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. 2014 May 6;26(3):132–138. doi: 10.1016/j.sdentj.2014.03.007

The effect of laterally positioned flap-revised technique and 24% ethylenediaminetetraacetic acid root conditioning on root coverage: A case report

Jagmohan Singh a,⁎, Vipin Bharti b
PMCID: PMC4095044  PMID: 25057234

Abstract

Complete root coverage is considered the true goal of treatment of gingival recession defects because only complete coverage assures recovery from the hypersensitivity and esthetic defects associated with recession areas. Previous studies have shown that the laterally positioned flap (LPF) technique or root surface biomodification yields a higher percentage of complete root coverage upon gingival recession treatment. This article highlights the use of the laterally positioned pedicle flap-revised technique (LPFRT) as a modification of the LPF technique, along with 24% EDTA gel as a root surface biomodification agent, in the management of localized gingival recession defects. Clinical examination revealed a Miller class II recession defect on the buccal aspect of the lower right central incisor, as well as the presence of aberrant frenum pull adjacent to the recession defect. The LPFRT, together with 24% EDTA gel, was speculated to cover the gingival recession defect. The frenectomy, along with periosteal fenestration, was planned simultaneously with LPFRT. After 6 months of therapy, the clinical condition was stable with complete root coverage and satisfactory healing of the gingival tissues at both the donor and recipient sites with no signs of inflammation.

Keywords: Ethylenediaminetetraacetic acid, Esthetics, Gingival recession, Pedicled flap, Root coverage

1. Introduction

Gingival recession is defined as the location of the marginal periodontal tissues apical to the cementoenamel junction (CEJ) (Loe et al., 1992). The etiology of gingival recession is multifactorial and may include plaque-induced inflammation, calculus and restorative iatrogenic factors, mechanical factors such as trauma from vigorous tooth brushing, tooth malposition, high frenum attachment, and uncontrolled orthodontic movements (Loe et al., 1992; Tugnait and Clerehugh, 2001). The main indications for surgical root coverage to correct recession defects include the need to improve localized soft tissue esthetics, reduce hypersensitivity, improve plaque control, and prevent further progression of the recession defect (Saha and Bateman, 2008).

Multiple surgical procedures such as coronally advanced flaps (CAFs), laterally positioned flaps (LPFs), free gingival grafts (FGGs), and subepithelial connective tissue grafts (SCTGs) appeared as novel approaches to achieve improvements in recession depth, clinical attachment level, and width of keratinized tissue (Chambrone et al., 2010). CAFs and LPFs are recommended if adequate keratinized tissue exists close to the recession defect (Patel et al., 2011). In these surgical approaches, the soft tissue utilized to cover the root exposure is similar to that originally present at the buccal aspect of the tooth harboring the recession defect and, thus, the esthetic result is more satisfactory. Furthermore, the post-operative course is less troublesome because other surgeries in donor sites far from the tooth harboring the recession defect are uninvolved (Patel et al., 2011; Milano, 1998).

LPFs are commonly used to cover isolated, denuded roots that have sufficient width, length, and thickness of keratinized tissue adjacent to the area of gingival recession. This surgical technique is not affected by vestibule depth due to the small coronal displacement required to cover the recession defect (Rasperini et al., 2011). This method is most suitable for root coverage in gingival recession with a narrow mesio-distal dimension (Tugnait and Clerehugh, 2001). Possible bone loss and gingival recession at the donor site are disadvantages of this method (Guinard and Caffese, 1978). Various modifications in LPF have been proposed in order to avoid the reported undesirable results on the donor site. Laterally positioned pedicle flap-revised technique (LPFRT) was introduced by Ruben et al. (1976) as a modification of the LPF technique first described by Grupe and Warren (1956). This flap is elevated from the donor zone as full-thickness mucoperiosteal tissue near the recession and split-thickness mucoperiosteal tissue on the distal portion (away from the recession). The objective of the full-thickness flap design is to place the periosteum over the exposed root to utilize its dynamic reparative potential and provide a more tenacious connective tissue-cementum fixation of the flap. The split-thickness portion of the flap will limit the post-operative complication of bone resorption by preserving the periosteal protection and blood supply to the septum (De waal et al., 1988). Recently, a randomized controlled clinical study has shown 95.5% mean root coverage and 83.4% complete root coverage (15 out of 18 patients) with a similar modified LPF technique in the management of localized Miller class I recession defects (Santana et al., 2010).

