Introduction
Gingival recession is the apical shift of the gingiva from its normal position on the crown of the tooth to levels on the root surface beyond the cemento-enamel junction (Loe et al., 1992). It may be localized or generalized and can be associated with one or more tooth surfaces (Kassab and Cohen, 2003).

Gingival recession has been an esthetic and functional problem recognized for many years (Carranza, 2006) and it is a fairly common clinical finding especially in the population who practice a very good oral hygiene (Albandar and Kingman) and several procedures have been proposed to preserve or enhance patient aesthetics.

Etiologic factors associated with gingival recession are abnormal tooth position (Kassab and Cohen, 2002), frenal pull (Ingervall et al., 1977; Buckley, 1981), pathology related to periodontal disease (Kassab and Cohen, 2002), bone dehiscence, thin marginal soft tissue, inflammatory viral eruption (Baker and Seymour, 1976), factitial injuries (Hasler and Schultz, 1968; Stewart, 1976; Krejci, 2000), mechanical trauma caused by tooth brushing (Breitenmoser et al., 1979), iatrogenic factors, such as faulty restorations (Kassab and Cohen, 2002) and uncontrolled orthodontic movement of teeth (Coatoam et al., 1981; Steiner et al., 1981).

Sequelae of gingival recession would be hypersensitivity, root caries, esthetic concerns, and inadequate gingival width (Seichter, 1987; Gray, 2000).

Over the years, various periodontal plastic surgical procedures have been proposed to correct the various mucogingival conditions. The techniques used for root coverage are based on tissue displacement whether by translation (pedicle flap procedures) or by grafting (free gingival or connective tissue graft procedures), and use of resorbable and non-resorbable membranes according to the principles of guided tissue regeneration (GTR) (Wennstrom, 1996).

Surgical procedures may be broadly divided into Pedicle soft tissue graft procedures (Lateral positioned flap, Double papilla flap and Coronally repositioned flap) and Free soft tissue graft procedures (Free gingival graft and Subepithelial connective tissue graft). The choice of which technique to use is based on site-specific characteristics and in some instances dic-tated by the patient.

In this article, a case of esthetic disharmony caused due to recession on a labially placed tooth treated by Lateral Positioned Flap technique is described.

Case report
A 19-years-old male patient, with good general health, reported to the Department of Periodontics, NIMS Dental College & Hospital complaining of esthetic dissatisfaction since last 6 months. The patient didn’t complain of pain or hypersentivity. Intraoral examination revealed an isolated Miller’s Class II recession in mandibular right central incisor, which was labially placed (Figure 1). On clinical examination loss of attachment was found to be 7 mm of which probing depth was 1 mm. Fremitus test was negative, there was no mobility of the tooth, oral hy-giene was good and no other pathology was seen. The patient was referred to the department of orthodontics for the correction of mal-alignment, but there he was advised extraction of that tooth followed by orthodontic treatment. The patient’s non acceptance of this treatment plan, led to the decision of perioplastic surgery; although it was contraindicated in this case.


Figure 1 Isolated Miller’s Class II recession in mandibular right central incisor

Procedure
The root surface was thoroughly debrided with ultrasonic & hand instruments and irrigated with sterile saline i.e. a complete oral hygiene procedure was carried out. Patient was recalled after 15 days. On the day of the surgery root convexity was reduced minimally and root biomodification with the help of tetracycline was carried out for 3 minutes. The root surface was again irrigated with saline.

Technique
After proper anesthesia, the tissue bordering the defect was trimmed free of sulcular epithelium with a blade no.15 and the root thoroughly planed (Figure 2). A partial thickness flap twice as wide as the defect was reflected beyond the mucogingival junction (Figure 3). The flap was then moved laterally to cover the exposed root, leaving the donor site covered by the periosteum/connective tissue (partial thickness flap). A short oblique releasing incision (cut back incision) at the base of the flap was made to avoid any tension that would impair the vascular circulation when the flap was positioned. The flap was then secured using 4-0 single interrupted sutures (Figure 4).


