Periodontal plastic surgery procedures aim to address various issues affecting the gums, alveolar mucosa, and bone, such as defects arising from anatomy, development, trauma, or plaque related diseases. These procedures not only serve aesthetic purposes but also contribute to maintaining optimal oral hygiene. The oral vestibule refers to the cavity within the mouth, bordered medially by the teeth and gingiva, laterally by the cheek and lip mucosa, and apically by movable and immovable mucosal borders. Vestibular depth is measured either from crest of lip or from coronal border of the attached gingiva to depth of muccobuccal fold[1]. Adequate vestibular depth is crucial for ensuring proper oral hygiene as a shallow vestibule can lead to food accumulation and hinder the maintenance of oral cleanliness. Additionally, when combined with inadequate gingiva, shallow vestibule may result in marginal tissue pulling and gingival recession, exacerbating plaque accumulation, gingival inflammation, tooth mobility, bone loss and further gingival recession. The tongue is a muscular organ that affects speech, position of the teeth, periodontal tissue, nutrition and swallowing[2]. Tongue tie may lead to various functional abnormalities that include abnormal speech, malocclusion, Wallace defines tongue tie as a “A condition in which the tip of the tongue cannot be protruded beyond the lower incisor teeth because of a short frenulum lingua, often containing scar tissue[3].

A 18-year-old male patient reported to the Department of Periodontology with two main concerns, Difficulty in maintaining oral hygiene in the lower anterior region with rapid accumulation of deposits for past six month and restricted tongue movement affecting pronunciations of words such as t,d,s,z,n,l,r and th ([Table. 1]). 

On clinical examination, vestibular depth of 2mm was observed in the lower anterior region from lower right canine to left canine along with short, fibrotic lingual frenum extending from the ventral surface of the tongue to the lingual gingiva was observed. Additionally, Cairo RT II gingival recession was measured with 3mm in the lower central, lateral incisors and canines ([Fig. 1] A and B). 

The patient was also scheduled for orthodontic treatment for correction of open bite necessitating adequate vestibular depth and improved gingival conditions to ensure optimal treatment outcomes. Following clinical examination, vestibuloplasty using scalpel technique and frenectomy using laser technique was planned. Informed consent was obtained from the patient. After two weeks of initial non-surgical periodontal therapy, A vestibuloplasty was performed under local anaesthesia using a combined approach of Godwin’s and Clark’s technique[4, 5]. By using a No: 15 C blade a horizontal incision was made on the oral mucous membrane of the lip[6]. The incision was extended to the canine region bilaterally and two vertical incisions were given to extend it towards the crest of the alveolar ridge ([Fig. 2]). 

The inner lip was undermined and secured to the periosteum at the newly established vestibular depth using 4-0 non resorbable silk sutures. The exposed alveolar bone was left to heal by secondary intention and was protected with Coe-pack periodontal dressing ([Fig. 3]). During the same surgical session by using laser technique (Diode 810nm), a lingual frenectomy was performed to relieve ankyloglossia[7] thereby enhancing tongue mobility and reducing lingual gingival traction on the mandibular incisors ([Fig. 4]). Post- surgical instruction along with antibiotics (Amoxycillin 500mg three times a day for 5 day) and analgesics (Ibuprofen 400 mg two times a day for 5 days) was prescribed. Patient was reviewed on 7th and 30th postoperative days to assess the vestibular depth and tongue tie. The initial vestibular depth was 2mm, which increased to 10mm at the 1-week, postoperative review, indicating an 8mm gain. The gain in vestibular depth was achieved using the combined Godwin and Clark vestibuloplasty technique ([Fig. 5]). Preoperatively, the patient exhibited restricted tongue movement due to short lingual frenum, at 1st week the tongue mobility had improved and free elevation to the palate achieved without restriction.   

Inadequate vestibular depth may result from the high insertion of muscles such as the mentalis, leading to an insufficient width of keratinized gingiva. A shallow vestibule limits access for adequate oral hygiene measures, leading to plaque accumulation along the gingival margin. Prolonged plaque accumulation can elicit an inflammatory response in the gingiva, which combined with continuous muscular stress, may result in recession of the gingival margin.

Consequently, maintenance of proper oral hygiene becomes increasingly difficult in patients with inadequate vestibular depth. Hence, surgical intervention was planned to increase the vestibular depth and facilitate effective plaque control and gingival maintenance. Vestibular depth measurement was recorded pre and post operatively using a periodontal probe (UNC-15) from the gingival margin to the muccobuccal fold at the site of surgery. Vestibuloplasty is a surgical procedure carried out to restore alveolar ridge heights by lowering muscle attachment on the buccal, labial and lingual aspects of the residual ridges[8, 9]. There is different technique to increase the vestibular depth I) Kazanjian technique, II) Godwin technique III) Clark’s technique. The major drawback of Kazanjian technique is severe scarring of lip causing reduced lip flexibility[10]. In this case we combined Godwin and Clark’s technique to minimize relapse, improve healing and for more predictable results. In addition to the shallow vestibule, the patient presented with short, fibrotic lingual frenum which not only restricted tongue movement but also exerted traction on the lingual gingiva of the mandibular anterior teeth. Frenectomy in such situations eliminates the source of undue tension, improves tongue movement and contributes to functional rehabilitation. In this case, the frenectomy was performed in the same surgical session, thereby reducing treatment time and enhance patient compliance.

The combined approach of Godwin, Clark’s technique for vestibuloplasty and frenectomy for tongue tie proved to be an effective surgical intervention, addressing both functional limitation and shallow vestibular depth. This dual procedure not only improved tongue mobility and oral function but also enhanced vestibular depth, thereby promoting long term gingival stability and facilitating better oral hygiene maintenance. The integrated approach offers a predictable and efficient option for managing cases with concurrent high frenum attachment.