40023.
qxd 1/6/05 4:14 PM Page 1734
Case Series
Laterally Moved, Coronally Advanced Flap: A Modified
Surgical Approach for Isolated Recession-Type Defects
G. Zucchelli,* C. Cesari,* C. Amore,* L. Montebugnoli,* and M. De Sanctis†
Background: Various modifications of the laterally
sliding flap have been proposed to reduce the risk of gin-
gival recession at the donor tooth site, but the reported
root coverage predictability was quite low. The goal of
the present study was to evaluate the effectiveness with
respect to root coverage of a modified surgical approach
of the laterally moved flap procedure for the treatment
of an isolated type of recession defect.
Methods: One hundred and twenty (120) isolated
gingival recessions (Miller Class I or II) with specific
features of the keratinized tissue lateral to the defects
were treated with a new approach to the laterally
moved flap. The main surgical modifications consisted
of the coronal advancement of the laterally moved flap
and the different thickness during flap elevation. Clin-
ical evaluation was made 1 year after the surgery.
Results: At the 1-year examination, 97% of the root
surface was covered with soft tissue and 96 defects
(80%) showed complete root coverage. A statistical and
clinically significant increase of keratinized tissue was
observed. These favorable results were accomplished
with no change in the position of gingival margin or
in the height of gingival tissue at the donor tooth/site.
Conclusions: The laterally moved, coronally ad-
vanced surgical technique was very effective in treat-
ing isolated gingival recessions. It combined the esthetic
and root coverage advantages of the coronally advanced
flap with the increase in gingival thickness and kera-
tinized tissue associated with the laterally moved flap.
The ideal gingival conditions must be present lateral to
an isolated recession defect in order to render the pro-
posed surgical technique an highly effective and pre-
dictable root coverage surgical procedure. J Periodontol
2004;75:1734-1741.
KEY WORDS
Dental esthetics; gingival recession/surgery;
keratin/physiology; surgical flaps; tooth root.
* Department of Oral Science, Bologna University, Bologna, Italy.
† Department of Periodontology, Siena University, Siena, Italy.
1734
Volume 75 • Number 12
T
he international literature has documented that
gingival recession can be successfully treated by
means of several surgical approaches, irrespec-
tively of the technique utilized, provided that the bio-
logic conditions for accomplishing root coverage are
satisfied; i.e., no loss of interdental soft and hard tissues
height.1
The selection of one instead of another surgical tech-
nique depends on the local anatomic characteristics of
the site to be treated and on the patient’s demands. The
patient influences the selection of the surgical technique
especially when concerned about an esthetic problem
due to the exposure of root surfaces during smiling or
function.
In such patients, pedicle flap surgical techniques
(coronally advanced or rotated flaps) are recommended
if there is adequate keratinized tissue close to the reces-
sion defect. In these surgical approaches, the soft tis-
sue utilized to cover the root exposure is similar to that
originally present at the buccal aspect of the tooth with
the recession defect and thus the esthetic result is more
satisfactory. Furthermore, the postoperative course is
less troublesome since other surgical sites far from the
tooth with recession defect, (palate, for example) are
not involved.
The coronally advanced flap is the first choice sur-
gical technique when there is adequate keratinized tis-
sue apical to the recession defect.2,3 Optimum root
coverage results, good color blending of the treated
area with respect to adjacent soft tissues, and recuper-
ation of the original morphology of the soft tissues mar-
gin can be predictably accomplished using this surgical
approach.2,3 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.3
Some unfavorable local anatomic conditions may ren-
der 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 sit-
uations the clinician should take the soft tissues located
laterally to the recession defect into consideration to
40023.qxd 1/6/05 4:14 PM Page 1735
J Periodontol • December 2004
evaluate the possibility to perform a laterally moved
flap.
Reports on the laterally moved flap surgical technique
are quite dated.4-17 Various authors suggested several
modifications to the original laterally sliding flap
described by Grupe and Warren in 19564 in order to
reduce the risk of gingival recession at the donor site:
Staffileno5 proposed the use of a partial thickness flap,
instead of a full-thickness one, to cover the root expo-
sure. Grupe and Warren6 suggested performing a sub-
marginal incision at the donor site in order to preserve
the marginal integrity of the tooth adjacent to the reces-
sion defect. Rubens et al.7 introduced a mix-thickness
flap which consisted of a full-thickness flap performed
close to the recession defect to cover exposed root, and
a split-thickness flap laterally to the full-thickness one,
to cover the bone exposed at the donor site of the full-
thickness flap.
