Vestibuloplasty by Lip Switch Procedure - a Case Report

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 a high standard of oral hygiene as inadequate oral hygiene is associated with mucogingival deformities.

Periodontal plastic surgery emphasizes 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 often associated with plaque accumulation and consequently marginal gingival inflammation.

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

Aberrant frenum along with inadequate vestibular depth which causes a gingival recession. Gingival recession is a very common clinical finding in the front region of the lower jaw.

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

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 Miller's grade I mobility with the reduced width of attached gingiva in the lower anterior region along with.

Phase I therapy included full-mouth scaling and root planning, the 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, hemoglobin, bleeding and clotting time) were carried out.

Pre-surgical preparation included scrubbing of the facial skin all around the oral cavity with povidone-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. Incisions were started by giving vertical incision mesial to one of the mandibular canines and starting at the junction of the attached and free gingiva an incision was made for a distance of 10 to 12 mm extending on to the lower lip. A similar incision was given a parallel to the other mandibular canine and 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 result was a loose flap of labial mucosa with its base on the gingiva which was then folded upward and a horizontal incision was made on the periosteum, which now becomes visible. The incision of the periosteum was extended in a vertical direction at its ends. The periosteum was then separated from the bone, forming a second flap with its base on the apical portion of the mandible. The loose flap of the labial mucosa was folded back and placed on the bone from which the periosteum was removed.

It was fixed with interrupted sutures to the inner surface of the periosteum, which was removed from the bone. The upper edge of the periosteum was also sutured to the mucous membrane of the lip to cover the area denuded by the reflection of the first (labial mucosal) from which the periosteum was removed. It was fixed with interrupted sutures to the inner surface of the periosteum, which was removed from the bone.

Following the surgical procedure, a periodontal dressing was placed to protect the operated area. The patient was prescribed Amoxicillin 500 mg TID for 5 days and anti-inflammatory (Paracetamol 500 mg) BD for 5 days for post-operative pain and discomfort . The patient was instructed to have intermittent cold fomentation on the first postoperative day and soft/liquid diet for 1 week along with the maintenance of good oral hygiene. The patient was recalled after two weeks for removal of sutures and re-evaluation of the clinical parameter. At two weeks the width of attached gingiva recorded was 6mm 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.

Edlan and Mejchar (1963) depicted a technique for vestibuloplasty which appeared to be particularly applicable to patients in whom there were no pockets and little or no gingival tissue present. This procedure also appeared to increase the width of the attached gingiva where other procedures were impracticable due to lack of vestibular depth2,3,4 We hereby present a case report of a patient who presented with the chief complaint of mobility in the lower anterior teeth and in whom vestibular extension was done with the technique described by Edlan and Mejchar to correct the shallow vestibule.

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

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).

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.