Background: A 45 years old female patient complaint
of trauma while brushing in lower front teeth. An extremely shallow vestibule
was observed with gingival recession in 31 and 41.The mandibular labial
vestibule was extended using the lip switch procedure or the Lip switch
technique technique. The procedure yielded a considerable gain in the width of
the attached gingiva, which maintained itself even 3 months after the surgical
procedure. Lip switch technique leads to a consistent and predictable increase
in the width of the attached gingiva and may be successfully used in the
treatment of a shallow vestibule.

Keywords:  Vestibuloplasty,
Lip switch technique, Edlan Mejchar technique,

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INTRODUCTION:

The overall oral
health is maintained by proper oral hygiene. Maintenance of oral hygiene
increases longevity of natural dentition.

Goal of oral
hygiene is to remove plaque, calculus, prevent dental caries and periodontal
disease. It has been documented that oral hygiene is directly linked to
periodontal disease. If oral hygiene is compromised it leads to periodontitis.

The objective of
periodontal therapy is to create an environment which results in good oral
hygiene practice by the patient.

Mucogingival
surgery is done to rectify defect in morphology, position & amount of gingiva
and alveolar mucosa. Mucogingival surgery term was introduced by Nathan
Friedman in 1957. In 1996, World Workshop in Clinical Periodontics renamed Mucogingival
surgery as Periodontal Plastic Surgery. Periodontal plastic surgery term was
proposed by Miller in 1993.

The occurrence
of mucogingival deformities often has an impact on patient’s aesthetics, oral
hygiene maintenance 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 refers to exposure of root surface by the apical migration of
junctional epithelium (JE), results in a unesthetic appearance and dentinal
hypersensitivity.1

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 Lip switch technique to correct the
shallow vestibule.

 

CASE REPORT:

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 grade
II recession in 31, 41. Width of attach gingiva was severly reduced , measuring
2mm. (Fig.1)

Phase I therapy
was initiated with patient education and motivation, full mouth scaling and
root planing, home plaque care measures and oral hygiene instructions were reinforced
to the patient. Vestibular extension of the patient’s mandibular labial
vestibule to increase the width of attached gingiva was planned. Routine blood investigations
(haemoglobin, total and differential leukocyte counts, blood glucose- fasting
and post-prandial, 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 30 seconds. The patient was
anesthetized using 2% Lidocaine

with Adrenaline
concentration of 1:80000.

The surgical
procedure Lip switch technique as described by Edlan and Mejchar was followed. With
the help of BP blade no. 15 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 was then separated the loose labial mucosa from
the underlying muscle. Now periosteum was visible. The incision of the
periosteum was extended in a vertical direction at its ends. Periosteum was separated
from the bone. Then interrupted sutures were placed on the inner surface of the
periosteum, which was separated from the bone.

After
surgical procedure a periodontal dressing (Coe Pac) was placed to protect the
operated area. The patient was prescribed Cap Amoxicillin 500 mg TID for 5 days
and anti-inflammatory Tab Diclofenac 50 mg BD for 5 days for post-operative
pain. Patient was instructed to have 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 every month and 3 months follow up was recorded and it was observed that
the achieved width attached gingiva remained constant throughout.

 

DISCUSSION:

Vestibuloplasty
is a surgical procedure designed to deepened oral vestibule by changing soft
tissue attachments. Various surgical modalities have been used for
vestibuloplasty including sub mucosal vestibuloplasty, secondary epithelisation
vestibuloplasty (Kazanjian
technique, Edlan-Mejchar vestibuloplasty) and
soft tissue grafting vestibuloplasty.

 

Edlan and
Mejchar technique was given by Edlan and B Mejchar (1963) and it is secondary epithelisation
vestibuloplasty. In secondary epithelisation the mucosa of vestibule is used to
line one side of the extended vestibule, and the other side heals by growing
new epithelial surface. Edlan and Mejchar technique is a modification of
Kazanjian technique.

Edlan and
Mejchar 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 depth.2,3,4 This
technique is also indicated in treatment of localized recession or for elimination
of a broad, high frenum.

 

Edlan and
Mejchar technique known as lip switch procedure or transpositional flap or
Edlan vestibuloplasty. The advantage of this technique no bone is left exposed,
it minimizes the chances of bone resorption and further recession. Another
advantage of this technique is there are no relapses of the vestibule and scar
formation is minimal. In the present case, an excellent clinical result was obtained
which was maintained even 3 month after surgery.

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

 

Problem
associated with shallow vestibule is improper maintenance of oral hygiene
because of traumatic brushing. 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.

Compared to another
widely used periosteal fenestration technique there is minimal contraction of
the vestibular depth gained and minimal scar formation. 5

This finding is
consistent with the observations of Wade (1969)6. A study done by Axel
Ergenholtz and Anders Hugoson stated that net gain was of 7.7 mm which was followed
upto 5 years. The condition was stabilized and maintained.3

 

CONCULSION:

 

Based on the clinical
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, this technique provides a predictable way in which oral
health can be achieved and maintained.