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Case Report Treatment of Miller Class I Gingival Recession with Using Nonpedicle Adipose Tissue after Bichectomy Surgical Technique: A Case Report Carmen Lucia Mueller Storrer , Leonardo Luiz Muller , Janes Francio Pissaia, Carla Frehner Andrade, Claudia Roberta Tenório Trevisani, and Tatiana Miranda Deliberador School of Health Science, Universidade Positivo, Curitiba, Paraná, Brazil Correspondence should be addressed to Carmen Lucia Mueller Storrer; [email protected] and Tatiana Miranda Deliberador; [email protected] Received 9 August 2019; Accepted 18 October 2019; Published 31 December 2019 Academic Editor: Giuseppe Alessandro Scardina Copyright © 2019 Carmen Lucia Mueller Storrer et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Gingival recession is an oral health problem that affects a large part of the population. Several treatments are suggested in the current literature; among them is the use of buccal fat pad grafting. The objective of this case report is to describe the treatment of a Miller Class I gingival recession using a nonpedicled buccal fat pad graft immediately after performing the surgery for buccal fat pad removal (bichectomy technique). First, bilateral surgical removal of the buccal fat pad was performed with the main objective of eliminating oral mucosa biting. The recipient site was prepared to receive a portion of the fat pad that was cut and macerated in a size that was sufficient to cover the recession. The patient was followed up at 15, 30, 60, and 365 days postsurgery, and the results showed an elimination of the oral mucosa biting and complete coverage of the gingival recession. It was concluded that the nonpedicled buccal fat pad graft is another option for the treatment of Miller Class I recessions. 1. Introduction Gingival recession is the apical displacement of the gingival tissue in relation to the cementoenamel junction resulting in the root surface being exposed to the oral environment [1]. This exposure may lead to dentin sensitivity, pain, risk of root caries, abrasion, and erosion lesions, in addition to not being esthetic. Its etiology is associated with several fac- tors such as biofilm accumulation, chemical and mechanical trauma, orthodontic treatment, quantity and quality of kera- tinized gingiva, and occlusal trauma [2–4]. Success in the treatment of gingival recessions is directly related to its severity. In Miller Class I and Class II recessions, there is no interproximal tissue loss; thus, complete root cov- erage is feasible [5]. Different surgical techniques such as free gingival graft, flap repositioning, and connective tissue graft have been used in the treatment of gingival recessions. Treatments with ped- icled buccal fat pad grafts are also described in the literature with satisfactory results regarding root coverage, clinical attachment level, and keratinized tissue gain [6, 7]. However, the use of nonpedicled buccal fat pad grafts is still poorly described [8]. Currently, the surgical technique of buccal fat pad remo- val/bichectomy technique (removal of part of the buccal adi- pose tissue) has been frequently performed in dentistry with the main objective of eliminating oral mucosa biting. In a systematic review of 8 of the 220 articles found, it was con- cluded that the bichectomy technique has an initial favorable outcome regarding facial aesthetics with a low rate of Hindawi Case Reports in Dentistry Volume 2019, Article ID 1049453, 5 pages https://doi.org/10.1155/2019/1049453

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  • Case ReportTreatment of Miller Class I Gingival Recession with UsingNonpedicle Adipose Tissue after Bichectomy Surgical Technique:A Case Report

    Carmen Lucia Mueller Storrer , Leonardo Luiz Muller , Janes Francio Pissaia,Carla Frehner Andrade, Claudia Roberta Tenório Trevisani,and Tatiana Miranda Deliberador

    School of Health Science, Universidade Positivo, Curitiba, Paraná, Brazil

    Correspondence should be addressed to Carmen Lucia Mueller Storrer; [email protected] Tatiana Miranda Deliberador; [email protected]

    Received 9 August 2019; Accepted 18 October 2019; Published 31 December 2019

    Academic Editor: Giuseppe Alessandro Scardina

    Copyright © 2019 Carmen Lucia Mueller Storrer et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original workis properly cited.