The most recent publication on the laterally moved
flap as root coverage surgical approach was published
in 1988.8 The reason for the lack of recent interest is
related to the fact that data do not seem to indicate
the laterally moved flap is an highly predictable and
effective root coverage surgical procedure. The
reported mean percentage of root coverage ranges
between 34% and 82%.9-17 Only one study reported
data relating the “percentage of complete (up to the
cemento-enamel junction) root coverage” and the range
was between 40% and 50%.8 The goal of the present
study was to evaluate the effectiveness of a modified
surgical approach of the laterally moved flap procedure
for treating isolated recession defects with respect to
root coverge.
MATERIALS AND METHODS
Patient and Site Selection
One hundred and twenty (120) young (age range 20 to
38 years) systemically healthy subjects with isolated
recession type defects were enrolled in the study. The
participants were selected on a consecutive basis among
patients consulting the Department of Periodontology,
University of Bologna. A screening examination revealed
that all subjects showed an unremarkable medical his-
tory and none had loss of periodontal support at other
tooth surfaces than those showing recession defects.
Patients smoking more than 20 cigarettes/day were
excluded from the study. In order to be included in the
study patients should have at least one recession defect
with the following characteristics: 1) isolated defect (no
recessions in the neighboring teeth); 2) Class I or II
defect according to Miller18 (no loss of interdental soft
and hard tissue height); 3) recession depth (RD) >2
mm; 4) lateral keratinized tissue width (KTW donor) at
least 6 mm greater than the width of the recession mea-
sured at the level of the cemento-enamel junction (CEJ);
and 5) lateral keratinized tissue height (KTH donor) at
Zucchelli, Cesari, Amore, Montebugnoli, De Sanctis
least 2 mm greater than the buccal probing depth (PD)
of the adjacent tooth/teeth (PD donor).
Following the screening examination all patients
received a prophylaxis including instruction in proper
oral hygiene measures and scaling and professional
tooth cleaning with the use of a rubber cup and a low
abrasive polishing paste. At teeth with recession type
defects a coronally directed roll technique was rec-
ommended to minimize the toothbrushing trauma to
the gingival margin. Surgical treatment of the reces-
sion defects was not scheduled until the patient could
demonstrate an adequate standard of supragingival
plaque control and absence of bleeding on probing
(BOP) in the recession site to be treated.
Clinical Characteristics of Patients and Selected
Sites
Full-mouth (FMPS) and local plaque scores were
recorded as the percentage of total surfaces (four per
tooth) which revealed the presence of plaque.19 Bleed-
ing on probing was assessed dichotomously at a force
of 0.3 N with a manual pressure-sensitive probe. Full
mouth (FMBS) and local bleeding scores were
recorded as the percentage of total surfaces (four per
tooth) which revealed the presence of bleeding upon
probing.19
The following clinical measurements were taken 1
week before the surgery and at 1 year follow-up. 1)
Recession depth (RD), measured from the CEJ to the
most apical extension of the gingival margin. 2) Reces-
sion width (RW), measured at the level of the CEJ. 3)
Probing depth at the treated (PD) and donor (PD donor)
teeth, measured from the gingival margin to the bot-
tom of the gingival sulcus. 4) Clinical attachment level
(CAL), measured from the CEJ to the bottom of the
gingival sulcus of the treated tooth. 5) Keratinized tissue
height at the treated (KTH) and donor (KTH donor)
teeth measured from the most apical extension of gin-
gival margin to the mucogingival line.
A single investigator performed the clinical meas-
urements at baseline and at 1 year. All measurements
were performed by means of a manual probe and were
rounded up to the nearest millimeter.
Surgical Technique (Figs. 1 and 2)
Recipient area. Initially, the recipient area for the later-
ally moved flap was prepared.
The flap recipient area resulted from the deepithe-
lialization of a triangular-shaped area delimited by three
incisions: 1) A horizontal incision (extended 3 mm in the
mesial-distal direction) at the level of the CEJ. 2) A
vertical beveled incision, parallel to the mesial gingival
margin of the recession, extending in alveolar mucosa.