Chemical root surface conditioning, which has been advocated in root coverage procedures, involves the use of a variety of agents to detoxify, decontaminate, and demineralize the root surface, thereby removing the smear layer and exposing the collagenous matrix of dentin and cementum (Selvig et al., 1981; Polson and Proye, 1982). A meta-analysis (Al-Hamdan et al., 2003) of guided tissue regeneration (GTR)-based root coverage revealed that root surface conditioning resulted in a significantly improved percentage of sites with complete root coverage. Various chemical agents have been used for root surface biomodification, such as citric and phosphoric acids, ethylenediaminetetraacetic acid (EDTA), and tetracycline hydrochloride (Oliveira and Muncinelli, 2012). EDTA gel operates at neutral pH, and its chelating property may enhance the attachment of connective tissue to the root surface by exposing more intact collagen fibers and, as a consequence, may enhance root coverage (Blomlof et al., 1996a,b).

In the treatment of gingival recessions, EDTA has been used with the subepithelial connective tissue graft and semilunar coronally repositioned flap (Kassab et al., 2006; Bittencourt et al., 2007) techniques. The aim of the present case report was to evaluate the root coverage of a Miller class II recession defect by means of LPFRT along with 24% EDTA gel.

2. Case report

A 28-year old male patient came to our department of periodontology with the chief complaints of receding gums and sensitivity of the lower teeth. The patient also complained of the difficulty of maintaining oral hygiene in the affected area. The patient was a non-smoker and systemically healthy, and his overall oral hygiene was reasonably good. On clinical examination, a Miller class II recession defect was present on the buccal surface of the lower right central incisor (Fig. 1). A clinical attachment loss of 7 mm was apparent on the midbuccal surface of the recession defect. The distance between the CEJ and the gingival margin was 5 mm (Fig. 2) and the distance between the gingival margin and the base of the sulcus was 2 mm (Fig. 3). The base of the sulcus was apical to the mucogingival junction (Fig. 3). Clinical examination also revealed a labial aberrant frenum pull mesial to the recession defect and slight malpositioning of the lower anterior teeth. Radiographically, no evidence was found regarding crestal bone loss, and the lamina dura was intact around the lower right central incisor.

Figure 1.

Figure 1

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Pre-operative view.

Figure 2.

Figure 2

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Distance between the cementoenamel junction and gingival margin.

Figure 3.

Figure 3

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Distance between the gingival margin and the base of the sulcus.

2.1. Treatment plan

The patient was reluctant to undergo free gingival and connective tissue grafting. Under conditions of acute scarcity of keratinized gingiva below the recession site and an adequate amount of attached gingiva present on the lower right lateral incisor, LPFRT (Espinel and Caffesse, 1981) as a modification of the LPF technique, along with 24% EDTA gel, was speculated to cover the gingival recession defect. The frenectomy, along with periosteal fenestration, was planned simultaneously with LPFRT to prevent the deleterious effects of aberrant frenum pull on the clinical outcomes. The entire treatment plan was initially submitted and approved by the Ethics Committee of our institute. After ethical approval, the surgical procedure was explained to the patient and informed consent was obtained.

2.2. Presurgical therapy

A general assessment of the patient was made through a review of medical history and routine laboratory investigations. The patient was reluctant to undergo orthodontic treatment for the malpositioning of the lower anterior teeth. The preparation of the patient included scaling, root planning, and oral hygiene instructions. The modified Stillman’s brushing technique was prescribed to the patient.

2.3. Parameters assessed

The following clinical parameters were assessed with the University of North Carolina (UNC)-15 periodontal probe (PCP-UNC 15; Hu-Friedy, Chicago, IL, USA) at baseline and at 6 months after the surgical procedure:

  • 1.

    Clinical recession depth (RD) was measured to the nearest mm from the CEJ to the most apical point of gingival margin.

  • 2.

    Probing depth (PD) was measured from the free gingival margin to the base of the sulcus and recorded at the nearest mm. PD was recorded twice at an interval of 48 h between the first and second recording to provide replicate measurements.

  • 3.

    Clinical attachment level (CAL) was calculated as PD plus RD.

