Journal of Indian Society of Periodontology
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Year : 2013  |  Volume : 17  |  Issue : 2  |  Page : 265-270  

Vestibular deepening by periosteal fenestration and its use as a periosteal pedicle flap for root coverage

1 Department of Periodontology, Subharti Dental College, Meerut, India
2 Department of Periodontology, Sardar Patel Dental College, Lucknow, India
3 Department of Periodontology, Benaras Hindu University, Varanasi, India
4 Department of Oral and Maxillofacial Surgery, Subharti Dental College, Meerut, India

Date of Submission07-Nov-2012
Date of Acceptance14-Mar-2013
Date of Web Publication6-Jun-2013

Correspondence Address:
Jaisika Rajpal
45/A, Aashirwad Bhawan, Beside Maittri Niwas Guest House, Krishna Nagar, Kanpur Road, Lucknow - 226 023
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-124X.113095

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Gingival recession along with reduced width of attached gingiva and inadequate vestibular depth is a very common finding. Multiple techniques have been developed to obtain predictable root coverage and to increase the width of attached gingiva. Usually, the width of gingiva is first increased and then the second surgery is caried out for root coverage. The newer methods of root coverage are needed, not only to reconstruct the lost periodontal tissues but also to increase predictability, reduce the number of surgical sites, reduce the number of surgeries and improve patient comfort. Hence, this paper describes a single stage technique for increasing the width of attached gingiva and root coverage by using the periosteal pedicle flap.

Keywords: Periosteal pedicle flap, single stage technique, vestibular deepening, width of attached gingiva

How to cite this article:
Rajpal J, Gupta KK, Srivastava R, Arora A. Vestibular deepening by periosteal fenestration and its use as a periosteal pedicle flap for root coverage. J Indian Soc Periodontol 2013;17:265-70

How to cite this URL:
Rajpal J, Gupta KK, Srivastava R, Arora A. Vestibular deepening by periosteal fenestration and its use as a periosteal pedicle flap for root coverage. J Indian Soc Periodontol [serial online] 2013 [cited 2022 Jun 25];17:265-70. Available from:

   Inroduction Top

Periodontal plastic surgery is defined as a "surgical procedure performed to correct or eliminate anatomic, developmental, or traumatic deformities of gingival or alveolar mucosa." [1]

The presence of "adequate" zone of gingiva was considered critical for the maintenance of marginal tissue health and for the prevention of continuous loss of connective tissue attachment (Naber's 1954). The prevailing concept is thus that a narrow zone of gingiva was insufficient (a) to protect the periodontium from injury caused by friction forces encountered during mastication and (b) to dissipate the pull on the gingival margin created by the muscles of the adjacent alveolar mucosa. [2]

Gingival recession displaces the gingival margin apically, reducing the vestibular depth, which is measured from the gingival margin to the bottom of the vestibule. Multiple techniques have been developed to obtain predictable root coverage; however, need for a graft that has its own blood supply, which can be harvested adjacent to the recession defect in sufficient amounts without requiring any second surgical site and has the potential for promoting the regeneration of lost periodontal tissue, is a long-felt need. [3]

The present case report describes a technique where the vestibular deepening was carried out with the fenestration technique and the layer of periosteum that was scraped to create the fenestration was used as a pedicle flap for the treatment of a single tooth gingival recession.

