Sling and Tag Suturing Technique for Coronally Advanced Flap

The coronally advanced flap (CAF), either by itself or combined with other soft
tissue grafts, provides predictable root coverage. However, it is a major challe
nge to suture and secure the flap coronally and stabilize its position over the
entire healing period. Thus, the purpose of this study was to introduce a modi{
ied incision
desrgn and a suturing technique (sling and tag ISATI to enhance the results of
CAF for root coverage. Ten patient with Miller Clax I gingival recessrbn defeos
(> 2.5 mm) were Feated. Clinical parameters assessed included recessrbn depth
(RD), recession width (RW), clinical attachment level (CAU, probing depth (PD),
gingival tissue thickness (GT), and keratinized gingiva wdth (KGIA4.
Measurernents were taken at baseline and 6 months and 7 year later The paired t
te.st was used to compare presurgical and postsurgical results. Statistically si
gnificant
(P < .05) reductions in RD (2.6 + 0.5 mm) and RW (2.9 + 0.9 mm) were
observed at 1 year An average of 93.O% + 1 4.8% root coverage was achieyed. ln
addition, a statistically significant CAL gain of 3.3 + 1.0 mm was obtained. No
statistically
significant difierences were found in PD and KGW before and after therapy.
The newly introducedflapdesign and SAf suturing technigue may enhance
the results of CAF for root coverage. (lnt J Periodontics Restorative Dent
2007;27:379-385.)
Gingival recession may result in dentinal
hypersensitivrty, discomfort, and
esthetic concerns and increase the
potential for root caries. Many techniques
have been proposed in the
attempt to beat recession defects.l{
The coronally reposhioned flap was
first reported for dre purpose of gaining
attachment of supporting tissue to
teeth suffering from advanced periodontal
disease,6,7 h was later modified
to repair gingival recession, with
horizontal incisions made in the
mucos and papillae to release the
tension of the flap and reposition it
incisally.s The coronally positioned flap
was shown to be a relatively e6y technique
that can produce optimal
rc$rhs.e,1o This procedure also eliminates
the need to.harvest donor tissue
from a second suEical area, thereby
minimizing the morbidity associated'
with donor sites.
The term coronally advanced flap
(CAD rans oined by Pini-Prato in 1 999
to better reflectfie procedure.ll CAF
has been shown to be a predictable
and rel'nbletechniqueto promote root
corerage and enhancethe clinical outcomes
of other procedures (eg,
guided tissue regeneration/guidedbone regeneration [GTR/GBR], GTRbased
root coverage, and zubepifrelial
connective tissue grafo). Several differenttypes
of inc'sion and flap designs
have been described.l2-ls Howeveq
none of the incision designs were
designed to enhance esthetic outcomes
and predictably reposition the
flap coronally to achieve complete root
coverage atthe same time. ln addition,
limited information is curently available
conceming suturing techniques
for the CAF. Nevertheless, one of the
potential dfficuhies of this procedure is
an inability to secure the flap coronally
and maintain its position during the
healing period. lntem.rpted sutures are
the mostcommonly used s.ruring technigue
reported in the literature to
accomplish the goal.12'14 Single sling
sutures have been appliedto a&ance
the flap to cover the exposed root surfaces
and connect papillae to the interdental
connective tissue. 10, 1 s
To overcome the aforementioned
challenges, a modified suturing technique
that combines double sling and
interrupted sutures has been developed.
The aim of this pilot case stud
was to evaluate the effectiveness of an
innovative flap design and the sling
and tag (SAT) sutr.rring technique used
wi*r tre CAF root coverage procedure.
Method and materials
Ten patients were recruited from the
University of Michigan School of
Dentistry. To be included, subjecs had
to be systemically healthy nonsmokers
who were able to maintain good oral
hygiene (O'Leary plaque score <
2trA16). They also had to have (1) no
gingival surgery within the past 12
mon*rs atthe defect ste; (2) maxillary
or mandibular incisors, canines, or premolan
wi*r Miller Class lfucial mucogingival
defecBlT; (3) gingival *rickness
> 0.5 mm (2 mm apicalto free gingival
margin); (4) keratinized gingivalwidth >
1 mm; and (5) recession defea depdr
> 2.5 mm. Patientswith compromised
healing potential or active infectious
diseases (hepatitis, tuberculosis, HIV,
etc) were excluded from the study,
along with those taking steroid meclications,
women who were pregnant or
attempting to become pregnant, and
those taking medications known to
cause gingival enlargement.
