REPOSITIONING FLAPS

REPOSITIONING FLAPS 

Introduction

• Repositioned (sliding) flaps can be moved at the end of the procedure in all three directions (apical, lateral, and coronal). 
• The repositioned flaps represent the pedicled grafts.
• These types of flaps allow the correction of certain mucogingival defects.

1. The flap positioned laterally.

1.1. Definition:

• The laterally positioned flap (LPL) has also been referred to as the laterally repositioned flap, laterally displaced flap, lateral translation flap, lateral sliding flap, and rotation flap.
• It is a pedicled graft, derived from plastic surgery techniques. 
• The donor site is represented by the gingiva laterally adjacent to the site to be treated. LPL, initially described by Grupe and Warren in 1956, is one of the oldest techniques in periodontal plastic surgery.

1.2. Indications:

The indications for this technique in plastic surgery are 

• Recovering from recessions 
• The addition of gum tissue to a tooth that has little or no gum tissue to restore the mucogingival complex.  
• The release of the included canine 

1.3. Operating protocol:

• Staffileno proposes partial-thickness dissection rather than full-thickness undermining to avoid bone exposure at the donor site.
• The intervention begins with the root preparation of the cementum that has been exposed to the oral environment, in order to make it “biologically compatible” with the connective tissue of the flap that will cover it.
• The edges of the recession are prepared: the edge furthest from the donor area is freshened with the blade, which traces an external bevel, so as to expose the connective tissue.

• The incision pattern includes an intrasulcular incision on the donor site tooth and a horizontal incision at the base of the papillae 
• The discharge incision is vertical up to the mucogingival line.

REPOSITIONING FLAPS

• Another incision in the mucosa in the extension of the recession frees the flap. 
• The gingival tissue is lifted by full-thickness detachment followed by dissection into the alveolar mucosa.
• The flap is then moved laterally and tried on.
• The flap is finally sutured with a suspensory stitch and separated stitches on the external edge.

1.4. Results:

In root coverage, the result is obtained from the first month and seems to improve slightly over time, but it depends on the following factors:

• The width and height of the recession.
• The presence of interproximal bone.
• Control of etiological factors.
• Hygiene and tobacco consumption.
• The skill of the practitioner.

• The recovery percentage is in the range of 34 to 82%. 
• In all cases the probing depth is reduced to the norm and the gain in clinical attachment is evident.

1.5. Advantages:

• Root coverage of approximately 60 to 70%
• Excellent aesthetic appearance.
• Obtaining a good height of keratinized tissue.
• Good vascularization of the displaced tissue, thanks to the pedicle.

1.6. Disadvantages:

• Uncertain root coverage.
• Fine intervention.
• Technique not well suited to the treatment of multiple recessions.
• Risk of recession or exposure of dehiscence on the donor tooth.
• Requirement for an adjacent donor site with sufficient height, width and thickness of keratinized tissue
• Risk of failure in the presence of a shallow frenulum or vestibule.

1.7. Modifications:

• Friedman and Levine 1964 extend the flap by an additional tooth and Ariaudo 1966 proposes a full-thickness, large-area flap (5 to 6 teeth) to leave only a small exposed bone surface.
• Grupe 1966 modified his own technique by making the horizontal incision at a distance from the gingival margin so as to respect the attachment system of the tooth located at the donor site. The discharge incision is stepped.

• Finally, the most current modification consists of associating lateral positioning with a connective tissue graft as proposed by Nelson in 1987

1.8. The papillary flap:

• The advantage of this technique lies in the use of the adjacent papilla as a donor site which is thicker than the vestibular gingiva opposite a root. 
• The advantage is to avoid the problem of recession on the tooth located at the donor site.

REPOSITIONING FLAPS

• The displacement of the interdental gingiva on the exposed root surface allows the treatment of several recessions in one step.
• This flap was named multi-papillary flap by Corn 1973. It involves moving a wide flap laterally and apically, including several interdental spaces.

REPOSITIONING FLAPS

1.9. The bi-papillary flap:

• Faced with the problem of the width of the recession and the narrowness of the papilla, it is preferable to perform a lateral translation of 2 papillae joined together rather than to perform a rotation. 
• Cohen and Ross 1968 proposed the double papilla technique in 1968, reevaluated in 1986 by Ross et al. 
• 
• This bipapillary technique is then used by Patur, through his incisions seeking closure of the wound.

2. Coronally displaced flap 1968. 

2.1. Definition:

• The coronally positioned flap (CPF) has also been called coronal repositioning flap, coronally repositioned flap, coronally displaced flap, and finally, coronal advancement flap.
• Like the laterally displaced flap, it is a pedicled graft derived from plastic surgery techniques.
• It consists of moving the gingival tissue present apically to the site to be treated in a coronal direction.

2.2. Indications:

• For the recovery of Miller CLI recessions
• In regenerative periodontal surgery (coverage of a membrane, coverage of a filling with bone or biomaterials, or exclusion of the epithelium in an interradicular lesion
• In implant surgery 

2.3. Surgical technique:

• Root preparation: surfacing of the cementum exposed to the oral environment. 
• The incision path should take into account the length of the flap displacement, which is equal to the height of the recession.

• This papillae outline is connected by a vertical and slightly oblique discharge incision to delimit a trapezoidal flap.

• The external surface of the papilla is de-epithelialized using a pair of scissors or a blade.
• The flap is detached in total thickness of a sufficient height so that this greater thickness corresponds to that of the root to be covered.
• The flap is tried in the desired position and possibly retouched
• The flap is finally sutured with a suspensory suture associated with interrupted stitches for discharges.
• The wound is completely closed and healing is by first intention.