    Gingival recession is an oral health problem that affects a large part of the population. Several treatments are suggested in thecurrent literature; among them is the use of buccal fat pad grafting. The objective of this case report is to describe the treatmentof a Miller Class I gingival recession using a nonpedicled buccal fat pad graft immediately after performing the surgery forbuccal fat pad removal (bichectomy technique). First, bilateral surgical removal of the buccal fat pad was performed with themain objective of eliminating oral mucosa biting. The recipient site was prepared to receive a portion of the fat pad that was cutand macerated in a size that was sufficient to cover the recession. The patient was followed up at 15, 30, 60, and 365 dayspostsurgery, and the results showed an elimination of the oral mucosa biting and complete coverage of the gingival recession. Itwas concluded that the nonpedicled buccal fat pad graft is another option for the treatment of Miller Class I recessions.

    1. Introduction

    Gingival recession is the apical displacement of the gingivaltissue in relation to the cementoenamel junction resultingin the root surface being exposed to the oral environment[1]. This exposure may lead to dentin sensitivity, pain, riskof root caries, abrasion, and erosion lesions, in addition tonot being esthetic. Its etiology is associated with several fac-tors such as biofilm accumulation, chemical and mechanicaltrauma, orthodontic treatment, quantity and quality of kera-tinized gingiva, and occlusal trauma [2–4].

    Success in the treatment of gingival recessions is directlyrelated to its severity. In Miller Class I and Class II recessions,there is no interproximal tissue loss; thus, complete root cov-erage is feasible [5].

    Different surgical techniques such as free gingival graft,flap repositioning, and connective tissue graft have been usedin the treatment of gingival recessions. Treatments with ped-icled buccal fat pad grafts are also described in the literaturewith satisfactory results regarding root coverage, clinicalattachment level, and keratinized tissue gain [6, 7]. However,the use of nonpedicled buccal fat pad grafts is still poorlydescribed [8].

    Currently, the surgical technique of buccal fat pad remo-val/bichectomy technique (removal of part of the buccal adi-pose tissue) has been frequently performed in dentistry withthe main objective of eliminating oral mucosa biting. In asystematic review of 8 of the 220 articles found, it was con-cluded that the bichectomy technique has an initial favorableoutcome regarding facial aesthetics with a low rate of

    HindawiCase Reports in DentistryVolume 2019, Article ID 1049453, 5 pageshttps://doi.org/10.1155/2019/1049453

    https://orcid.org/0000-0002-1188-8848https://orcid.org/0000-0001-7468-460Xhttps://orcid.org/0000-0003-4076-4905https://creativecommons.org/licenses/by/4.0/https://creativecommons.org/licenses/by/4.0/https://creativecommons.org/licenses/by/4.0/https://creativecommons.org/licenses/by/4.0/https://doi.org/10.1155/2019/1049453

  • complications, but there is a lack of randomized clinical tri-als to evaluate long-term outcomes [9].

    The objective of this case report is to describe the treat-ment of a Miller Class I gingival recession using a nonpedicledbuccal fat pad graft immediately after performing the surgeryfor buccal fat pad removal.

    2. Case History

    Prior to the surgical intervention, the patient was informedabout the surgical procedure and signed an ethical consentform.

    The patient, a young female, presented to the DentistryClinic reporting a lack of gingival symmetry between themaxillary left and right canines and with the desire to elimi-nate oral mucosa biting. The clinical exam confirmed the facerounded (Figure 1) and cheek biting and revealed a MillerClass I gingival recession on the maxillary left canine(Figure 2). The removal of the Bichat fat pad was suggestedto the patient with the objective of eliminating the oralmucosa biting and using the tissue for the root coverage.

    The surgical procedure was initiated by harvesting thebuccal fat pad. The incision location is at the vestibule fun-dus, at the distal caries of the second molar with a 30mmdistance from the vestibule and above the Parotid duct(Figure 3). The incision is made, initially, by perforatingthe alveolar mucosa, buccinator muscle, and connective tis-sue capsule that surrounds the Bichat buccal fat pad. Then,the incision is extended about 1.5 cm until it reaches themesial caries of the first molar (Figure 4). A curved hemostatwas used to enlarge the tissues. The buccal extension of the

    Bichat ball is completely removed by careful circular move-ments (Figure 5). 4ml of buccal fat pad was removed. Thedonor site was immediately sutured with a 4.0 silk thread(braided black silk, Technofio, Goiania, GO, Brazil) with asimple suture (Figure 6).

