4.1.2. Advanced Flaps Procedures
Since the lining mucosa is elastic, a mucosal flap raised beyond the mucogingival
junction can be stretched in coronal direction to cover exposed root surfaces. The coronally
advanced flap procedure has been described by several authors (Allen and Miller Jr, 1985;
Harris and Harris, 1994; Milano, 1998; Romanos et al., 1993; Wennström and Zucchelli,
1997; Bernimoulin et al., 1975).
The coronally advanced flap is the first choice surgical technique when there is adequate
keratinized tissue apical to the recession defect. Optimum root coverage results, good color
blending of the treated area with respect to adjacent soft tissues, and recuperation of the
original morphology of the soft tissues margin can be predictably accomplished using this
surgical approach. Furthermore, the coronally advanced flap is very effective in treating
multiple recession defects affecting adjacent teeth with obvious advantages for the patient in
terms of esthetics and morbidity. Some unfavorable local anatomic conditions may render the
coronally advanced flap contraindicated: 1) the absence of keratinized tissue apical to the
recession defect; 2) the presence of gingival (―Stillman‖) cleft extending in alveolar mucosa;
3) the marginal insertion of frenuli; 4) the presence of deep root structure loss; or 5) presence
of a very shallow vestibulum. In these situations the clinician should take the soft tissues
located laterally to the recession defect into consideration to evaluate the possibility to
perform a laterally moved flap (Zucchelli et al., 2010; Wennström and Zucchelli, 1996;
Zucchelli and De Sanctis, 2000).
The coronally positioned pedicle graft has many advantages over other surgical
procedures used to cover exposed roots. It does not require a separate surgical site to obtain a
graft. The tissue utilized will be a perfect color and contour match with the surrounding
tissue. Additionally, the procedure is simple to perform and does not require a lot of time
(Harris and Harris, 1994).
In aim to evaluate the predictability of the procedure several clinical studies have been
evaluated by Bouchard et al., 2001. The mean depth of the recession defects treated was 3.7
mm (3.3–4.1mm). The mean % of root coverage for advanced flaps was reported to be 77%
Aesthetic Periodontal Therapy – Root Coverage
9
(55–98), while the % of teeth with complete root coverage was 45% (9-84%) (Bouchard et
al., 2001).
More recently, Cairo et al. (2008) reviewed the clinical outcomes of the coronally
advanced flap on a total of 794 Miller Class I and II gingival recessions in 530 patients from
25 RCTs. This systematic review confirms that the coronally advanced flap procedure is a
safe and reliable approach in periodontal plastic surgery and is associated with consistent
recession reduction and frequently with complete root coverage. The results of meta-analyses
showed that only two combinations (coronally advanced flap + connective tissue graft and
coronally advanced flap + enamel matrix derivative) provided better results than coronally
advanced flap alone. Coronally advanced flap + connective tissue graft resulted in better
clinical outcomes for both complete root coverage (OR=2.49) and recession reduction (10.49
mm) compared with coronally advanced flap, and no other therapy provided better results
than coronally advanced flap + connective tissue graft. The combination of coronally
advanced flap + enamel matrix derivative was associated with a higher probability to obtain
complete root coverage (OR=3.89) and a higher amount of recession reduction (0.58 mm)
than coronally advanced flap alone. A possible benefit following root coverage procedures
may be the augmentation of keratinized tissue. This systematic review showed that coronally
advanced flap + connective tissue graft was associated with better clinical outcomes in terms
of keratinized tissue gain following therapy.
The technique for the coronally advanced flap procedure is:
The coronally advanced flap is initiated by two horizontal bevelled incisions (3mm in
length), mesial and distal to the recession defect located at a distance from the tip of the
anatomical papillae equal to the depth of the recession plus 1 mm.Two bevelled oblique,
slightly divergent, incisions starting at the end of the two horizontal incisions and extending
to the alveolar mucosa. The resulting trapezoidal-shaped flap is elevated with a split–full–
split approach in the coronal–apical direction. In order to permit the coronal advancement of
the flap, all muscle insertions present in the thickness of the flap are eliminated. This is done
keeping the blade parallel to the external mucosal surface. Coronal mobilization of the flap is
considered ―adequate‖ when the marginal portion of the flap was able to passively reach a
level coronal to the CEJ of the tooth with the recession defect. In fact, the flap should be
stable in its final coronal position even without the sutures. The root surface is mechanically
treated with the use of curettes. It must be considered that only the portion of the root
exposure with loss of clinical attachment (gingival recession1 probeable gingival
sulcus/pocket) is instrumented. Exposed root surfaces belonging to the area of anatomic bone
dehiscence were not instrumented not to damage connective tissue fibres still inserted in to
the root cementum. The facial soft tissue of the anatomic inter-dental papillae coronal to the
horizontal incisions is disepithelized to create connective tissue beds to which the surgical
papillae of the coronally advanced flap are sutured. By moving the flap coronally to reach the
tip of the disepitelized anatomical papillae, the vestibular soft tissue should be positioned 1
mm coronal to the cemento-enamel junction to account for soft tissue shrinkage. The suture
of the flap is started with two interrupted periosteal sutures performed at the most apical
extension of the vertical releasing incisions; then, it proceeded coronally with other
interrupted sutures, each of them directed, from the flap to the adjacent buccal soft tissue, in
the apical–coronal direction. This is done to facilitate the coronal displacement of the flap and
to reduce the tension on the last coronal sling suture (De Sanctis and Zucchelli, 2007) (Figure
3.).
A. L. Dumitrescu, Liviu Zetu and Silvia Teslaru
10
Figure 3. Coronally advaced flap procedure. a. A recession defect on the lower canine. b. Close suturing
of the pedicle graft to cover the exposed root surface. c. Healing outcome 3 months post-operatively. d.
Healing outcome 1 year post-operatively.
For the treatment of isolated gingival recession, Zucchelli et al. (2004) proposed the use
of a
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