3) A beveled intrasulcular incision along the distal gin-
gival margin of the recession defect and extending in
alveolar mucosa up to crossing the preceding vertical
1735
40023.qxd 1/6/05 4:14 PM Page 1736
A Modified Flap for Recession Defects
Figure 1.
Schematic of the laterally moved, coronally advanced surgical technique.
Legend: dotted line, receiving area for flap; x, recession width; SP, surgical
papilla (3 mm wide); Att G, attached gingiva; PD, probing depth.
incision (incision 2 above) (this incision is the same as
2 in the flap design described below).
The depithelialization of this area was performed with
a 15c blade kept parallel to the external gingival sur-
face; a 3 mm-wide connective tissue area lateral and
apical to the root exposure provided anchorage bed to
the laterally moved flap.
Flap area (Fig. 1). The flap design consisted of three
incisions: a) The bevelled intrasulcular incision, which
is the same as incison 3 of the recipient area. b) A hor-
izontal submarginal incision extending in the mesial-
distal direction 6 mm more than the width of the
recession defect measured at the CEJ. The outline of
the horizontal incision varied based on the need to pre-
serve at least 1 mm of non-probeable keratinized tissue
at the adjacent donor tooth/teeth and include at least a
1 mm band of keratinized tissue all along the mesial-
distal extension of the flap. If one considers that a prob-
ing depth of at least 1 mm was present at the buccal
aspect of the adjacent donor tooth, a 3 mm height of
keratinized tissue (KT donor) (1 mm probeable, 1 mm
of attached gingiva, and 1 mm for the flap) had to be
measured lateral to the gingival recession. In the pres-
ence of a PD donor of 2 mm, at least a 4 mm height of
keratinized tissue was required. c) A beveled oblique
vertical incision, extending into alveolar mucosa, parallel
to the first intrasulcular incision (incision a). When the
flap was moved in the distal-mesial direction (opposite
to the direction of the lip muscle insertions) another
short horizontal incision was performed at the most api-
cal extension of this vertical incision (cut back) in order
to facilitate mesial mobilization of the flap.
1736
Volume 75 • Number 12
The flap was elevated mix-thickness (Fig. 2B). Dur-
ing flap elevation, the thickness of the flap varied depend-
ing on the thickness required for the central portion of
the flap covering the avascular root surface with respect
to the most peripherical 3 mm extended area (the sur-
gical papillae) covering the connective tissue beds pre-
pared laterally to the root exposure (deepithelialized
anatomic papillae). In practice, the surgical papillae of the
flap were elevated keeping the blade almost parallel to
the long axis of the tooth, while the central portion of the
flap was raised up with greater thickness using the blade
with a 45° inclination with respect to the underlying bone
surface. In this latter area, great care was taken to leave
the periosteum protecting the underlying bone.
Once the mucogingival line was reached, flap eleva-
tion was continued split-thickness, keeping the blade
parallel to the bone surface, to expose at least 5 mm of
periosteum apical to the bone dehiscence of the tooth
with the recession defect.
Flap elevation was terminated when it was possible
to passively move the flap laterally above the exposed
root. In order to allow coronal advancement of the flap,
all muscle insertions present were eliminated. This was
done keeping the blade parallel to the external mucosal
surface. Coronal mobilization of the flap was considered
adequate when the marginal portion of the flap was able
to passively reach a level coronal to the cemento-enamel
junction. In fact, the flap should be stable in its final
coronal position even without the sutures.
The root surface was mechanically treated with
curets; only the portion of the exposed root with loss
of clinical attachment (gingival recession + probeable
gingival sulcus/pocket) was instrumented. Exposed
root surface belonging to area of anatomic bone dehis-
cence was not instrumented to avoid damaging con-
nective tissue fibers still inserted in the root cementum.
The remaining facial soft tissue of the anatomic inter-
dental papillae was deepithelialized to create connective
tissue beds to which the surgical papillae of the laterally
moved, coronally advanced flap were sutured (Fig. 2B).