   Case Report Top

A 17-year-old girl reported to the Department of Periodontics with the chief complaint of unesthetic appearance of her front lower teeth [Figure 1]. On examination, it was found that 6 mm deep and 4 mm wide class II gingival recession (Miller, 1985) was there on the lower left central incisor [Figure 2] and [Figure 3]. The tooth was slightly labially placed and patient also gave the history of tooth brush trauma. The vestibular depth and the width of attached gingival were also inadequate in the region. There was no mobility associated with the tooth. For the root coverage, increase in width of attached gingiva and vestibular deepening the periodontal plastic surgery was planned with a single stage fenestration technique and root coverage using the periosteal pedicle graft. The patient was advised for the treatment of the isolated gingival recession defect. The patient was in good systemic health with no contraindications for periodontal surgery. She was explained about the surgery and signed informed consent was taken by the patient. A general assessment of the patient was made through her history, clinical examination and routine laboratory investigations. Before surgery, the patient received phase-I therapy, which included oral hygiene instructions and scaling and root planning with ultrasonic and hand instruments. Two weeks after phase I therapy, the patient was planned for surgical procedures. On the day of surgery, local anesthesia was first administered bilaterally by using a mental nerve block. A horizontal incision was made using a no. 15 surgical blade at the mucogingival junction retaining all of the attached gingiva [Figure 4] and [Figure 5]. A split thickness flap was reflected sharply, dissecting muscle fibers and tissue from the periosteum. This was then sutured in the depth of the vestibule using resorbable 5-0 sutures [Figure 6]. A strip of periosteum was then removed at the level of the mucogingival junction, causing a periosteal fenestration exposing the bone. The care was taken not to remove the periosteal strip completely and to leave it pedicled to the bone and the rest of the surrounding periosteum at the lateral end [Figure 7] and [Figure 8]. The recipient site preparation included two horizontal incisions. First, intracrevicular incision and a second incision made parallel and apical to the first incision [Figure 9]. The incisions were followed by split-thickness dissection of the facially located tissue up to the level of the vestibular incision so as to create a tunnel [Figure 10] and [Figure 11]. The exposed root surface was root planed with curettes to remove bacterial contamination and was biomodified using the tetracycline powder mixed with saline. The pedicled periosteal donor tissue was then moved vertically towards the recession area, passing through the tunnel [Figure 12], [Figure 13] and [Figure 14]. At repositioning, the osteoperiosteal portion was closely adapted to the recipient site by pressing for 3 min and then sutured along with the overlying gingival tissue, to the recipient bed, using 5-0 resorbable sutures [Figure 15] and [Figure 16].
Figure 1: Class II Miller's recession in lower left central incisor

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Figure 2: 6 mm length of recession

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Figure 3: 4 mm width of recession

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Figure 4: Vestibular incision placed extending from canine to canine exposing the periosteum

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Figure 5: Diagrammatic representation – (a) Incision for vestibular deepening and (b) periosteum exposed

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Figure 6: Labial mucosa sutured to the periosteum at the apical level

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Figure 7: Diagrammatic representation: (a) Elevated periosteum and (b) bone fenestration after elevating periosteal pedicle flap

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Figure 8: Periosteum scraped to create the fenestration, periosteum remains attached to bone at one end

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Figure 9: Diagrammatic representation: (a) Crevicular incision and (b) 2nd horizontal incision

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Figure 10: Tunnel created at the recipient site

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Figure 11: Diagrammatic representation of the preparation of the tunnel at the reciepient site after raising a partial thickness flap

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Figure 12: Pedicled periosteal graft placed over the area of recession through the prepared tunnel

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Figure 13: Diagrammatic representation: (a) Periosteal pedicle flap attached at lateral end to bone which acts as a pedicle, (b) periosteum, and (c) bone fenestration after elevating periosteal pedicle flap

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Figure 14: Periosteal graft closely adapted to exposed root

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Figure 15: Diagrammatic representation: (a) Periosteal pedicled flap sutured on the recession after passing through the tunnel and (b) periosteal pedicle flap elevated and rotated toward the recession defect

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Figure 16: Graft sutured with 5‑0 resorbable suture

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Periodontal dressing (Coe-Pak; GC America Inc.) was applied over the operated area covering the exposed bone [Figure 17]. Antibiotic therapy (amoxicillin 500 mg, Thrice daily and analgesic (ibuprofen 400 mg twice daily) was prescribed for 5 days. Tooth-brushing was discontinued for the first 2 weeks at the surgical site and 0.2% chlorhexidine mouth rinse was instructed till 4 weeks after surgery. Coepak was removed 10 days after the surgical procedure and the patient was asked to maintain meticulous oral hygiene. Healing had proceeded uneventfully, with secondary wound closure [Figure 18]. In 3 weeks, healing was nearly complete, with minimal post-operative discomfort to the patient [Figure 19]. At 6 months post-operative, root coverage was nearly 100% of the recipient site, with minimal probing depths, no inflammation, and a favorable esthetic result [Figure 20].
Figure 17: Coe‑pak placed

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Figure 18: Post‑operative view after 10 days

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Figure 19: 3 weeks post‑operative view

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Figure 20: 6 months post‑operative view showing complete root coverage

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   Discussion Top

The major therapeutic goals of mucogingival surgery are esthetics, treatment of hypersensitivity and prevention of root surface caries. [4] It was believed that an "inadequate" zone of gingiva would (a) facilitate subgingival plaque formation because of the improper pocket closure resulting from the movability of the marginal tissue and (b) favor attachment loss and soft-tissue recession because of less tissue resistance to apical spread of plaque-associated gingival lesion. It was also considered that a narrow gingiva in combination with a shallow vestibular fornix might (a) favor the accumulation of food particles during mastication, and (b) impede proper oral hygiene measurement. [5] Hence, vestibular deepening should be considered where patients experience discomfort during brushing and chewing. [6]