    Figure 1: The clinical exam confirmed the face rounded and theindication for Bichectomy technique.

    Figure 2: Miller Class I gingival recession on the maxillary leftcanine (recipient site).

    Figure 3: The incision location in donor site: vestibule fundus, atthe distal caries of the second molar with a 30mm distance fromthe vestibule and above the parotid duct.

    Figure 4: Extension of the incision: from the distal caries of thesecond molar to the mesial caries of the first molar.

    Figure 5: Removal of the buccal extension of the Bichat ball.

    Figure 6: Simple suture in donor site with 4.0 silk thread.

    2 Case Reports in Dentistry

  • The preparation of the recipient site (gingival recessionon the maxillary left canine) was performed with an intrasul-cular incision and two divergent vertical incisions toward thevestibule bottom (Figure 7). A partial thickness flap was thenraised, and a periosteal releasing incision was made so theflap could be loosened and slid to cover the graft. The canineroot was then scaled and planned with 5-6 Gracey curettes(Figure 8) (Hu-Friedy, Chicago, IL, USA) and irrigated withsterile saline solution. A portion of the buccal fat pad wascut into a size that was sufficient to cover the recipient site,its surface was macerated with a scalpel blade, and the graftwas positioned (Figure 9). The graft was stabilized with anX suture using a 5.0 resorbable suture thread (polyglycolicacid suture, Technofio, Goiania, GO, Brazil), and the flapwas then coronally positioned and anchored with simpleand suspension sutures (Figure 10).

    As postoperative medications, amoxicillin 500mg (8/8 hfor 07 days) and ibuprofen 400mg (8/8 h for 03 days) wereprescribed. The patient was instructed to rinse the surgicalsite with 0.12% 58 chlorhexidine digluconate solution twicea day, for 1 week. The suture was removed 15 days postsur-gery (Figure 11), and follow-up visits were scheduled at 30(Figure 12), 60 (Figure 13), and 365 (Figure 14) days.

    Figure 7: Preparation of the recipient site: with an intrasulcularincision and two diverging vertical incisions up to the alveolarmucosa.

    Figure 8: Scaled and planned with 5-6 Gracey curettes in canineroot prior to receiving graft of adipose tissue.

    Figure 9: Macerated portion of the buccal fat pad cover of therecipient site.

    Figure 10: Flap coronally positioned and anchored with simple andsuspension sutures.

    Figure 11: Removal of sutures 15 days postoperatively.

    3Case Reports in Dentistry

  • The patient reported that the oral mucosa biting wascompletely eliminated and that she was satisfied with theesthetic and functional results of the buccal fat pad removalsurgery. Additionally, she was satisfied with the root coverageof the maxillary left canine, which favored smile esthetics andreduced dentin sensitivity.

    3. Discussion

    The free gingival graft technique presents good results in thetreatment of gingival recessions. However, it is not recom-mended in esthetic areas, since the color discrepancy is unfa-vorable [7]. Root coverage using subepithelial connectivetissue graft is considered the gold standard when comparedto the other surgical techniques, as it provides satisfactoryroot coverage, gain in clinical attachment level, and kerati-nized tissue, resulting in therapeutic and esthetic success[10]. However, the palatal donor site usually entails a pro-nounced postoperative pain, and therefore, different autoge-

    nous graft alternatives have been applied in the treatment ofgingival recessions [11].

    The results of the proposed treatment have beendescribed as positive, and success has been attributed to theease in harvesting the buccal fat graft through a fast surgicaltechnique with low donor site morbidity and a low rate ofcomplications [12]. The positive results are also attributedto the rich vascular supply that guarantees maintaining thevitality of the graft and the presence of stem cells that aid intissue regeneration and differentiation of the grafted adiposetissue into stratified squamous epithelium and dense connec-tive tissue [13]. There is a report of long-termmaintenance ofthe graft structure and volume since the buccal fat pad doesnot undergo lipolysis [14].