The suturing began with two interrupted periosteal
sutures in the most apical extension of the vertical releas-
ing incisions, then proceeded coronally, along the mesial
vertical incision, with other interrupted sutures, each of
them directed from the flap to the adjacent buccal soft
tissue in the apical-coronal direction. More apically an
horizontal double mattress suture was placed to reduce
lip tension on the marginal portion of the flap. After these
sutures, the most marginal portion of the flap was sta-
ble in the coronal position without disrupting forces acting
on it at the time of the marginal sling suture3 (Fig. 2C).
This sling suture permitted a precise adaptation of the
buccal flap on the underlying root surface and to stabi-
lize every single surgical papilla over the interdental con-
nective tissue bed. In all treated cases, at the end of the
surgery, the flap margin resided coronal to the cemento-
40023.qxd 1/6/05 4:14 PM Page 1737

J Periodontol • December 2004 Zucchelli, Cesari, Amore, Montebugnoli, De Sanctis

twice daily for 1 minute. Fourteen

days after the surgical treatment,
the sutures were removed. Plaque
control in the surgically treated area
was maintained by chlorhexidine
rinsing for an additional 2 weeks.
After this period the patients were
again instructed in mechanical
tooth cleaning of the treated tooth
region using a soft toothbrush and
a roll technique. All patients were
recalled for prophylaxis 1, 3, and 5
weeks after suture removal and
subsequently every 3 months until
the final examination (12 months).

Data Analysis
A software program‡ was used for
the statistical analysis. The Student
t test for paired data was used to
compare baseline and 1-year clin-
ical parameters. A general linear
model was fitted relating 1 year
Figure 2. root coverage to three categorical
A) Preoperative clinical view: a 6 mm deep gingival recession with 1 mm height of probeable (jaw, tooth, smoking) and six con-
keratinized tissue (no attached gingiva) is present at tooth #13.The recession width, measured at tinuous (RD, KT, KT donor, KT flap,
the level of the CEJ, is 5 mm. A deep root abrasion is associated with the soft tissue recession. Distal BD, CD flap) factors as covariates
to the root exposure, there is an adequate width (11 mm) and height (6 mm) of keratinized tissue
to perform the laterally moved, coronally advanced surgical approach. B) The recipient area has (analysis of covariance).
been prepared mesially to the root exposure and the flap raised.The anatomic interdental papillae Regarding root coverage, each
have been deepithelialized to create connective tissue beds to which the surgical papillae will be value was dichotomized accord-
sutured. Note that the marginal soft tissue and, more apically, the periosteum have been preserved ing to whether coverage was com-
to prevent gingival recession at the donor tooth site. C) Suture of the flap.The flap has been plete (gingival margin at the level
positioned coronal to the CEJ. Note that the soft tissue (arrow) deriving from the deepithelialization
of the receiving area has been used to partially cover the periosteum left in place at the donor site. of the CEJ) or not and multiple
This reduces the secondary intention wound healing area. D) Postoperative (1 year) clinical view logistic regression was used to
shows that complete root coverage, increased amount and thickness of keratinized tissue, and good estimate the odds ratios between
color blending of the treated area were achieved. 1 year complete root coverage
and KT flap, with the following
confounding factors forced into the
enamel junction (Fig. 2C). No surgical dressing was model: jaw, tooth, smoking, RD, KT, KT donor, BD,
applied. and CD flap.
A two-way table showing the frequency of occur-
Clinical Measurements rence of unique pairs of values for %RC and KT flap
At time of the surgery the following clinical measure- was arranged, and a chi-square test was used to
ments were taken: 1) height of keratinized tissue in the perform a hypothesis test to determine whether or not
flap (KTH flap), measured at the center of the flap; the two variables were dependent.
2) depth of the buccal bone dehiscence (BD) measured
from the CEJ to the most apical extension of the buc- RESULTS
cal bone crest; and 3) amount of coronal displacement Following the initially provided oral hygiene phase as
of the flap (CD flap) measured from the CEJ to the flap well as at the post-treatment examinations, all patients
margin, at time of suturing and calculated as the fol- showed low frequencies of plaque-harboring tooth sur-
lowing difference: (incisal margin– faces (<20%) and bleeding gingival units (<15%), indi-
CEJ) – (incisal margin – flap). cating an acceptable standard of supragingival plaque
control. Thirty-eight (38) patients were identified as
Post-Surgical Infection Control smokers (<10 cigarettes/day).
