Microsurgical approach for the management of gingival cleft: A case series and decision-making process

Gingival clefts, once known as "Stillman's Cleft", now considered an obsolete phenomenon, cannot be neglected in clinical practice, especially when it is persistent and epithelialized. The attached gingiva and alveolar mucosa are composed of epithelial layers with subjacent connective tissue. Gingival clefts, notwithstanding their intrinsic differences, may exhibit keratinized or non-keratinized tissue. Coupled with additional risk factors, it can result in progressive attachment loss and gingival recession.

Two cases with three distinct types of gingival clefts were described. Case 1 was identified as having a 2 mm white cleft coupled with lack of attached gingiva, while Case 2 was described as having a 3 mm white and red cleft which were treated with gingival cleft approximation subsequent to connective tissue grafting, non-surgical periodontal therapy and cleft approximation, respectively. The diagnostic confirmation was verified using an operating microscope set at a magnification of 5×, while the subsequent surgical stages were carried out with a magnification of 8×. These treatments yielded complete elimination and closure of the gingival clefts in addition to increased width of attached gingiva and soft tissue phenotype in Case 1 where bilaminar approach was utilized. The three clefts were effectively addressed using an operating microscope for both non-surgical and surgical interventions in the cleft management.

All the three clefts exhibited complete elimination and closure of the gingival cleft. At 3 years follow up, there was reduction of the probing depth (1 mm) and attachment gain (1 mm) in all the three clefts. There was increase in width of attached gingiva to 3 mm and increase in soft tissue thickness in Case 1, where connective tissue graft was utilized. As microsurgical treatment approach was employed, the patients did not manifest with any intra-operative or postoperative complications. The first case showed the presence of soft tissue bulk at the treated site warranting debulking at 12 months postoperatively. The stability of the width of attached gingiva was maintained over the course of the 3-year follow-up period. The use of a microsurgical method in these settings enhances the predictability of outcomes than a macrosurgical approach.

The utilization of microsurgical techniques for the closure of gingival clefts allows for the accurate and meticulous insertion and placement of grafts, resulting in improved outcomes and enhanced aesthetic results. These techniques also minimize tissue trauma and postoperative discomfort. The treatment technique should be personalized to the individual's specific needs, considering factors such as type and extent of cleft, etiology and amount of attached gingiva. Nonetheless, microsurgical approaches for such cases are no more a discretion but an obligation.

Identification of gingival cleft should not be overlooked during routine periodontal examination. Diagnosed gingival clefts should be observed for clinical changes after completion of Phase I therapy. Only "white" gingival clefts require definitive surgical treatment. Untreated clefts can lead to root sensitivity, root caries and marginal tissue recession.