ABSTRACT:Background: A 45 year old female patient complaintof trauma while brushing in lower front teeth. An extremely shallow vestibulewas observed with gingival recession in 31 and 41.Methods: The mandibular labial vestibule wasextended using the lip switch procedure or the Edlan-Mejchar technique. Results: The procedure yielded a considerablegain in the width of the attached gingiva, which maintained itself even oneyear after the surgical procedure. Conclusions: Edlan-Mejchar technique leads to aconsistent and predictable increase in the width of the attached gingiva andmay be successfully used in the treatment of a shallow vestibule.Keywords:   INTRODUCTION:Maintenance oforal hygiene is required for optimum periodontal health that increases thelongevity of the person’s natural dentition.

The objective of periodontaltherapy is to reproduce an environment which results in high standard of oralhygiene as inadequate oral hygiene is associated with mucogingival deformities.Periodontalplastic surgery emphasize on biological, functional problems that affect theperiodontium and focused to improve esthetic appearance. The occurrenceof mucogingival deformities often has an impact on patients in provisions of aestheticsand function. A shallow vestibule is associated with plaque accumulation and consequentlymarginal gingival inflammation which leads to mobility, bone loss, gingivarecession.

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Gingivalrecession means exposure of root surface by the apical migration of junctionalepithelium (JE), results in a unesthetic appearance and dentinalhypersensitivity.1Varioussurgical modalities have been used for vestibuloplasty including sub mucosalvestibuloplasty, secondary epithelisation vestibuloplasty, Edlan-Mejcharvestibuloplasty and soft tissue grafting vestibuloplasty.We 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 technique described by Edlan and Mejchar to correct theshallow vestibule.  METHOD: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,Sardar Patel Postgraduate Institute of Dental & Medical Science, Lucknow. Onintraoral examination it was found that patient had Millers grade I mobility withreduced width of attached gingiva in the lower anterior region along with(Fig.1)Phase I therapyincluded full mouth scaling and root planing, occlusalcorrection wasdone where indicated and oral hygiene instructions were reinforced to thepatient.

, a vestibular extension of the patient’s mandibular labial vestibuleto increase the width of attached gingivawas planned. Routineblood investigations (total and differential leukocyte counts, blood glucose-fasting and post-prandial, haemoglobin, bleeding and clotting time) werecarried out.              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 one minute. The patient wasanesthetized using 2% Lidocainewith Adrenalineconcentration of 1:80000. The surgical procedure asdescribed byEdlan and Mejchar was followed. Vertical incisions were given on mesial aspect ofthe 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 thicknessflap then separated the loose labial mucosa from the underlying muscle. Theincision of the periosteum was extended in a vertical direction at its ends..

It was fixedwith interrupted sutures to the inner surface of the periosteum, which wasremoved from the bone. Aftersurgical procedure a periodontal dressing (Coe Pac) was placed to protect theoperated area. The patient was prescribed. Amoxicillin 500 mg TID for 5 daysand anti-inflammatory (Diclofenac 50 mg) BD for 5 days for post-operative pain.Patient was instructed to have liquid/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 6 months and one year for regular follow up and it was observed that theachieved width attached gingiva remained constant throughout. DISCUSSION:Edlan andMejchar (1963) 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 depth2,3,4 Edlan and Mejchartechnique also known as lip switch procedure. The advantage of this techniqueis that healing occurs by first intention and no bone is left exposed, therebyminimizing the chances of bone resorption and further recession. Anotheradvantage of this technique is there is no relapses of the vestibule. In thepresent case, an excellent clinical result was obtained which was maintainedeven one year after surgery.

Several technique have been developed since 1956,but most of them are unsatisfactory due to scar formation and frequent relapseof the state of the vestibule. Various brushingtechniques require the placement of the toothbrush at the gingival margin,which may not be possible with reduced vestibular depth. It has been reportedthat with minimal of 1 mm of attached gingiva, proper gingival health cannot beestablished.This finding is consistent withthe observations of Wade (1969)5. CONCULSION: Thus, based on the findings ofthe present case it can be concluded that in cases with a shallow vestibule ispresent and a reduced width of attached gingiva on the labial aspect of themandibular anterior teeth, the technique advocated by Edlan and Mejcharprovides a predictable way in which oral health can be achieved and maintained.



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