Patients were instructed not to brush in the treated area
but to use a chlorhexidine solution (0.12%) mouthrinse ‡ Version 6.09, SAS Institute, Cary, NC.

1737
40023.qxd 1/6/05 4:14 PM Page 1738

A Modified Flap for Recession Defects Volume 75 • Number 12

One-hundred and twenty isolated recession type Table 1.

defects in 100 patients were treated with the laterally-
Clinical Parameters (mean ± SD) at
moved coronally-advanced surgical technique. In 20
patients two recessions in different quadrants were Baseline and 1 Year Post-Surgery
treated. Thirty-eight (31.6%) recessions were treated
in smoking patients. Seventy recessions were located Baseline 1 Year Change t P*
in the upper jaw and 50 in the lower jaw. Twenty-eight REC depth 4.4 ± 1.2 0.2 ± 0.5 4.2 ± 1.0 44.40 <0.01
incisors, 42 cuspids, 32 premolars, and 18 molar
(mesial root with no furcation involvement). CAL 5.7 ± 1.3 1.3 ± 0.5 4.4 ± 1.0 47.30 <0.01
Table 1 shows baseline and 1-year mean data for PD 1.3 ± 0.5 1.2 ± 0.4 0.1 ± 0.6 1.46 NS
the clinical parameters assessed. At baseline, the mean
depth of the recession defects was 4.4 ± 1.2 mm with KT 0.4 ± 0.5 2.6 ± 0.6 2.2 ± 0.7 33.20 <0.01
a mean clinical attachment loss amounting to 5.7 ± KT donor 4.7 ± 0.9 4.5 ± 0.7 0.2 ± 0.4 1.92 NS
1.3 mm. The depth of the recessions ranged from 3 to
* Paired Student t test.
8 mm. The mean height of the gingival keratinized tis-
sue apical to the recession was 0.4 ± 0.5 mm; 61% of
the recession sites had <1 mm of gingival height. The
height of keratinized tissue lateral to the defect was Table 2.
4.7 ± 0.9 mm and no recession was present in the
Results From General Linear Model
donor teeth.
Probing depth remained shallow (1.3 mm versus Relating 1-Year Root Coverage to Three
1.2 mm) and no statistically significant difference was Categorical ( jaw, tooth, smoking) and Six
demonstrated between the baseline and 1-year follow- Continuous (RD, KT, KT donor, KT flap,
up values (Table 1). BD, CD) Factors as Covariates
The height of keratinized tissue at the treated teeth
increased from 0.4 ± 0.5 mm to 2.6 ± 0.6 mm. The Factor F Ratio P Value
mean increase in keratinized tissue, 2.2 ± 0.7, was sta-
tistically significant (P <0.01) (Table 1). Jaw 2.91 0.09
The height of keratinized tissue lateral to the defects Tooth 1.45 0.23
changed from the baseline mean value of 4.7 ± 0.9 mm
to the 1-year value of 4.5 ± 0.7 mm. This change Smoking 0.02 0.89
(0.2 mm) was not statistically significant (Table 1). RD 324.7 <0.01
One year following the surgical procedure the mean
recession depth had decreased to 0.2 ± 0.5 mm, cor- KT 0.30 0.58
responding to a root coverage of 4.2 ± 1.0 mm. In KT donor 3.59 0.06
terms of mean percentage of root coverage, 96.0% ±
8.2% of the exposed root was covered with soft tissue. KT flap 21.3 <0.01
The change in gingival recession depth was highly sig- BD 0.01 0.94
nificant (P <0.01).