2.4. Variants:

• When the apically located gingival tissue is insufficient in height and thickness, an epithelial-connective gingival graft could be used to improve the quality of the donor site; this is therefore a technique carried out in two stages.
• The graft is performed 2 months before the flap, the operating protocol of which is identical to that of the single-stage technique.

2.5. The coronally positioned semi-lunar flap:

This technique was described by Tarnow in 1986, it is a variant of the coronally displaced flap.

1. Objectives:

• Root coverage of narrow recessions.

2. Indications:

• Miller Class I Recession, Single or Multiple

3. Surgical technique:

• Asepsis.
• Local anesthesia.
• This type of flap combines several techniques which have in common the fact of not making vertical discharge incisions,

• Intrasulcular incision completed by an arcuate incision at the level of the mucogingival line.
• From the intrasulcular incision, a half-thickness dissection is performed up to the semilunar incision.

• This releases a pedicled and vascularized flap not by its apical part but by its lateral edges.
• The flap is pulled coronally and applied to the recession and maintained under compression for 5 minutes, making sutures unnecessary. 
• Then protected by a bandage.

4. Disadvantages:

• Possibility of scar bands in the alveolar mucosa at the site of the semilunar incision

2.6. Results:

• It is noted that the coverage percentages vary from 65 to 99% for the flap positioned coronally, in a single stage.
• From 70 to 72% for the semi-lunar flap
• 36 to 74% for the two-stage flap.
• The height of the keratinized tissue is obviously increased by the two-step technique.
• Attachment gain varies from 3.3 to 5.3 mm
• For the single-step technique this increase is non-existent at just 1mm.

2.7. Advantages:

• Root coverage of approximately 80 to 90%.
• Excellent aesthetic appearance except for the two-step technique.
• Technically not difficult intervention.
• Little post-operative pain and discomfort
• Good vascularization of the displaced tissue thanks to the pedicle.

2.8. Disadvantages:

• Root coverage not fully predictable.
• Intervention limited to class recessions (I).
• Risk of failure in the presence of a shallow vestibular frenulum or very thin gingival tissue.

3. The flap positioned apically

3.1. Definition:

• This operation uses the apical sliding flap, partial or full thickness, with the combined goals of eliminating pockets, widening the attached gingiva, deepening the vestibule and repositioning the frenum apically.

3. 2. Indications:

• The partial thickness flap is generally used to avoid bone denudation and the concomitant risks of bone resorption and worsening of dehiscences and fenestrations.
• The total flap is more indicated when direct access to the bone is desired for bone remodeling.

3. 3. Surgical technique: 

Full thickness apically positioned flap

• The first principle of this intervention is to preserve the existing keratinized tissue by moving it to a more apical position and immobilizing it with a suture to the periosteum left in place.
• The second principle is to have access to the bone through a full thickness flap, to perform the necessary bone resection.
• The tracing begins with an intrasulcular incision up to bone contact, in order to preserve all keratinized tissue.
• Then vertical discharging incisions distal and mesial to the flap in question penetrate deep into the alveolar mucosa to allow the flap to move without folding.

• Mucoperiosteal detachment exposes bone for a few millimeters, usually down to the mucogingival line.

• The height of this detachment depends on the extent of the bone correction to be carried out. 
• Then, a partial thickness dissection is continued beyond, leaving in place the periosteum covered by gingival connective tissue.

• Bone resection is then performed according to the general principles of resective bone surgery.

REPOSITIONING FLAPS

• The flap is then moved and tried in the desired position. It is fixed by a vertical mattress suture system with anchoring to the periosteum for the interrupted, interdental stitches.

Partial thickness flap: 

1- Make a vertical incision from the marginal gingiva into the vestibule at both ends of the operating field.

2-Internal bevel incision, inside the pockets, going from the marginal gingiva to the crest of the vestibular cortex.   

REPOSITIONING FLAPS

3- A partial thickness flap is cut, leaving the periosteum and a thin layer of connective tissue on the bone.   

4-Detach the internal wall of the pockets from the teeth, descale the root surfaces and then polish them.

5-Place the flap in the apical position and even out the edges of the flap so that it conforms to the contour of the bone rim.

6-Secure the flap, remove excess clot, ensure that the flap rests firmly on the subadjacent tissue and suture it using suspended or lateral silk interrupted sutures. 

REPOSITIONING FLAPS

7-Apply a compress until the bleeding stops and cover the area with a periodontal dressing.

3.4. Advantages:

• Aesthetic appearance of the unmodified gum.
• Less painful sequel.

3.5. Disadvantages:

• Difficulty on the lingual surfaces, impossible on the palatal surfaces .
• Dissection and suturing of the periosteum requires some practice

Post-operative advice

• Taking painkillers.
• Avoid loss of dressing or deposit.
• Avoid hot and spicy food for the first few hours.
• Semi-solid food.
• Avoid brushing the operated area.
• Avoid smoking (heat can be harmful).
• Avoid physical exertion for the first 3 hours.
• In case of excessive edema or bleeding, you should return.

CONCLUSION

There are many flap surgery techniques , the differences between them are not always clear.

The choice of a technique will be based on compliance with the indications and the goal to be achieved by the intervention or the practitioner will always ensure tissue economy.

We will note that debridement, scaling, root surfacing remains an important step and directs the success of any technique.

REPOSITIONING FLAPS

Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.
 

REPOSITIONING FLAPS