    El Haddad et al. [7] reported the therapy with pedicledbuccal fat pad grafting in a maxillary first molar with the buc-cal root surface almost completely exposed, presenting gradeIII mobility and Class II furcation involvement. One monthafter treatment, there was an average gain of 8mm in rootcoverage and gained keratinized tissues with excellent match-ing of color and texture were observed. In 2010, Kumari et al.[15] used the same technique to cover aMiller Class III defectin a maxillary right molar and obtained a 4mm gain in theattachment level. Agarwal [6] also applied the techniquein a maxillary molar with class IV gingival recession andobtained clinical attachment level and keratinized tissue gain.Ercan et al. [12] described two clinical cases, where the firstone showed a gain of 7mm in the attachment level, reducingthe gingival recession to 4mm. Panda et al. [16] performed asubepithelial graft using the pedicled buccal fat pad and buccalflap advancement for root coverage of a Miller Class III gingi-val recession exhibiting a 7mm attachment loss and obtainedkeratinized tissue gain—which was initially absent—in addi-tion to a gain of 4mm in the attachment level.

    In 2015, Deliberador et al. [8] conducted a split-mouthrandomized controlled trial to analyze the transplant effi-ciency of a nonpedicled buccal fat pad graft for the treat-ment of Miller Class I and Class II gingival recessions andcompared the results with those of a subepithelial connec-tive tissue graft. The authors concluded that the use of abuccal fat pad graft can be considered a predictable alterna-tive, as no significant statistical differences were observedbetween the two techniques with respect to the estheticresults, gain in clinical attachment level, gain in keratinizedtissue, and root coverage; thus, both therapies were consid-ered to be clinically successful.

    In the present case report, a nonpedicled buccal fat padgraft was performed with flap advancement, resulting incomplete root coverage, with maintenance of the extensionof the keratinized tissue width, normal color and texturecharacteristics, and a small increase in gingival volume. Theresults were maintained after one year of follow-up suggest-ing that the technique is safe and effective, in agreement witha previously performed study [8].

    4. Conclusion

    Nonpedicled buccal fat pad graft is an effective technique inthe treatment of Miller Class I gingival recessions and may

    Figure 12: 30-day postoperative follow-up.

    Figure 13: 60-day postoperative follow-up.

    Figure 14: 1-year postoperative follow-up.

    4 Case Reports in Dentistry

  • be considered a treatment option. The technique is safe andeasy to perform, presents excellent esthetic and therapeuticresults, and can also be applied in areas distant from thedonor site or even in the lower arch.

    Additional Points

    Key Messages. The aim of this case report is to address thetreatment of a Miller Class I gingival recession using a non-pedicled buccal fat pad graft after buccal fat pad removal sur-gery (bichectomy technique).

    Consent

    The authors certify that they have obtained all appropriatepatient consent forms. In the form, the patient has givenher consent for her images and other clinical informationto be reported in the journal. The patient understands thather name will not be published and due efforts will be madeto conceal identity, but anonymity cannot be guaranteed.

    Conflicts of Interest

    The authors declare that they have no conflicts of interest.

    References

    [1] F. Cairo, “Periodontal plastic surgery of gingival recessions atsingle and multiple teeth,” Periodontology 2000, vol. 75,no. 1, pp. 296–316, 2017.

    [2] K. F. G. Yared, E. G. Zenobio, and W. Pacheco, “A etiologiamultifatorial da recessão periodontal,” Revista Dental Pressde Ortodontia e Ortopedia Facial, vol. 11, no. 6, pp. 45–51,2006.

    [3] M. G. Marini, S. L. A. Greghi, E. Passanezi, and A. C. P.Sant’ana, “Gingival recession: prevalence, extension and sever-ity in adults,” Journal of Applied Oral Science, vol. 12, no. 3,pp. 250–255, 2004.