The significance of factors (jaw, tooth, smoking, CD 0.18 0.66
RD, KT, KT donor, KT flap, BD, and CD flap) affect-
ing 1-year root coverage was evaluated by fitting a
general linear model (Table 2). The R-squared statis-
tic indicates that the model as fitted is highly signifi- The results from the multiple logistic regression
cant and explains 87.1% of the variability in root adjusted for all confounding factors showed a statisti-
coverage. cally significant relationship (chi square 38.2; P <0.01)
The most significant variables entering the model between complete root coverage and KT flap at time
and affecting root coverage was the RD at baseline of the surgery (odds ratio = 7.5; 95% confidence interval
(F = 324.7; P <0.01), and KT flap at time of the surgery 3.33 to 17.04). Figure 3 displays a plot of the fitted
(F = 21.3; P <0.01). Better results in terms of root cov- model versus KT flap at time of the surgery.
erage were accomplished in cases with deeper reces- Table 3 shows the frequency distribution of the per-
sion at baseline and with greater amount of keratinized centage of treated cases with complete root coverage,
tissue comprised in the flap at time of the surgery. in relation to the amount of keratinized tissue com-
Complete root coverage (gingival margin at the level prised in the flap at the time of the surgery.
of the CEJ) was accomplished in 80.0% (96 out of Complete root coverage was accomplished in 42%
120) of the treated cases. (7 out of 17) of the treated cases when 1 mm of ker-

1738
40023.qxd 1/6/05 4:14 PM Page 1739
J Periodontol • December 2004
Figure 3.
Plot of the fitted model (logistic regression) showing the relationship
between root coverage and KT flap (95% CI).
Table 3.
Frequency Distribution of the Percentage
of Cases With Complete Root Coverage at
1 Year in Relation to the Height of
Keratinized Tissue in the Flap
KT Flap (mm) N Complete Coverage/N Cases
1 7/17 (42%)*
2 35/40 (87%)
3 45/48 (94%)
4 8/8 (100%)
* Statistically significant differences (chi-square test).
atinized tissue was measured in the middle of the sur-
gical flap. The percentage of cases with complete root
coverage doubles (87%) when the keratinized tissue
included in the flap was 2 mm. This difference is sta-
tistically significant (chi-square = 46.4; P <0.01). The
percentage of treated cases with complete root cov-
erage further increases when the keratinized tissue the
flap increases but the differences (between 2 and 3 mm
or 2 and 4 mm) are not statistically significant.
Clinical attachment level decreased from 5.7 ±
1.3 mm to 1.3 ± 0.5 mm. The mean clinical attach-
ment gain, 4.4 ± 1.0 mm, was statistically significant
(P <0.01) (Table 1).
DISCUSSION
The results of the present case series study indicate
that the laterally-moved coronally-advanced surgical
approach was highly effective and predictable in
obtaining root coverage of isolated gingival recession
Zucchelli, Cesari, Amore, Montebugnoli, De Sanctis
type defects. This technique, in fact, resulted in a very
high mean percentage of root coverage (96%) and
complete soft tissue root coverage (up to the CEJ)
was accomplished in the great majority (80%) of
treated cases. These root coverage outcomes were
associated with a clinically and statistically highly sig-
nificant clinical attachment gain with no significant
change in the depth of the probing buccal pocket. Fur-
thermore, a clinically and statistically highly signifi-
cant increase in the height of keratinized tissue was
demonstrated at the buccal aspect of treated teeth.
These favorable results at the treated teeth were
obtained with no change in the position of gingival
margin and in the height of gingival tissue at the donor
tooth/site lateral to the defects.
This rate of successful outcomes of the treatment
is similar to that demonstrated for other root cover-
age procedures (coronally advanced flap3 and bilam-
inar techniques2) and it is higher than that previously
reported for the laterally moved flap techniques.4-17
This difference can be explained by a more rigid
case selection and by modifications in the surgical
technique.
The analysis of the literature revealed that the limit-
ing condition for performing the laterally moved flap as
a root coverage surgical procedure was the presence of
keratinized tissue lateral to the recession defect. Previ-
ous studies did not quantify the minimum width and
height of keratinized tissue which must be present lat-
eral to gingival defects in order to render the laterally-
moved flap a predictable root coverage surgical
procedure.4-17 A certain amount of the lateral kera-
tinized tissue, in fact, must be preserved in situ to pre-
vent gingival recession at the donor site/tooth, while
the remaining part is used to cover the exposed root sur-
face and the adjacent connective tissue beds.
The clinical cases treated in the present study were
selected among those presenting specific characteris-
tics of the gingival tissue lateral to the recession
defects: presence of a keratinized tissue width at least
6 mm greater than the width of the recession mea-
sured at the level of the CEJ and a keratinized tissue
height at least 2 mm greater than the buccal PD of the
adjacent tooth/teeth.
