ABSTRACT: to create an environment which results in

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

Keywords:  Vestibuloplasty,Lip switch technique, Edlan Mejchar technique,INTRODUCTION:The overall oralhealth is maintained by proper oral hygiene. Maintenance of oral hygieneincreases longevity of natural dentition. Goal of oralhygiene is to remove plaque, calculus, prevent dental caries and periodontaldisease. It has been documented that oral hygiene is directly linked toperiodontal disease. If oral hygiene is compromised it leads to periodontitis.The objective ofperiodontal therapy is to create an environment which results in good oralhygiene practice by the patient.

Mucogingivalsurgery is done to rectify defect in morphology, position & amount ofgingiva and alveolar mucosa. Mucogingival surgery term was introduced by NathanFriedman in 1957. In 1996, World Workshop in Clinical Periodontics renamedMucogingival surgery as Periodontal Plastic Surgery. Periodontal plasticsurgery term was proposed by Miller in 1993.The occurrenceof mucogingival deformities often has an impact on patient’s aesthetics, oralhygiene maintenance and function.

A shallow vestibule is associated with plaqueaccumulation and consequently marginal gingival inflammation which leads tomobility, bone loss, gingiva recession. Gingivalrecession refers to exposure of root surface by the apical migration of junctionalepithelium (JE), results in a unesthetic appearance and dentinalhypersensitivity.1We herebypresent a case report of a patient who presented with the chief complaint oftrauma while brushing in lower anterior teeth and in whom vestibular extensionwas done with the Lip switch technique to correct the shallow vestibule.

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 CASE REPORT:A 45 year oldfemale presented with the chief complaint of trauma while brushing in the loweranterior region reported to the outpatient of Department of Periodontology, SardarPatel Postgraduate Institute of Dental & Medical Science, Lucknow. On intraoralexamination it was found that patient had Millers grade I mobility with reducedwidth of attached gingiva in the lower anterior region along with grade IIrecession in 31, 41. Width of attach gingiva was severly reduced , measuring2mm.

(Fig.1)Phase I therapywas initiated with patient education and motivation, full mouth scaling androot planing, home plaque care measures and oral hygiene instructions werereinforced to the patient. Vestibular extension of the patient’s mandibularlabial vestibule to increase the width of attached gingiva was planned. Routineblood investigations (haemoglobin, total and differential leukocyte counts, bloodglucose- fasting and post-prandial, bleeding and clotting time) were carriedout.                Fig 1. Preoperative                                                    Fig 2. Vertical & Horizontal incision made                 Fig 3.

Suture placed                                                    Fig 4. Mesurements made after 15 days SURGICAL TECHNIQUE: Pre-surgicalpreparation was done by scrubbing of the facial skin all around the oral cavitywith povidine iodine solution and the patient was made to rinse with 0.2%Chlorhexidine digluconate mouthrinse for 30 seconds. The patient wasanesthetized using 2% Lidocainewith Adrenalineconcentration of 1:80000. The surgicalprocedure 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 aspectof the both mandibular canines and starting at the junction of the attached andfree gingiva. An incision was made for a distance of 11 to 12 mm extending onto the lower lip. These two incisions were joined by a horizontal incisionacross the midline. A split thickness flap was then separated the loose labialmucosa from the underlying muscle. Now periosteum was visible. The incision ofthe periosteum was extended in a vertical direction at its ends. Periosteum wasseparated from the bone. Then interrupted sutures were placed on the innersurface of the periosteum, which was separated from the bone.

Aftersurgical procedure a periodontal dressing (Coe Pac) was placed to protect theoperated area. The patient was prescribed Cap Amoxicillin 500 mg TID for 5 daysand anti-inflammatory Tab Diclofenac 50 mg BD for 5 days for post-operativepain. Patient was instructed to have soft diet for 1 week along with otherpost-operative instructions.

The patient was recalled after two weeks for removalof sutures. No postoperativecomplications were created. At two weeks the width ofattached gingiva recorded was 7 mm approximately. The patient was recalledafter every month and 3 months follow up was recorded and it was observed thatthe achieved width attached gingiva remained constant throughout. DISCUSSION:Vestibuloplastyis a surgical procedure designed to deepened oral vestibule by changing softtissue attachments. Various surgical modalities have been used forvestibuloplasty including sub mucosal vestibuloplasty, secondary epithelisationvestibuloplasty (Kazanjiantechnique, Edlan-Mejchar vestibuloplasty) andsoft tissue grafting vestibuloplasty. Edlan andMejchar technique was given by Edlan and B Mejchar (1963) and it is secondaryepithelisation vestibuloplasty.

In secondary epithelisation the mucosa ofvestibule is used to line one side of the extended vestibule, and the otherside heals by growing new epithelial surface. Edlan and Mejchar technique is amodification of Kazanjian technique. Edlan andMejchar depicted a technique for vestibuloplasty which was applicable topatients in whom there were no pockets and little or no gingival tissuepresent. This procedure also increases the width of the attached gingiva whereother procedures were impracticable due to lack of vestibular depth.2,3,4 Thistechnique is also indicated in treatment of localized recession or forelimination of a broad, high frenum.

 Edlan andMejchar technique known as lip switch procedure or transpositional flap orEdlan vestibuloplasty. The advantage of this technique no bone is left exposed,it minimizes the chances of bone resorption and recession. Another advantage ofthis technique is there are no relapses of the vestibule and scar formation isminimal.

In the present case, an excellent clinical result was obtained whichwas maintained even 3 month after surgery.Several techniques have been developed since1956, but most of them are unsatisfactory due to scar formation and frequentrelapse of the state of the vestibule.  Compared to another widely usedperiosteal fenestration technique there is minimal contraction of thevestibular depth gained and minimal scar formation. 5This finding isconsistent with the observations of Wade (1969)6. A study done byAxel Ergenholtz and Anders Hugoson stated that net gain was of 7.7 mm which wasfollowed upto 5 years. The condition was stabilized and maintained.

3Problemassociated with shallow vestibule is improper maintenance of oral hygienebecause of traumatic brushing. Various brushing techniques require theplacement of the toothbrush at the gingival margin, which may not be possiblewith reduced vestibular depth. It has been reported that with minimal of 1 mmof attached gingiva, proper gingival health cannot be established.

 CONCULSION: Based on the clinicalfindings of the present case it can be concluded that in cases with a shallow vestibuleand a reduced width of attached gingiva on the labial aspect of the mandibularanterior teeth, this technique provides a predictable way in which oral healthcan be achieved and maintained.