|Year : 2012 | Volume
| Issue : 1 | Page : 75-78
Double papilla flap technique for dual purpose
P Mohan Kumar1, N Ravindra Reddy2, S Sunil Kumar1, S Chakrapani1
1 Department of Periodontics, SIBAR Institute of Dental Sciences, Guntur, India
2 Department of Periodontics, CKS Teja Institute of Dental Sciences, Tirupathi, Andhra Pradesh, India
|Date of Web Publication||10-Sep-2012|
P Mohan Kumar
Flat No. 303, R. K. Gold Apartments, Sriram Nagar, 5th Road, Eluru, W.G. Dist.
Source of Support: None, Conflict of Interest: None
Marginal tissue recession exposes the anatomic root on the teeth, which gives rise to common patient complaints. It is associated with sensitivity, tissue irritation, cervical abrasions, and esthetic concerns. Various types of soft tissue grafts may be performed when recession is deep and marginal tissue health cannot be maintained. Double papilla flap is an alternative technique to cover isolated recessions and correct gingival defects in areas of insufficient attached gingiva, not suitable for a lateral sliding flap. This technique offers the advantages of dual blood supply and denudation of interdental bone only, which is less susceptible to permanent damage after surgical exposure. It also offers the advantage of quicker healing in the donor site and reduces the risk of facial bone height loss. This case report presents the advantages of double papilla flap in enhancing esthetic and functional outcome of the patient.
Keywords: Attached gingiva, keratinized gingiva, marginal tissue recession
|How to cite this article:|
Kumar P M, Reddy N R, Kumar S S, Chakrapani S. Double papilla flap technique for dual purpose. J Orofac Sci 2012;4:75-8
|How to cite this URL:|
Kumar P M, Reddy N R, Kumar S S, Chakrapani S. Double papilla flap technique for dual purpose. J Orofac Sci [serial online] 2012 [cited 2018 Jan 18];4:75-8. Available from: http://www.jofs.in/text.asp?2012/4/1/75/99888
| Introduction|| |
Gingival recession may be the result of pathological and physiological processes and sometimes may result from some forms of periodontal therapy. One of the biggest challenges that periodontists face today is to create a form and appearance that is acceptable and pleasing to the patient in all periodontal plastic surgical procedures.  Grupe and Warren were the first to describe the sliding flap as a method to repair isolated gingival defects in 1956. They reported elevating a full-thickness flap one tooth away from the defect and rotating it to cover the recession. In 1967, Hattler reported the use of a sliding partial thickness flap to correct mucogingival defects on two or three adjacent teeth. In 1968, Cohen and Ross described the double papilla repositioned flap using the interproximal papillae to cover recessions and correct gingival defects in areas of insufficient gingiva not suitable for a lateral sliding flap. 
This case report describes the double papilla flap technique to treat recession defect and to increase the width of attached gingiva in relation to 44.
| Case Report|| |
A 32-year-old non-smoking male patient with no contributory systemic history complained about recessed gums in lower front tooth region since 1 year. On thorough history taking, and clinical and radiographic examination, the recession was found to be due to faulty tooth brushing and there was no interdental soft tissue loss, malposition, and interproximal bone loss in relation to 44, which falls into class II recession according to Miller, Category IV according to Sullivan and Atkins, and into Visual recession according to Liu and Solt [Figure 1].
Scaling and root planing (SRP) was performed using Gracey curette no. ½ to treat the diseased root surface to make it biologically compatible with a healthy periodontium (Jones and O'Leary). Double papilla flap was indicated in Millers Class II recession with inadequate attached gingiva because of sufficient width and length of interdental papilla on both sides of the area of gingival recession. This technique uses the interdental papillae adjacent to the gingival recession to cover recessions with less tension to the pedicle flap.
Following administration of local anaesthesia with 2% Lidocaine, two horizontal incisions were made on both sides, parallel to the cemento-enamel junction of the tooth to be treated with a no. 15 blade [Figure 2]. Vertical incisions were made on the mesial and distal aspects of the surgical site and placed at the line angles of the teeth after "V" shaped excision of marginal gingiva. The releasing incision was extended into alveolar mucosa without making contact with the bone. A partial thickness pedicle flap with sufficient mesial and distal interdental papilla was prepared by giving scalloped internal bevel incision with a no. 15 blade [Figure 3]. Interdental papilla was undermined while lifting the papilla gently with the side of the blade and separated from the underlying connective tissue. It was made sure that mesial and distal papilla flaps were wider than the recipient site to cover the root and to provide a margin for attachment to the connective tissue.
|Figure 2: Horizontal incisions placed in relation to 44 by using B. P. blade no. 15|
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Both the papilla flaps at the center of the root surface were sutured to ensure coverage of the denuded root surface. Interrupted sutures (3-0 coated vicryl is preferred) were placed across the medial surface of the two papilla flaps, beginning apically and working coronally [Figure 4].