Clinical parameters were recoriCed
at baseline and 6 months and 1 year
after surgery. The parameters included
probing depth (PD), dinical attachment
level (CAU, keratinized tissue width
(|(IVV), recession depth (RD), recession
width (R\A4, gingival tissue thickness
(GT), Plaque lndex (Pl), and Gingival
lndex (GI). The percentage of root coverage
was calculated as (lRD baseline
-RD 1 year/RD baseline) x '100%. PD
was measured atdrree points on a stent
(mesiobuccal, midbuccal, distobuccal)
to the nearest 0.5 mm with a UNC
probe, with the free gingival maqgin
and the most apical part of the sulcus
as reference points. CALwas measured
from the three points on the stent widr
a UNC probe. The measurement was
made from the cementoenamel junction
(CEJ)ora fixed reference pointto
the most apicalpart of the sulcus. KTW
was measured atthe midbuccal point
from the mucogingival junction (MGJ)
to the free gingival margin with a Boley
gauge. RD was meas.rred fiom the CEJ
or a fxed refurence pointto the most
apical point of the free gingival margin
witr a Boley gauge. RW was measured
at 1 mm apical to fre CU ora fixed reference
point in the mesiodistal direction
with a Boley gauge. GTwas measured
ata midbuccalline 2 mm apical
to the free gingival margin by pene'
trating an endodontic reamer into the
gingival tissue. Pl was recorded according
to Silness and Loe.18 Gl was
recorded according to Loe.le All clinical
parameters were measured by an
independent examiner.
Surgi cal and sutunng technigues
Alltechniques are illustr:ated in Figs 1
and 2.
1. Prior to surgery, patients received
oral hygiene instructions and professional
dental prophylaxis, plus
scaling and root planing if indicated.
Adequate plaque control
and minimal gingival inflammation
were achieved before surgery.
2. After local anesthesia, a sulcular
incision was made on the buccal
side of the teeth with recession.
The incision at the papillae was
made by following their outline.
The distance between the tip of
the papillae and the incision was
the recession depth plus 1 mm or
more. Two vertical incisions were
made with a 15C blade at the line
angle of adjacent teeth and
extended beyond the MGJ (see
Figs 1a, 1b, and 2b).
3. A full-thickness flap was reflected
slightly beyond the MGJ. A partial-
thickness flap was prepared
apically to gain mobility of the flap. A 15C blade was placed parallel
to the long axis of the tooth,
and a horizontal incision was
made through the periosteum
and muscle layer. Theflap needed
to be able to be repositioned
coronally without tension.
4. An epithelial layer at the papillae
was removed using a 12D or 15C
blade to expose the underlying
connective tissue bed.
5. Exposed root surfaces received
mechanical treatrnent such as root planing with high-speed or lowspeed
finishing burs and curettes
until the surfaces were hard and
smooth (see Figs Zcto Zel.
6. A double sling suture (5-0 Vicryl,
Ethicon/Johnson & Johnson) was
placed at the papillae of the flap,
leaving at least 2 mm from all margins,
to secure the flap coronally
to the CEJ after the knot was
made (see Figs 1c and 20.
7. lnterrupted tag sutures were
placed at the centers of the papil-
Fig 1e Sutures rn place.
lae to facilitate adaptalion of the
flap and underlying connective tissue
(see Figs 1d and 2g).
8. Oblique interrupted sutures were
placed in a 45-degree direction
toward the coronal at the vertical
incisions to furthersecure the flap
(see Figs'ld and 2g).
9. Pressure was applied atthe surgical
site with mo'sturized gauzefor
3 minutes to stop bleeding and
eliminate dead space underneath
the flap
Postoperative instructions were
provided to all patients. Analgesics
were prescribed to control postoperative
discomfort. No antibiotics were
used. Patientsweretold notto brush or
floss the surgical sites for 3 to 4 weeks.
lnstead, they were asked to rinse with
sah water and 0.1 2% chlorhexidine gluconate
mou*rwash altemately to control
plaque. Sutures were removed 10
to 14 days after surgery. Oral hygiene
instructions were given and professional
cleaning performed if indicated
(ie, visible plaque present).
Statistica/ analysis
Data were reported as means t standard
deviations. The paired ttestwas
used to detect significant differences
between presurgical and postsurgical
clinical parameters. Significance was
reported atthe 95% confidence level.