Both the mesial-distal and the apical-coronal dimen-
sions of the flap are critical for accomplishing root cov-
erage. The stability of a flap over a denuded root
depends on the mesial-distal dimension of the pedicle,
(the wider the pedicle, the greater the blood supply to
the marginal portion of the flap) and on the blood sup-
ply from the peripherical regions of the flap (surgical
papillae) which must be wide enough (3 mm in the
present study) to perform nutritional exchanges with
the underlying vascular connective tissue beds (depithe-
lialized anatomical papillae). The apical-coronal dimen-
sion of the gingival tissue lateral to the recession is
1739
40023.qxd 1/6/05 4:14 PM Page 1740
A Modified Flap for Recession Defects
critical, not only to prevent gingival recession at the
donor tooth/teeth, but also to ensure root coverage.
The presence of keratinized tissue all along the mesial-
distal extension of the flap improves the marginal sta-
bility of the flap itself and facilitates flap stabilization at
time of suturing. Present study data indicated that 2
mm keratinized tissue in the flap is preferred. Better
root coverage outcomes were achieved in cases with
a 2 mm height compared to those where there was
only 1 mm of keratinized tissue.
The main modification of the present surgical tech-
nique, with respect to those previously proposed, was
the elimination of all muscle insertions in the thickness
of the flap to permit the coronal advancement of the
laterally moved flap. The elimination of lip tensions on
the flap likely compensated for the difference in the
apical-coronal position between the submarginal hori-
zontal incision and the cemento-enamel junction. Fur-
thermore, the coronal advancement of the flap allowed
the surgical papillae to cover the anatomic papillae
which represented the most coronal areas for anchor-
ing the flap and a critical source for vascular exchanges.
In addition, coronal advancement of the flap beyond the
cemento-enamel junction likely compensates for the
post-surgical soft tissue contraction, resulting in no
exposure of the root surface.
Thereafter, the proposed surgical technique com-
bined the root coverage and esthetic advantages of the
coronally advanced flap3 with the increase in gingival
thickness and in the amount of keratinized tissue asso-
ciated with the use of the laterally moved flap.
The different thickness during flap elevation (greater
in the central area than in the more peripherical portions
of the flap) represented another aspect of the proposed
surgical technique. The two main goals to be accom-
plished were an increase in root-coverage predictability
and an improvement in esthetic outcome. As previously
reported in the literature,20,21 the stability of a flap over
a denuded avascular root surface becomes more pre-
dictable by increasing the thickness of the flap. In a
thicker flap the amount of vascularized connective tis-
sue increases and the post-surgical soft tissue contrac-
tion decreases. Both these factors improve the possibility
of accomplishing and maintaining root coverage. In
order to further increase the thickness of the flap, full-
thickness elevation should have been performed, but
this would have also increased the risk of gingival reces-
sion and/or bone dehiscence/fenestration at the donor
site/tooth. Furthermore, the appearance of an unes-
thetic scar following the healing of the exposed bone
area was highly probable. The preservation of periosteum
to protect the donor site was critical for the esthetic end
result. The lower thickness of the surgical papillae, com-
pared to that of the mid-portion of the flap, facilitated
the nutritional exchanges between them and the under-
lying deepithelialized anatomical papillae and improved
1740
Volume 75 • Number 12
the blending in terms of color and thickness of the sur-
gically treated area with respect to adjacent soft tissues.
Another feature of the present surgical technique was
the sequence of sutures: the apical stabilization sutures
in the most apical extension and along the releasing
incision and the double mattress horizontal suture at
the fornix were performed before the marginal sling
suture. Thus the most marginal portion of the flap was
stable in the desired coronal position without disrupt-
ing forces acting on it at the time of the final suture. Fur-
thermore the double mattress suture reduced lip tension
on the marginal portion of the flap during the first heal-
ing period and avoided the use of surgical periodontal
dressing.
REFERENCES
1. Wennström JL. Mucogingival surgery. In: Lang NP,
Karring T, eds. Proceedings of the 1st European Workshop
on Periodontology. Berlin: Quintessence Publishing Co.;
1994:193-209.