The indications for surgical treatment of gingival recession include reducing root sensitivity, minimizing cervical root caries, increasing the zone of attached gingiva, and improving esthetics. Miller defined complete root coverage as the location of soft-tissue margin at the Cemento-enamel junction presence of clinical attachment to the root, sulcus depth of 2 mm or less and absence of bleeding on probing. [7] Several surgical techniques have been developed to correct the gingival recession defects. The purposes of developing new techniques are to increase predictability and to reduce patient discomfort, number of surgeries and the number of surgical sites, together with the need to satisfy the patient's esthetic demands, which include the final color and a tissue blend of the grafted area. [8] The ideal requirement of graft is that it should have its own blood supply and the potential for promoting the regeneration of lost periodontal structures. The adult human periosteum is highly vascular and is known to contain fibroblasts and their progenitor cells (i.e., Osteoblasts) and stem cells. In all age groups, the cells of the periosteum retain the ability to differentiate into fibroblasts, osteoblasts, chondrocytes, adipocytes, and skeletal myocytes. The tissues produced by these cells include cementum with the periodontal ligament fibers and bone; [9] in addition, the presence of the periosteum adjacent to gingival recession defects occurs in sufficient amounts, making it suitable for a graft. The adult human periosteum is highly vascular and comprises of at least two layers, an inner cellular layer or cambium layer and outer fibrous layer. [10],[11],[12] Because of the osteogenic potentiality of periosteum it has been considered as a grafting material for the repair of bone and joint defects. [13],[14] There are very limited studies, which have mentioned the use of periosteum for the treatment of gingival recession defects successfully. Mahajan reported the successful treatment outcome by using the periosteal pedicle graft for treating gingival recession defects. [15],[16] Lekovic et al. and Kwanm et al. used periosteum as a barrier membrane for the treatment of periodontal defects in their studies. [17],[18],[19] A recent study reported that periosteal cells release a vascular endothelial growth factor. [20] The present case report successfully demonstrated a single stage technique for vestibular deepening and recession coverage utilizing the periosteum as autograft for the treatment of gingival recession defect. The success rates of root coverage procedures vary because coverage depends on several factors, including location and classification of the gingival recession and the technique used. An increase in gingival height independent of the number of millimeters is considered a successful outcome of gingival augmentation procedures. [6]

The present case demonstrates that an adequate attachment occurred after the use of the pedicled periosteal flap in the treatment of denuded root. An increase in the width of keratinized gingiva occurred after the combined vestibular deepening procedure. According to LoMelcher such periosteal activation may result in the differentiation of cells portraying the ability to produce cementum and connective tissue and may lead to enhanced cementogenesis and fiber reattachment to tooth structure, demineralized in situ. [21] Histologic studies done by Wilderman and Wentz have shown connective tissue attachment of the replaced tissues to previously denuded root surfaces. [22] Thus, it seems obvious that some kind of connective tissue reattachment is a possibility with the osteostimulated repositioned periosteal flap. The success of the technique may be due to the high vascularity of the graft, the single surgical site, patient comfort, reduced intraoperative time and minimum post-operative complications and the low cost of treatment.

Throughout the follow-up period, the patient maintained good plaque control and hence the plaque did not have any influence on the final stable attachment that was achieved.

The limitation of the technique remains that it is technique sensitive and it can be used only for single tooth recessions with an inadequate width of attached gingiva. However, the lack of a second surgical site and good post-operative results achievable makes it a viable procedure for Miller's Class II recessions with an inadequate width of attached gingiva. The technique used here is proposed to give better results than the previous techniques described in literature owing to the dual blood supply, i.e., from the pedicled periosteum and secondly from the periosteum present below the gingival mucosa used to create the tunnel.

   Conclusion Top

The present case reported an excellent post-operative outcome showing great coverage of exposed root surface and increase in width of attached gingiva and keratinized gingiva. The advantages of periosteal pedicled flap over the gold standard technique i.e., subepithelial connective tissue graft for treating the gingival recession is that:

  1. The periosteal pedicle flap does not require a second operation to obtain a donor tissue
  2. Sufficient amount of tissue can be obtained from adjacent to the defect
  3. Less surgical trauma
  4. Vestibular deepening and root coverage in a single stage
  5. Dual blood supply to the periosteum
  6. Less post-operative complications
  7. Better patient satisfaction.
Thus, it can be concluded that a periosteal pedicled flap, when combined with a fenestration technique for vestibular deepening, offers a successful and viable alternative for the coverage of localized gingival recessions with an inadequate width of attached gingiva.