    [4] G. Serino, J. L. Wennström, J. Lindhe, and L. Eneroth, “Theprevalence and distribution of gingival recession in subjectswith a high standard of oral hygiene,” Journal of Clinical Peri-odontology, vol. 21, no. 1, pp. 57–63, 1994.

    [5] A. P. Yadav, A. Kulloli, S. Shetty, S. S. Ligade, S. S. Martande,and M. J. Gholkar, “Sub-epithelial connective tissue graft forthe management of Miller’s class I and class II isolated gingivalrecession defect: a systematic review of the factors influencingthe outcome,” Journal of Investigative and Clinical Dentistry,vol. 9, no. 3, article e12325, 2018.

    [6] C. Agarwal, G. V. Gayathri, and D. S. Mehta, “An innovativetechnique for root coverage using pedicled buccal fat pad,”Contemporary Clinical Dentistry, vol. 5, no. 3, pp. 386–388,2014.

    [7] A. S. El Haddad, M. Y. A. Razzak, andM. El Shall, “Use of ped-icled buccal fat pad in root coverage of severe gingival reces-sion defect,” Journal of Periodontology, vol. 79, no. 7,pp. 1271–1279, 2008.

    [8] T. M. Deliberador, C. T. Trevisani, C. L. M. Storrer et al.,“Non-pedicled buccal fat pad grafts to treatment for class Iand II gingival recessions: a clinical trial,” Brazilian DentalJournal, vol. 26, no. 6, pp. 572–579, 2015.

    [9] L. B. Moura, J. R. Spin, R. Spin-Neto, and V. A. Pereira-Filho,“Buccal fat pad removal to improve facial aesthetics: an estab-lished technique?,” Medicina Oral, Patología Oral y CirugíaBucal, vol. 23, no. 4, pp. e478–e484, 2018.

    [10] L. Chambrone, D. Chambrone, F. E. Pustiglioni, L. A.Chambrone, and L. A. Lima, “Can subepithelial connectivetissue grafts be considered the gold standard procedure inthe treatment of Miller class I and II recession-type defects?,”Journal of Dentistry, vol. 36, no. 9, pp. 659–671, 2008.

    [11] S. El-Haddad and M. El-Shall, “Two-Year Clinical Evaluationof Pedicled Buccal Fat Pad Alone and with Emdogain for RootCoverage of Severe Gingival Recession Defects: A Case Series,”The International journal of periodontics & restorativedentistry, vol. 37, no. 6, pp. 901–901, 2017.

    [12] E. Ercan, C. Çandirli, C. Uysal, B. C. Uzun, and E. Yenilmez,“Treatment of severe gingival recession using pedicled buccalfat pad: histological and clinical findings,” Clinical and Exper-imental Health Sciences, vol. 6, no. 4, pp. 191–194, 2016.

    [13] E. Farré-Guasch, C. Martí-Pagè, F. Hernádez-Alfaro, J. Klein-Nulend, and N. Casals, “Buccal fat pad, an oral access sourceof human adipose stem cells with potential for osteochondraltissue engineering: an in vitro study,” Tissue Engineering PartC: Methods, vol. 16, no. 5, pp. 1083–1094, 2010.

    [14] P. W. Poeschl, A. Baumann, G. Russmueller, E. Poeschl,C. Klug, and R. Ewers, “Closure of oroantral communicationswith Bichat’s buccal fat pad,” Journal of Oral and MaxillofacialSurgery, vol. 67, no. 7, pp. 1460–1466, 2009.

    [15] B. N. Kumari, R. Thiagarajan, V. Narayanan, P. Devadoss,B. Mammen, and P. Emmadi, “A new technique for root cov-erage using buccal fat pad–a short case report,” QuintessenceInternational, vol. 41, no. 7, pp. 547–549, 2010.

    [16] S. Panda, M. D. Fabrro, A. Satpathy, and A. C. Das, “Pedicledbuccal fat pad graft for root coverage in severe gingival reces-sion defect,” Journal of Indian Society of Periodontology,vol. 20, no. 2, pp. 216–219, 2016.

    5Case Reports in Dentistry

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