for additional investigation of treatment of multiple recession defects and other oral sites, including lingual/palatal sites.2 This case report demonstrates the feasibility of using autogenous SCTG for correction of lingual recession as well as soft tissue augmentation.

Summary

Why is this case new information?

■To the best of the authors’ knowledge, first case report to describe the use of SCTG along with the VISTA technique to treat lingual recession

What are the keys to successful management of this case?

■ Removal of the etiologies associated with defects (plaque-induced inflammation, tongue piercings, traumatic habits, etc.)

■ Surgical technique, especially usage of correct instruments (VISTA #5 instrument for easy adaptation to the concavity of the lingual cortical plate and hence good for tunnel preparation), tension release of flap, as well as securing the flap coronally throughout the healing period

■ Harvesting good-quality CTG to increase gingival thickness and ensure long-term stability of the result

What are the primary limitations to success in this case?

■ Case selection (purely recession defect with no intrabony defect component)

Acknowledgment

The authors report no conflicts of interest related to this case report.

CORRESPONDENCE:

Dr. Kriti Mehrotra Vijay, Rm. no 5, Department of Periodontics, Bapuji Dental College and Hospital, Davangere-557004, Karnataka, India. E-mail: kriti1004@gmail.com.

References

1.Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-225.

2.Tatakis DN, Chambrone L, Allen EP, et al. Periodontal soft tissue root coverage procedures: A consensus report from the AAP regeneration workshop. J Periodontol 2015;86(Suppl. 2):S52-S55.

3.van Palenstein Helderman WH, Lembariti BS, van der Weijden GA, van ’t Hof MA. Gingival recession and its association with calculus in subjects deprived of prophylactic dental care. J Clin Periodontol 1998;25:106-111.

4.Parra C, Jeong YN, Hawley CE. Guided tissue regeneration involving piercing-induced lingual recession: A case report. Int J Periodontics Restorative Dent 2016;36:869-875.

5.Soileau KM. Treatment of a mucogingival defect associated with intraoral piercing. J Am Dent Assoc 2005;136:490-494.

6.Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop. J Periodontol 2015;86(Suppl. 2):S8-S51.

7.Claffey N, Shanley D. Relationship of gingival thickness and bleeding to loss of probing attachment in shallow sites following nonsurgical periodontal therapy. J Clin Periodontol 1986;13:654-657.

8.Hurzeler MB, Weng D. A single-incision technique to harvest subepithelial connective tissue grafts from the palate. Int J Periodontics Restorative Dent 1999;19:279-287.

9.Wilcko MT, Wilcko WM, Murphy KG, et al. Full-thickness flap/ subepithelial connective tissue grafting with intramarrow penetrations: Three case reports of lingual root coverage. Int J Periodontics Restorative Dent 2005;25:561-569.

10.Zucchelli G, Bentivogli V, Ganz S, Bellone P, Mazzotti C. The connective tissue graft wall technique to improve root coverage and clinical attachment levels in lingual gingival defects. Int J Esthet Dent 2016;11:538-548.

11.Bradley JC. The clinical significance of age changes in the vascular supply to the mandible. Int J Oral Surg 1981;10(Suppl. 1):71- 76.

12.Fujita S, Ide Y, Abe S. Variations of vascular distribution in the mandibular anterior lingual region: A high risk of vascular injury during implant surgery. Implant Dent 2012;21:259-264.

13.Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor BB. Int J Periodontics Restorative Dent 2011;31:653-660.

14.Wennstrom JL. Mucogingival considerations in orthodontic treatment. Semin Orthod 1996;2:46-54.

15.Romanos GE, Gupta B, Crespi R. Endosseous arteries in the anterior mandible: Literature review. Int J Oral Maxillofac Implants 2012;27: 90-94.

indicates key references.

Department of Periodontics, Bapuji Dental College and Hospital, Davangere, India.

Submitted April 1, 2017; accepted for publication June 13, 2017

doi: 10.1902/cap.2017.170020

Read the full article at http://onlinedigeditions.com/article/Minimally+Invasive+Treatment+Of+Mandibular+Anterior+Lingual+Defects+By+Vestibular+Incision+Subperiosteal+Tunnel+Access+Technique+And+Connective+Tissue+Graft%3A+A+Case+Report/2908895/445120/article.html.

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