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INTRODUCTION:

Maintenance of
oral hygiene is required for optimum periodontal health that increases the
longevity of the person’s natural dentition. The objective of periodontal
therapy is to reproduce an environment which results in high standard of oral
hygiene as inadequate oral hygiene is associated with mucogingival deformities.

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Periodontal
plastic surgery emphasize on biological, functional problems that affect the
periodontium and focused to improve esthetic appearance.

The occurrence
of mucogingival deformities often has an impact on patients in provisions of aesthetics
and function. A shallow vestibule is associated with plaque accumulation and consequently
marginal gingival inflammation which leads to mobility, bone loss, gingiva
recession.

Gingival
recession is defined as exposure of root surface by the apical migration of
junctional epithelium (JE), results in a unesthetic appearance and dentinal
hypersensitivity.1

Various
surgical modalities have been used for vestibuloplasty including sub mucosal
vestibuloplasty, secondary epithelisation vestibuloplasty, Edlan-Mejchar
vestibuloplasty and soft tissue grafting vestibuloplasty.

We hereby
present a case report of a patient who presented with the chief complaint of
trauma while brushing in lower anterior teeth and in whom vestibular extension
was done with the technique described by Edlan and Mejchar to correct the
shallow vestibule.

 

METHOD:

A 45 year old
female presented with the chief complaint of trauma while brushing in the lower
anterior region reported to the outpatient of Department of Periodontology,
Sardar Patel Postgraduate Institute of Dental & Medical Science, Lucknow. On
intraoral examination it was found that patient had Millers grade I mobility with
reduced width of attached gingiva in the lower anterior region along with
(Fig.1)

Phase I therapy
included full mouth scaling and root planing, occlusal

correction was
done where indicated and oral hygiene instructions were reinforced to the
patient. , a vestibular extension of the patient’s mandibular labial vestibule
to increase the width of attached gingiva

was planned. Routine
blood investigations (total and differential leukocyte counts, blood glucose-
fasting and post-prandial, haemoglobin, bleeding and clotting time) were
carried out.

SURGICAL TECHNIQUE:

 

Pre-surgical
preparation was done by scrubbing of the facial skin all around the oral cavity
with povidine iodine solution and the patient was made to rinse with 0.2%
Chlorhexidine digluconate mouthrinse for one minute. The patient was
anesthetized using 2% Lidocaine

with Adrenaline
concentration of 1:80000. The surgical procedure as

described by
Edlan and Mejchar was followed. Vertical incisions were given on mesial aspect of
the both mandibular canines and starting at the junction of the attached and
free gingiva. An incision was made for a distance of 11 to 12 mm extending on
to the lower lip. These two incisions were joined by a horizontal incision
across the midline.

A split thickness
flap then separated the loose labial mucosa from the underlying muscle. The
incision of the periosteum was extended in a vertical direction at its ends..

It was fixed
with interrupted sutures to the inner surface of the periosteum, which was
removed from the bone.

After
surgical procedure a periodontal dressing (Coe Pac) was placed to protect the
operated area. The patient was prescribed. Amoxicillin 500 mg TID for 5 days
and anti-inflammatory (Diclofenac 50 mg) BD for 5 days for post-operative pain.
Patient was instructed to have liquid/soft diet for 1 week along with other post-operative
instructions. The patient was recalled after two weeks for removal of sutures. No postoperative complications were created. At
two weeks the width of attached gingiva recorded was 7 mm approximately. The
patient was recalled after 6 months and one year for regular follow up and it
was observed that the achieved width attached gingiva remained constant
throughout.

 

DISCUSSION:

Edlan and
Mejchar (1963) depicted a technique for vestibuloplasty which was applicable to
patients in whom there were no pockets and little or no gingival tissue
present. This procedure also increases the width of the attached gingiva where
other procedures were impracticable due to lack of vestibular depth2,3,4

Edlan and
Mejchar technique also known as lip switch procedure. The advantage of this technique
is that healing occurs by first intention and no bone is left exposed, thereby
minimizing the chances of bone resorption and further recession. Another advantage
of this technique is there is no relapses of the vestibule. In the present
case, an excellent clinical result was obtained which was maintained even one
year after surgery.

Several technique have been developed since 1956,
but most of them are unsatisfactory due to scar formation and frequent relapse
of the state of the vestibule. 

Various brushing
techniques require the placement of the toothbrush at the gingival margin, which
may not be possible with reduced vestibular depth. It has been reported that
with minimal of 1 mm of attached gingiva, proper gingival health cannot be
established.

This finding is consistent with
the observations of Wade (1969)5.

Thus, based on the findings of
the present case it can be concluded that in cases with a shallow vestibule and
a reduced width of attached gingiva on the labial aspect of the mandibular
anterior teeth, the technique advocated by Edlan and Mejchar provides a
predictable way in which gingival health can be achieved and maintained.

 

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