3. Surgical procedure

3.1. Laterally positioned flap-revised technique

After proper isolation of the surgical field, the operative sites were anesthetized using 2% Lignocaine with 1:100,000 adrenaline (Alphacaine®; DFL™, Rio de Janeiro, RJ, Brazil). At the recipient site, a collar of gingival tissue was removed around the recession defect by two vertical incisions that joined at a point apical to the base of the recession defect (Fig. 4). Subsequently, the exposed root surface was planned with finishing burs and mini-Gracey curettes to remove edges, grooves, and dental plaque, and to reduce the convexity of the most coronal portion of the root. The donor site, i.e., one tooth away from the recession, was prepared by executing, with a #15 surgical blade, a vertical incision extending from the gingival margin to the oral mucosa up to the level of the base of the lower right central incisor, and extending further into the alveolar mucosa by an oblique releasing incision (cut-back incision) facing the recession, to provide adequate mobility of the flap. The sliding flap was detached as follows: first, the one-half of the flap located further from the recession defect was reflected as a split-thickness flap by performing a sharp dissection with a #15 surgical blade, and the other one-half of the flap located closer to the recession defect was reflected as a full-thickness flap by performing blunt dissection with the periosteal elevator. The entire flap was then released with an undermining incision through the periosteum at its apical base (Fig. 5).

Figure 4.

Figure 4

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Collar of tissue was removed around the recession site.

Figure 5.

Figure 5

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Frenectomy along with periosteal fenestration was done simultaneously with LPFRT.

3.2. Frenectomy and periosteal fenestration procedure

After flap elevation, the labial frenum was detached and resected to the level of vestibular fornix by a horizontal incision at the level of the mucogingival junction on the mesial corner of the flap pointing toward the recipient site. At the base of the incision, where the bone begins to form a shelf due to the mental prominence, a rectangular periosteal strip of 2–3 mm in width was bluntly dissected to accomplish the periosteal fenestration (Carranza et al., 1966) (Fig. 5). This fenestration causes scar formation, which seems to have the essential characteristics of attached gingiva. In the future, this scar (resembling a zone of attached gingiva) serves to dissipate the detrimental pull of the aberrant frenum on the marginal gingiva (Carranza et al., 1966).

3.2.1. Application of 24% EDTA gel and suturing of flap

Before the placement of the flap over the recession defect, the exposed root surface was conditioned with 24% EDTA gel (PrefGel®; Straumann Biologics Division®, Waltham, MA, USA) (Fig. 6) for 2 min and thoroughly rinsed with saline for 30 s. The flap was rotated laterally to completely cover the recession defect and extended for approximately 2 mm coronal to the CEJ. The flap was carefully sutured by a sling suture (Fig. 7). A gentle pressure was applied for few minutes to minimize the clot that forms under the pedicle flap, and the periodontal dressing (Coe-Pak™; GC America®, Alsip, IL, USA) was used to cover the surgical site.

Figure 6.

Figure 6

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Root conditioning with 24% EDTA gel.

Figure 7.

Figure 7

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Sling sutures placed.

3.3. Post-operative care

Amoxicillin 500 mg and Ibuprofen 400 mg were prescribed three times daily for 5 days. The patient was advised to follow all normal oral post-operative hygiene instructions, including rinsing the oral cavity with 0.12% chlorhexidine digluconate mouth rinse for 2 weeks. The patient was advised to avoid pulling on his lips to observe the surgical site. Both dressings and sutures were removed 10 days after surgery (Fig. 8a). The post-operative follow-up was conducted at 1 (Fig. 8b), 3 (Fig. 8c), and 6 months after surgery (Fig. 8d).

Figure 8.

Figure 8

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(a) The recipient site 10 days post-operatively, (b) the recipient site 1 month post-operatively, (c) the recipient site 3 months post-operatively, and (d) the recipient site 6 months post-operatively.

4. Results

The treated site showed a 6 mm gain in CAL, a 5 mm reduction in RD, and a 1 mm reduction in PD at 6 months (Table 1). Complete coverage was achieved 6 months after the procedure with excellent tissue contour and color. No post-operative complication was observed, and healing was satisfactory both at donor and recipient sites. The patient did not experience any post-operative morbidity.

Table 1.

Clinical parameters at baseline and 6 months following treatment.

Parameters Baseline 6 months
PD 2 1
RD 5 0
CAL 7 1
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PD: Probing depth; RD: Clinical recession depth; CAL: Clinical attachment level.

