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.
Lip switch technique, Edlan Mejchar technique,
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.
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.
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.
recession refers to exposure of root surface by the apical migration of junctional
epithelium (JE), results in a unesthetic appearance and dentinal
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 Lip switch technique to correct the shallow vestibule.
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
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
Fig 1. Preoperative
Fig 2. Vertical & Horizontal incision made
Fig 3. Suture placed
Fig 4. Mesurements made after 15 days
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
concentration of 1:80000.
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.
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.
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
technique, Edlan-Mejchar vestibuloplasty) and
soft tissue grafting vestibuloplasty.
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.
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.
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 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. 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
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.
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.