Modified semilunar coronally advanced flap: A case series.

Dentists traditionally think of periodontal treatment as a means of saving the teeth while leaving the patient with an esthetic problem. The goal of gingival esthetics is to maintain normal healthy gingival appearance around teeth that must be restored. Gingival recession represents a significant concern for patients and a therapeutic problem for the clinician. Root coverage is the goal of periodontal plastic surgery when treating gingival recessions in the esthetic zone. Correction of mucogingival recession deformities with a variety of periodontal plastic surgical procedures have been described each demonstrating a variable degree of success. This case report presents to you the treatment outcomes and predictability of modified semilunar coronally advanced flap (Kamran Haghighat) techniques described for the treatment of recession defects on single and multiple adjacent teeth, respectively.

INTRODUCTION

Gingival recession is defined as exposure of the tooth by the apical migration of the gingiva. The etiologic factors for gingival recession are inflammatory periodontal disease,[1] mechanical trauma,[2] tooth malposition, root prominence, aberrant frenal attachment,[3] orthodontic tooth movement,[45] underlying alveolar dehiscence,[56] ginigival phenotype,[7] and iatrogenic restorative and periodontal treatment-related factors.[8]

The classification of ginigival recession was given by Sullivan and Atkins in 1965 as shallow narrow, shallow wide, deep narrow, and deep wide. Later, P.D. Miller in 1985 classified gingival recession into Class I: Marginal tissue recession that does not extend to the mucogingival junction, there is no loss of bone or soft tissue in the interdental area, can be narrow or wide. Class II: Marginal tissue recession that extends to or beyond the mucogingival junction, there is no loss of bone or soft tissue in the interdental area, can be wide and narrow. Class III: Marginal tissue recession that extends to or beyond the mucogingival junction, there is bone and soft tissue loss interdentally or malpositioning of the tooth. Class IV: Marginal tissue recession that extends to or beyond the mucogingival junction, there is severe bone and soft tissue loss interdentally or severe tooth malposition.

Mucogingival recession deformities can be corrected with a variety of periodontal plastic surgical procedures each demonstrating a variable degree of success. Mucogingival surgery as defined by Friedman refers to surgical procedures done to correct relationships between gingiva and oral mucosa.[9] Periodontal plastic surgery is defined by 1996 World Workshop in Clinical Periodontics as surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva.[9]

The different root coverage procedures are free gingival autograft,[10-13] free C/T autograft,[10-13] pedicle autograft[14-20] such as a laterally positioned flap and coronally positioned flap – semilunar pedicle (Tarnow), sub-epithelial C/T graft (Langer), guided tissue regeneration, and the Pouch and Tunnel technique. The different pedicle grafts are rotational flaps like the laterally positioned, double papilla, and transpositional flap, and advanced flaps like coronally advanced flap and semilunar flap.[10-16]

Millers Classes I and II gingival recession shows 100% success rate to root coverage procedures, Class III shows 50 to 70% success, and Class IV shows only 0 to 10% success.[21]

A modified semilunar coronally advanced flap has been described for the treatment of recession defects on multiple adjacent teeth.

Modified semilunar coronally advanced flap

This technique was first described by Kamran Haghighat in 2006.[22]

Technique

Described for the treatment of gingival recession present on the adjacent teeth. Following careful debridement of exposed root surfaces, a semilunar incision is made apically following the curvature of the gingival margins of the teeth exhibiting the gingival recession. The most apical extent of the arc of the incision is typically located in the mucosa. The lateral extent of the incisions curves coronally within the keratinized tissue to terminate apical to papillae mesial and distal to the teeth exhibiting the recession (A), and maintaining an adequate distance from the papilla tip in the vertical axis (the arrow indicates the distance of the incision from the tip of the papilla) such that the vascularity of the mobilized papilla is not compromised [Figure 1].