5. Discussion

The complete root coverage represents the ultimate clinical goal of surgical root coverage procedures. Complete root coverage will not only lead to an esthetic correction but also helps in resolution of hypersensitivity and prevention of root abrasion (Chambrone et al., 2012). Previous studies have shown that LPF (Santana et al., 2010) or root surface biomodification (Al-Hamdan et al., 2003) yields higher percentages of complete root coverage following the treatment of localized gingival recession defects. The results of the present case report indicate that the use of LPFRT, along with 24% EDTA gel, yielded complete root coverage.

LPF involves repositioning of donor tissue from an area adjacent to the recession defect to cover the exposed root surface (Patel et al., 2011). A recent randomized controlled clinical study (Santana et al., 2010) revealed 95.5% mean root coverage and 83.4% complete root coverage with the similar modified LPF technique as that of LPFRT in the management of Miller class I gingival recession defects. Furthermore, another clinical study has revealed a statistically significant increase in the width of keratinized tissue (the distance between the gingival margin and the mucogingival junction) with the LPF compared to the CAF technique. The accomplishment of complete coverage using the LPFRT technique in the present case report may be due to the full-thickness (mucoperiosteal) portion of the flap (De waal et al., 1988).

Various studies have attempted to improve the percentage of root coverage outcome with root surface biomodification (Oliveira and Muncinelli, 2012). Root surface biomodification agents are used in an attempt to eliminate the smear layer and endotoxins, to uncover and widen the orifices of dentinal tubules, and to expose the dentin collagen matrix. This collagen matrix is thought to provide a substrate that supports the chemotaxis, migration, and attachment of fibroblasts that are fundamental to successful periodontal wound healing (Polson et al., 1984; Lowenberg et al., 1986). These procedures are believed to induce cementogenesis and to enhance attachment either by connective tissue in-growth and/or demineralization (Willey and Steinberg, 1984). Nevertheless, various studies have failed to show any beneficial effect when root surface biomodification agents (i.e., citric acid) were used along with FGGs and LPFs (Wennstrom, 1996; Laney et al., 1992; Ibbott et al., 1993). Furthermore, a systematic review (Roccuzzo et al., 2002) documented that root surface biomodification agents have no role in improving the outcomes of surgical root coverage procedures. The discordant results may be explained by the fact that the root preparation was performed with root surface biomodification agents having low pH properties (citric acid), which are known to necrotize the flap and the adjacent periodontium.

Among the various root surface biomodification agents, the 24% EDTA gel operates at a neutral pH; this property has been reported to preserve the vitality of the adjacent teeth (Blomlof et al., 1996a,b). Furthermore, along with LPFRT, 24% EDTA gel may enhance the tenacious connective tissue attachment to the root surface by exposing more intact collagen fibers and, as a consequence, may enhance root coverage. To best of our knowledge, no studies have reported complete root coverage using the LPFRT technique together with 24% EDTA gel in the management of localized gingival recession defects. Therefore, a direct comparison with other studies is not possible. The complete root coverage outcome of the current case report is supported by the meta-analysis of GTR-based root coverage, in which the conditioned root surfaces had a higher percentage of complete root coverage compared to those not treated with root conditioning agents (Al-Hamdan et al., 2003).

Although LPFRT and 24% EDTA gel yielded complete root coverage, the confirmative effect of this treatment combination will remain controversial. To elucidate the combined effect, the inclusion of a control group (Only LPFRT) is essential. It is important to emphasize that this is a short-term report and that longitudinal clinical studies with larger sample sizes are required to provide solid evidence of the complete root coverage outcome of LPFRT along with 24% EDTA gel in the management of Miller class II recession defects.

6. Conclusion

Within limits of the present case report, it may be concluded that, along with LPFRT, 24% EDTA gel not only provides a biocompatible surface, but also improves the tenacious connective tissue attachment of the flap to the root surface and, as a consequence, enhances the clinical outcome in the form of complete root coverage.

Ethical statement

The study protocol was approved by the Ethics Committee of Government Dental College and Hospital, Patiala.

Conflict of interest

The authors report no conflict of interest related to this case report. The case report was self-funded by the first author.

Footnotes

Peer review under responsibility of King Saud University.

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Contributor Information

Jagmohan Singh, Email: jagmohan231@gmail.com.

Vipin Bharti, Email: gdc_perio@yahoo.com.

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