2. Wennström JL, Zucchelli G. Increased gingival dimen-
sions. A significant factor for successful outcome of root
coverage procedures? A 2-year prospective clinical
study. J Clin Periodontol 1996;23:770-777.
3. Zucchelli G, De Sanctis M. Treatment of multiple reces-
sion type defects in patients with aesthetic demands. J
Periodontol 2000;71:1506-1514.
4. Grupe HE, Warren RF. Repair of gingival defects by a
sliding flap operation. J Periodontol 1956;27:92-95.
5. Staffileno H. Management of gingival recession and root
exposure problems with periodontal disease. Dent Clin
North Am 1964;3:111-120.
6. Grupe HE. Modified technique for sliding flap operation.
J Periodontol 1966;37:491-495.
7. Ruben MP, Goldman HM, Janson W. Biological consid-
erations in laterally repositioned pedicle flaps and free
autogenous gingival grafts in periodontal therapy In:
Stahl SS, ed. Periodontal Surgery – Biologic Basis and
Technique. Springfield, IL: Charles C. Thomas; 1975:235.
8. Oles RD, Ibbott CG, Laverty WD. Effects of root curet-
tage and sodium hypochlorite treatment on pedicle flap
coverage of localized recession. J Can Dent Assoc 1988;
54:515-517.
9. Smuckler H. Laterally positioned mucoperiosteal pedicle
grafts in the treatment of denuded roots. A clinical and
statistical study. J Periodontol 1976;47:590-595.
10. Guinard EA, Caffesse RG. Treatment of localized gingi-
val recessions. Part III. Comparison of results obtained
with lateral sliding and coronally repositioned flaps. J
Periodontol 1978;49:457-461.
11. Espinel MC, Caffesse RG. Comparison of the results
obtained with the lateral positioned pedicle sliding flap
revised technique and the lateral sliding flap with a free
gingival graft technique in the treatment of localized gin-
gival recession. Int J Periodontics Restorative Dent 1981;
1(6):30-37.
12. Waite IM. An assessment of the postsurgical results fol-
lowing the combined laterally positioned flap and gingi-
val graft procedure. Quintessence Int 1984;15:441-450.
13. Zade RM, Hirani SH. A clinical study of localized gingi-
val recession treated by lateral sliding flap. J Indian Dent
Assoc 1985;57:19-26.
14. Oles RD, Ibbott CG, Laverty WD. Effects of citric acid
treatment on pedicle flap coverage of localized recession.
40023.qxd 1/6/05 4:14 PM Page 1741

J Periodontol • December 2004 Zucchelli, Cesari, Amore, Montebugnoli, De Sanctis

J Periodontol 1985;56:259-261. Correspondence: Dr. Giovanni Zucchelli, Dipartimento di

15. Kunjamma S, Varma BRR, Nandakumar K. A compar- Scienze Odontostomatologiche, Bologna University, Via S.
ative evaluation of coverage of denuded root surface by Vitale 59, 40125 Bologna, Italy. Fax 39-05-1225208; e-mail:
gingival autograft and lateral sliding flap operation. giovanzu@tin.it.
J Indian Dent Assoc 1986;58:527-534.
16. Caffesse RG, Alspach SR, Morrison EC, Burget FG. Lat- Accepted for publication April 1, 2004.
eral sliding flaps with and without citric acid. Int J Peri-
odontics Restorative Dent 1987;7(6):43-57.
17. Caffesse RG, Guinard EA, Treatment of localized gingi-
val recessions. Part IV. Results after three years. J Peri-
odontol 1980;51:167-170.
18. Miller PD. Root coverage using a free soft tissue auto-
graft following citric acid application. III. A successful
and predictable procedure in areas of deep-wide reces-
sion. Int J Periodontics Restorative Dent 1985;5(2):15-
37.
19. O’Leary TJ, Drake RB, Naylor JE. The plaque control
record. J Periodontol 1972;43:38.
20. Borghetti A, Gardella JP. Thick gingival autograft for the
coverage of gingival recession: A clinical evaluation. Int
J Periodontics Restorative Dent 1990;10:217-229.
21. Holbrook T, Ochsenbein C. Complete coverage of de-
nuded root surface with a one-stage gingival graft. Int J
Periodontics Restorative Dent 1983;3(3):9-27.

1741