Figure 1

Schematic diagram of modified semilunar flap design

A partial thickness intrasulcular incision is made along the gingival margins of the two adjacent teeth (B). A partial thickness flap, extending from the marginal tissue coronally to the double semilunar incision apically is mobilized. The mesial and distal papillae are left intact. Over the middle papilla, between the two teeth with recession defects, the incision along the gingival margin is extended to create a new middle papilla tip (C) located apical to that of the original, at a distance equal to that of the recession defect. Following a partial thickness flap reflection over the midline papilla, the remaining orginal papilla is de-epithelialized. The partial thickness flap is coronally advanced with the newly created papilla positioned over the de-epithelialized segment (F). The flap is sutured through the midline papilla to stabilize it coronally.

CASE REPORTS

Case 1

A 42 year-old male patient reported to the Department of Periodontics for the treatment of recession defects for esthetic and tooth sensitivity reasons.

On examination, recession defects were present on 13, 14, and 15 for 10 years and had increased since the last 3 years. The patient showed good plaque control and tissues showed no signs of inflammation. A modified semilunar coronally advanced flap technique was performed. 3/0 ethicon sutures were placed [Figures 2–8].

Figure 2

Recession on 13

Figure 8

9 months post operative

Recession on 14

Recession on 15

Incision

Flap coronally displaced and sutures placed

3 months post operative

Healing was uneventful and complete coverage of defect was maintained for 9 months.

Case 2

A 30-year-old female patient reported with a chief complaint of recession defects on 13 and 14.

A modified semilunar coronally advanced flap technique was performed. 3/0 ethicon sutures were placed.

Case 3

A 38-year-old male patient reported with a chief complaint of mild Class 1 gingival recession in 21 and 22.

A modified semilunar flap technique was performed. 3/0 ethicon sutures were placed.

DISCUSSION

The success of root coverage procedures is determined by the amount of recession coverage as assessed by measuring the distance between the cementoenamel junction and the gingival margin is considered as the primary outcome variable for the therapeutic endpoint of success. Probing depth and clinical attachment level are also used as descriptors of the success of root coverage procedures.[21]

The conditions necessary for the success of root coverage procedures are appropriate case selection with no loss of interdental papilla and interdental alveolar bone adjacent to gingival recession and sufficient interdental papilla adjacent to gingival recession area, sufficient blood supply ensured to donor tissue, root surface covered with thick donor tissue (flap and graft), donor tissue adapted closely to the recipient site, and sutured. The dead space between the donor tissue and recipient site will interfere with circulation and no severe decay or abrasion on the exposed root.[21]

The criteria for successful root coverage are as follows: The gingival margin is on CEJ in Class I, Class II gingival recession, the depth of gingival sulcus is within 2 mm, there is no bleeding on probing, there is no hypersensitivity, and color match with adjacent tissue is esthetically harmonious.[21]

10 cases were treated using the modified semilunar coronally advanced flap technique and all 10 cases met the criteria for successful root coverage. All cases showed minimal post-operative discomfort as there was no need of a donor site. Significant clinical root coverage was seen for a period of 9 months. Suturing helped in stabilization of mobilized pedicle and helped in bringing the marginal tissues to the desired location.[22] This technique allowed for better control over flap repositioning and also reduces apical tissue retraction while attempting for root coverage on multiple adjacents.[22] It is useful in highly scalloped gingival margins where coronal manipulation and stability are difficult.[22] To employ this technique, adequate thickness and width of keratinized tissue should be present apical to the defect.[22] This particular incision design allows for partial thickness dissection over the middle papilla, which provides for adequate vascularity and better repositioning and it also eliminates potential scarring from vertical incisions.[22]

CONCLUSION

This technique is particularly valuable when previous attempts for root coverage with soft tissue autografts have resulted in residual recession defects on adjacent teeth and thicker tissue biotype which is amenable to partial thickness dissection. This technique allows for better control over flap repositioning than semilunar coronally advanced flaps.