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This month's On The Chair is a very interesting case presentation of localised gingival recession. Dr.Ajay Kakar highlights a procedure to ensure good soft tissue coverage with minimum risks of the graft failing. The Bridge FlapThe
Bridge Flap is a soft tissue surgical technique for
coverage of areas of high arched recession on individual
or groups of two or three teeth. The primary concept of
this technique is that a connected soft tissue flap is
slid over the area of recession after releasing muscular
tension at the vestibular end. Essentially the original
attached gingiva is used for the coverage and the
vestibular alveolar mucosa is pushed in place of the
attached gingiva. The denuded alveolar mucosa heals by
secondary intention. The author picked up this technique
from Dr. Hannes Wachtel, Germany. This
surgical procedure is indicated for high arched buccal
gingival recession in upper or lower teeth. A maximum of
two or three teeth in conjunction can be covered by this
procedure. It is imperative that the papillary gingiva be
intact along the adjacent teeth to achieve good results.
The best results are obtained when the recession is
limited to a single tooth. This procedure is not
indicated if the recession is circuferential with
horizontal bone loss all around the tooth. It is assumed
in this procedure that the interproximal bone is intact
with good soft tissue coverage. The procedure is usually
carried out for aesthetic reasons. It may also be done to
reduce hypersensitivity due to exposed dentin.
The
patient was administered local anaesthesia in the upper
right side posterior area. The LA should be administered
deep into the vestibule since horizontal incisions have
to be taken in the alveolar mucosa and balloning of the
soft tissue should be avoided as much as possible. The
first step is to determine the number of teeth which have
to be covered. The surgical field will extend one tooth
on either side of the number of teeth to be covered. In
this case the coverage had to be done for the premolar
and hence the surgical field extended horizontally from
the canine to the first molar.
Now
this loose envelope flap is slid down coronally and
positioned in the desired location so as to cover the
denuded tooth surface. The lips are stretched to check
for any muscular tension. The flap should stay in place
without any tension while stretching the lips. The root
surface has been thoroughly debrided prior to the
procedure . Further root planing was done with the help
of graceys currettes. Optionally the root surface might
be treated with citric acid with the hope of getting
better attachment. No root surface demineralization was
done in this case.
Conclusion
This procedure is a very useful surgical procedure to eliminate the problem of clinicall recession and hypersensitivity. Even though it sounds scary that the vestibular incision is left alone, it hardly causes any patient discomfort and usually heals uneventfully in about a weeks time.
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The patient presented in this communication
is a 25 year old male who was very concsious of his
premolar on the right side looking longer than the
premolar on the left side. The patient has had othodontic
treatment carried out approximately 6 years ago. On
examination it was noticed that the upper right premolar
had about 3 mm of recession on the buccal side. The
zenith of the gingiva on the premolar was more or less
apically placed in relation to the molar. The most
probable cause of the recession was a very aggressive
toothbrushing habit. A bridge flap procedure was
suggested to the patient and he readily accepted the
suggestion. 
The first incision is a horizontal incision
which has to be taken in the vestibular mucosa. The
vertical position of this incision has to be now
calculated. Determine the extent of coverage to be
obtained. Add the width of the attached gingiva to this
figure and add 3 mm to the total obtained. The horizontal
incision has to be placed at a distance equal to this
figure from the existing zenith of the gingiva. The
incision is a partial thickness incision and extends
horizontally from the first molar to the canine. 
Then a partial thickness
flap is raised from the vestibule downwards till the
attached gingiva is reached. The flap is continued
downwards (coronally) but now it is a full thickness
flap, till the gingival crevice is reached. On
completion, an envelope flap is created coronal to
apical. Care has to be taken that the interproximal
papillae are intact and fully reflected. The patency of
the reflection can be checked with the help of the
periosteal elevator by inserting from the cervical end
and getting the end out from the vesibular incision. 
The flap is now placed
coronally and a sling suture taken around the tooth with
the bites in the papillae. The purpose of this sling
suture was just to hold the flap in place. The next step
is to unfold and pat the loose alveolar mucosa over the
space created by the attached gingiva which has slid
coronally. The vestibular incision has to be left
untouched with instructions to the patient not to strech
the lips repeatedly for the next few days. The vestibular
incision will heal by secondary intention over the next
few days. It is important to note that no sutures have to
be taken for the horizontal incision made at the
vestibular end. It is this incision which releases the
pull back forces which would otherwise have been exerted
on the coronally displaced flap. 
The patient was duly
instructed and an ice pack given for external
application. No pack was placed around the surgical site.
No antibiotics were given and a pain killer was
administered for one day and appropriate diet
instructions were given. 
The patient was checked
the next day and then after six days. The patient was
comfortable on day one with no complaint of swelling or
pain. On Day Six the sling suture was removed and the
vestibular wound was already healing. Three weeks post op
showed good healing with the desired coverage acheived.
The patient was thoroughly satisfied with the results
obtained.