A. L. Dumitrescu, Liviu Zetu and Silvia Teslaru
12
Despite the lack of tension in the mobilized pedicle, its stability in the more desired
coronal position is questionable, as no suturing of the advanced flap portion is indicated. This
is of particular concern when the procedure is considered for teeth with highly scalloped
gingival margins, where coronally manipulating the tissue could be more demanding
(Haghighat, 2006). The semilunar flap is a modification of a technique described in the late
1960s for incisally repositioning the gingival tissues to address recession defects on labial
surfaces of maxillary cuspids (Sumer, 1969; Haghighat, 2006).
In a in a split-mouth design the outcome of gingival recession therapy using subepithelial
connective tissue graft or the semilunar coronally positioned flap procedure was evaluated by
Bittencourt et al. (2006). No statistically significant differences were observed between
groups in any of the clinical parameters at baseline. Recession height, recession width, width
of keratinized tissue, thickness of keratinized tissue, probing depth, and clinical attachment
level were measured at baseline and 6 months post-surgery. In the subepithelial connective
tissue graft group, recession height decreased from 2.20 ± 0.56 mm to 0.21 ± 0.25 mm,
corresponding to a mean root coverage of 90.95% ± 11.46%. In the semilunar coronally
positioned flap group, recession height decreased from 2.15 ± 0.59 mm to 0.10 ± 0.19 mm,
corresponding to a mean root coverage of 96.10% ± 7.69. Complete root coverage was
accomplished in 52.94% of the treated cases in the subepithelial connective tissue graft group
and in 76.47% in the semilunar coronally positioned flap group (Bittencourt et al., 2006).
After 30 months, the mean percentages of root coverage were 89.25% and 96.83% for the
semilunar coronally positioned flap and subepithelial connective tissue graft groups,
respectively. Complete root coverage at the final observation was achieved in 58.82% of the
treated cases in the semilunar coronally positioned flap group and in 88.24%
of the patients in
the subepithelial connective tissue graft group. The comparison between 6 and 30 months
showed that two patients in the subepithelial connective tissue graft group gained attachment
and achieved complete root coverage; this only occurred in one patient in the semilunar
coronally positioned flap group. The subepithelial connective tissue graft group maintained a
statistically significant increase in thickness of keratinized tissue (
P
<0.05) at 30 months. At
this time, there were no significant differences between the two groups with regard to
recession height, recession width, width of keratinized tissue, thickness of keratinized tissue,
probing depth and clinical attachment level. With regard to esthetic improvement, after 30
months, patients in semilunar coronally positioned flap and subepithelial connective tissue
graft groups were generally satisfied with both procedures (82.3% and 100%, respectively).
Although they presented similar good results, more patients preferred, based on esthetics
achieved, treatment with subepithelial connective tissue graft. This can be explained by the
higher percentage of complete RC and the absence of hypertrophic scars or fibrosis in this
group, whereas in the semilunar coronally positioned flap group, seven patients complained
about the presence of hypertrophic scars, although they were not visible while smiling
(Bittencourt et al., 2009).
The modified semilunar coronally advanced flap for the correction of gingival recession
present on adjacent teeth was described by Haghighat (2006). Semilunar incisions were made
apical to the recession defects, starting within mucosa and extended mesio-distally, arching
more coronally to terminate apical to the papillae mesial and distal to the teeth exhibiting the
defects. The papilla between the teeth with recession was coronally advanced after a split
thickness dissection and sutured more coronally, over the deepithelialized portion of the
original papilla.
Aesthetic Periodontal Therapy – Root Coverage
13
This technique provides better control over flap repositioning than previously described
semilunar coronally advanced flaps and reduces the likelihood of apical tissue retraction when
attempting root coverage on two adjacent teeth. This is particularly of value for highly
scalloped gingival margins where coronal manipulation and stability are difficult. As
described with the original semilunar flap procedure, adequate thickness and width of
keratinized tissue apical to the recession defect are required. In cases exhibiting a thin-tissue
biotype, tissue augmentation either before or at the time of the corrective surgery is
advocated. Therefore, the technique is of value in the correction of residual recession defects
on two adjacent teeth where previous attempts at coverage using soft tissue autografts have
been made (Haghighat, 2006).
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