   References Top

1.Takei H, Azzi R, Han T. Periodontal plastic and esthetic surgery. In: F.A. Carranza, editor. Clinical Periodontology. 10 th ed. St. Louis: Elsevier; 2009. p. 1005-30.  Back to cited text no. 1
2.Ochsenbein C. Newer concept of mucogingival surgery. J Periodontol 1960;31:175-85.  Back to cited text no. 2
3.Mahajan A. Treatment of multiple gingival recession defects using periosteal pedicle graft: A case series. J Periodontol 2010;81:1426-31.  Back to cited text no. 3
4.Paolantonio M. Treatment of gingival recessions by combined periodontal regenerative technique, guided tissue regeneration, and subpedicle connective tissue graft. A comparative clinical study. J Periodontol 2002;73:53-62.  Back to cited text no. 4
5.Wennstrom J, PiniPrato GP. Mucogingival therapy periodontal plastic surgery. In: Lindhe J, Karring T, Lang N, editors. Clinical Periodontology and Implant Dentistry. 4 th ed. Copenhagen: Blackwell Munksgaard; 2003. p. 576-650.  Back to cited text no. 5
6.Wennström JL, Zucchelli G. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996;23:770-7.  Back to cited text no. 6
7.Miller PD Jr. Root coverage with the free gingival graft. Factors associated with incomplete coverage. J Periodontol 1987;58:674-81.  Back to cited text no. 7
8.Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Root coverage revisited. Periodontol 2000 2001;27:97-120.  Back to cited text no. 8
9.Greenwell H, Fiorellini J, Giannobile W, Offenbacher S, Salkin L, Townsend C, et al. Oral reconstructive and corrective considerations in periodontal therapy. J Periodontol 2005;76:1588-600.  Back to cited text no. 9
10.Bhaskar SN. In: Orbans™ Histology and Embryology. 11 th ed. St. Louis:Mosby; 2002. p. 209.  Back to cited text no. 10
11.Simon TM, Van Sickle DC, Kunishima DH, Jackson DW. Cambium cell stimulation from surgical release of the periosteum. J Orthop Res 2003;21:470-80.  Back to cited text no. 11
12.Youn I, Suh JK, Nauman EA, Jones DG. Differential phenotypic characteristics of heterogeneous cell population in the rabbit periosteum. Acta Orthop 2005;76:442-50.  Back to cited text no. 12
13.De Bari C, Dell'Accio F, Vanlauwe J, Eyckmans J, Khan IM, Archer CW, et al. Mesenchymal multipotency of adult human periosteal cells demonstrated by single-cell lineage analysis. Arthritis Rheum 2006;54:1209-21.  Back to cited text no. 13
14.Sakata Y, Ueno T, Kagawa T, Kanou M, Fujii T, Yamachika E, et al. Osteogenic potential of cultured human periosteum-derived cells-A pilot study of human cell transplantation into a rat calvarial defect model. J Craniomaxillofac Surg 2006;34:461-5.  Back to cited text no. 14
15.Mahajan A. Periosteal pedicle graft for the treatment of gingival recession defects: A novel technique. Aust Dent J 2009;54:250-4.  Back to cited text no. 15
16.Lekovic V, Kenney EB, Carranza FA, Martignoni M. The use of autogenous periosteal grafts as barriers for the treatment of Class II furcation involvements in lower molars. J Periodontol 1991;62:775-80.  Back to cited text no. 16
17.Lekovic V, Klokkevold PR, Camargo PM, Kenney EB, Nedic M, Weinlaender M. Evaluation of periosteal membranes and coronally positioned flaps in the treatment of Class II furcation defects: A comparative clinical study in humans. J Periodontol 1998;69:1050-5.  Back to cited text no. 17
18.Kwan SK, Lekovic V, Camargo PM, Klokkevold PR, Kenney EB, Nedic M, et al. The use of autogenous periosteal grafts as barriers for the treatment of intrabony defects in humans. J Periodontol 1998;69:1203-9.  Back to cited text no. 18
19.Bourke HE, Sandison A, Hughes SP, Reichert IL. Vascular endothelial growth factor (VEGF) in human periosteum normal expression and response to fracture. J Bone Joint Surg Br 2003;85B Suppl 1:4.  Back to cited text no. 19
20.Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976;47:256-60.  Back to cited text no. 20
21.Wilderman MN, Wentz FM. Repair of a dentogingival defect with a pedicle flap. J Periodontol 1965;36:218-31.  Back to cited text no. 21
22.Wilderman, M.N. and Wentz, F.M.: Repair of a dentogingival defect with a pedicle flap. J. Periodontal. 1965;36:218.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]

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