Figure 2 Recipient bed prepared


Figure 3 Partial thickness flap reflected beyond the mucogingival junction


Figure 4 Flap sutured onto the recession defect

Pressure was exercised on the flap with fingers and wet gauze to minimize blood clot thickness and encourage fibrinous adhesion. Coe-pack was applied on the wound and left in place for 1 week.

Patient was recalled every week for a regular checkup and was found to be maintaining a good oral hygiene. Sutures were removed after a period of 14 days. Healing was satisfactory. The treated site showed 5 mm gain in clinical attachment level after 2 weeks. More than 70% root coverage was achieved with excellent tissue contour and color (Figure 5). The gingival tissue of both donor and recipient site showed satisfactory healing with no signs of inflammation at final evaluation after 1 month.


Figure 5 Root coverage after 1 month

Discussion
History: Grupe & Warren were the first to describe the positioned flap as a method to repair isolated gingival defects (1956). They reported elevating a full-thickness flap one tooth away from the defect and rotating it to cover the recession (Grupe and Warren, 1956). In 1966, Grupe modified this technique to a submarginal incision on donor site (Grupe, 1966). In 1964, Staffilena used partial thickness flap to protect donor site from recession (Edward, 2006). In 1964b, Corn modified this technique by adding a cut-back incision to release tension (Edward, 2006). He also took pedicle from edentulous ridge. In 1967, Hattler reported the use of a positioned partial thickness flap to correct mucogingival defects on two or three adjacent teeth (Hattler, 1967). In 1978, Goldman & Smukler added periosteally stimulated flap (Goldman and Smukler, 1978) and in 1983, they used partialfull rotated flap technique (Goldman et al., 1983). The lateral positioned flap is commonly used to cover isolated, denuded roots that have adequate donor tissue lateral and vestibular depth. The advantage of the pedicle graft versus the free gingival autograft is the presence of its own blood supply in the base that will nourish the graft and facilitate the reestablishment of vascular anastomoses at the recipient site during the healing phase.

Indications of lateral positioned flap are inadequate amount of attached gingiva, single or multiple adjacent recessions that have adequate donor tissue lateral (root coverage), recession next to an edentulous area (Carranza, 2006).

The most common complication is a slight recession at the donor site. There might also be increased possibility of dehiscence and fenestrations at donor site. This is most likely to occur if the periodontium is of thin biotype. Another complication is necrosis or loosening of the flap. This happens if the flap is too thin, in a partial thickness flap, because of faulty technique or inadequate anatomy. The flap will loosen if the dissection was insufficient, and the flap was sutured with tension (Carranza, 2006).

The contraindications for a lateral positioned flap are the presence of deep interproximal pockets, deep or extensive root abrasion or erosion, significant loss of interproximal height and excessive root prominence due to labial placement of the teeth and absence of alveolar housing on its labial aspect, as in this case. Thus mucogingival surgery was contraindicated in this case, but in order to meet the patient’s esthetic demand, root coverage procedure was attempted. Although complete root coverage could not be achieved because of severe tooth prominence.

Conclusion
Early diagnosis and instructions on oral hygiene may favour non-surgical conservative procedures and prevent the progression of gingival recession. Although if present, it is imperative to evaluate the extent of the recession and the patient expectation before selecting the most suitable technique for the case, pointing out the importance of taking into account the indications, contraindications and limitations of each technique. When esthetics is the priority and periodontal health is good then surgical root coverage is a potentially useful therapy even though it may be an improper/contraindicated case. As it can be noted in the reported case, class II gingival recession along with the labial placement of the tooth in the dental arch which definitely is a contraindication of root coverage procedure is treated by means of a Lateral Positioned Flap to meet the patients concern for esthetics and more than 70% root coverage was achieved which is a fairly good result. Thus, Lateral Positioned Flap proved to be a fair attempt for root coverage.

Conflicts of interest
None declared.

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