Firm and gentle pressure was applied to the flap for 2-3 min with cotton-free gauze moistened with sterile saline solution to further secure a successful connection. To protect the surgical area during the initial phase of healing, periodontal dressing was given which protected the flap from displacement. Care was taken not to displace the flap or impinge on its base while placing the periodontal dressing. The patient was advised not to brush the treated site for 4 weeks and instead 0.2% chlorhexidine rinse was prescribed for 4 weeks. Postoperatively, antibiotics and analgesics were prescribed as required. Seven days after the surgery, the periodontal pack was removed. The patient was examined at 1st and 4th weeks to assess healing and then followed up at 6 months for reassessment of clinical parameters postoperatively [Figure 5] and [Figure 6].
|Figure 5: One week postoperative photograph. Note the recession coverage in relation to 44|
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|Figure 6: Six months postoperative photograph. Note 3 mm keratinized gingiva measured from mucogingival junction to marginal gingiva|
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The procedure used in this case produced significant improvement in the clinical parameters and was effective in obtaining root coverage. Root coverage of 2 mm and the increased width of attached gingiva up to 2 mm were observed when compared to baseline measurements [Table 1].
| Discussion|| |
The periodontist should not only focus on health and on the adequacy of attached gingiva, but should also focus on to create form and esthetic appearance of the gingiva that is acceptable and pleasing to the patient. 
This case report describes about the use of double papilla flap to correct the gingival recession and to increase the width of attached gingiva in Millers Class II recession. For Class II recession, in which attached gingiva is not present on the area of recession and papillary recession has not occurred, complete root coverage is possible using a variety of techniques, including a connective tissue graft or guided tissue regeneration. , In this case, double papilla flap was planned using the interproximal papillae to cover recession and to correct gingival defects in areas of insufficient gingiva not suitable for a lateral sliding flap. , This technique offers the advantages of dual blood supply and denudation of interdental bone only, which is less susceptible to permanent damage after surgical exposure. In this case, partial thickness flap was preferable because it offers the advantage of quicker healing in the donor site and reduces the risk of facial bone height loss, particularly if the bone is thin or the presence of a dehiscence or a fenestration is suspected. ,
Double papilla flap technique for root coverage can be achieved with less tension to the pedicle flap and this technique can be used when sufficient width and length of the interdental papilla on both sides of the area of gingival recession are present. The main advantage of this technique is that additional donor site is not required when achieving partial root coverage along with increasing attached gingiva. 
The procedure used in this case is technically demanding and has limited application because the main objective of this technique is to increase the width of attached gingival and not the root coverage. Complete root coverage can be obtained when this technique is combined with connective tissue grafting. 
In this case, recession coverage was of 2 mm and the width of attached gingival was increased up to 2 mm when compared to baseline measurements of 4 mm recession and no (0 mm) attached gingiva. Hence, the double papilla flap technique was used to cover recession and to increase the width of attached gingiva.
| Conclusion|| |
Clinicians must be aware of the variety of techniques to treat gingival recession and the periodontist should focus on how to create form and esthetic appearance of the gingiva that is acceptable and pleasing to the patient. The use of double papilla flap procedure to correct Class II gingival recession and to increase the width of attached gingiva was successful and demonstrated predictable esthetic improvement.
| Acknowledgments|| |
Dr. Krishnamurthy, Prof., Department of Periodontics, and Dr. Roopa. D., Prof. and HOD, Department of Periodontics, CKS Teja Institute of Dental Sciences, Tirupathi, are gratefully acknowledged.
| References|| |
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|2.||Grupe HE, Warren RF. Repair of gingival defects by a sliding flap operation. J Periodontol 1956;27:92-5. |
|3.||Guinard EA, Caffesse RG. Treatment of localized gingival recessions. Part I. Lateral sliding flap. J Periodontol 1978;49:351-6. |
|4.||Jones W, O'Leary T. The effectiveness of in vivo root planning in removing bacterial endotoxin from the roots of periodontally involved teeth. J Periodontol 1978;49:337-42. |
|5.||Nelson SW. The subepithelial connective graft: A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102. |
|6.||Pennel BM, Higgason JD, Towner JD, King KO, Fritz BD, Salden JF. Oblique rotated flap. J Periodontol 1965;36:305-9. |
|7.||Smukler H. Laterally positioned mucoperiosteal pedicle grafts in the treatment of denuded roots. J Periodontol 1976;47:590-5. |
|8.||Wikesjö UM, Baker P, Christersson L, Genco RJ, Lyall RM, Hic S, et al. A biomedical approach to periodontal regeneration: Tetracycline treatment conditions dentin surfaces. J Periodontal Res 1986;21:322-9. |
|9.||Wilderman MN, Wentz FM. Repair of a dentogingival defect with a pedicle flap. J Periodontol 1965;35:218-31. |
|10.||Harris RJ, Miller LH, Harris CR, Miller RJ. A comparison of three techniques to obtain root coverage on mandibular incisors. J Periodontol 2005;76:1758-67. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]