Results
Ten consecutive patients (mean age
oI 42 x.10.7 years) with Miller Class I
buccal gingival recession defects were
treated. The average RD at baseline
was 2.8 + 0.3 mm. No adverse events
occurred during the course of the
stud. Tables 1 and 2 present patient
demographics and clinical parameters
at baseline and 6 months and 'l year
after surgery.
CAF combined wifr fre SAT suturing
technique resulted in a mean RD
reduction of 2.6 * 0.5 mm at 1 year
postoperatively (from 2.8 + 0.3 mm
before surgery to 0.2 + 0.4 mm after
suEery), conesponding to a mean root covenge of 93.0% x.14-B% (l'able 1).
The improvement was statistically significant
(P < .05).
CALs changed significantly (P <
.05), from 4.6 t 0.8 mm to 1.3 t 0.5
mm, a mean gain of 3.3 * 1.0 mm
fiable 2). There was statistically significant(
P< .05) reduaion in R1ffat 1 year
when compared to baseline (from 2.9
+ 0.9 mm to 0 mm). GT was significantly
increased by an average of 0.2
t 0.3 mm. However, there were no
significant changes in KGW, PD, Gl,
and Pl.
Discussion
The purpose of this case studwasto
determine the effectiveness of the
newly developed innovative flap
design and the SAT (sling and tag)
suturing technique for the CAF root
coverage procedure. The results indicated
that both modifications were
successful, providing an average of
93% coverage. CAF has been shown
to be a prediaable and reliable procedure
for root coverage as well as
enhancing other procedures (eg,
GTR/GBR, GTR-lcased root coverage,
and subepithelial connective tissue
graf$. C,AF is a simple and effective
method to achieve root coverage
when frere is no need to augmentthe
keratinized tissue.e When other procedures
are combined, such assubep
ithelial connective tissue grafting, CAF
will be essentialfor blood supply and
stabilization of the grafra h also can be
used as a second grafting procedure
aftera free gingival graftto obtain root
coverage.l3
The resute of this case studwere
comparable or superior to those of
other studies1o,1120 and meta-analyses.
21l3 Jhe improved outcomesmay
be partially attributed to the modified
incision design, meticulous flap management,
and the SAT suturing technique.
The proposed modified incision
design possesses several
advantages. The incision at the papillae,
which follows their outline, adapts
the flap to the underlying tissue better,
makes suturing easier, improves the
postsuEical appearance, and reduces
the need for firture gingivoplasty. The
distance between the tips of the papillae
and the incision is the recession
depth plus 1 mm ormore. tts purpose
is to assure that when the flap adapts
with the tips of the papillae, the flap
can cover the CEJ for at least 1 mm
coronally without leaving any redundanttissue
to interfere with suturing at
the papillae.
Afterfl ap elevation, attention must
be focused on dissecting the periosteum
and muscle at the base of the
flap. This procedure is aimed at releasing
the tension of the flap when it is
positioned coronally. lt has been
proven that more reduction of reces.
sion can be obained when a flap has
no or minimal tension before suturing.
20 The proposed suturing techniques
demonstrated superiority in
securing the flap coronally, adapting
the flap closely widr underlying tissue,
and stabilizing the wound. At the 2-
week postoperative follow.up visit, the
tissue had stayed in 'rts new position.
There were no adverse complications.
Wound healing was uneventful. A double
sling suture placed at the papillae
of the flap ensures that the tissue will
be repositioned coronal to the CEJ.
The advantage ofthis versus the conventional
sling suture is thatthe suturing
material passes the flap twice in the
papillae; when the knot is tightened,
the tension of the suturing material is
not intensffied atone point. When tension
is evenly distributed, the flap will
have less chance of being lacerated.
Therefore, the suture can hold the flap
in poskion for a longer period after
surgery. lntemrpted sutures placed at
the centers of the papillae facilitate
closed adaptation of the flap and
underlying connective tissue. The
intentions are to improve wound healing,
enhanceappeaance, and reduce
the need for future gingivoplasty.
Oblique intem.rpted suures are placed
at the vertical incisions to stabilize the
flap in the coronal direction.
The modifications of the flap
design and SAT suturing techniques
work in {avor of maintaining the flap
coronally. Repositioning of the flap over
the CEJ allows a longer healing time
for connective tissue to attach to previously
exposed root surfaces.24 After
healing is complete, the gingivaltissue
contracts apically and stays at or
slightly apical to the CEl, which corrects
the recession defects.
The results of this pilotstudy indicate
tratthe use of a newly introduced
flap design andthe SATsuturing technique
during the CAF procedure for
root coverage could be beneficial in
promoting clinical outcomes.