Coronally Advanced Flap

 

Coronally Advanced Flap

Coronally Advanced Flap is also known as coronally advanced tunnel technique.

• For minimizing the incisions and reflection of flaps and to provide good blood supply to donor tissue, the placement of subepithelial donor connective tissue into the pouches beneath the papillary tunnels allows for close contact of donor tissue to the recipient site. The positioning of the graft in the pouch and through the tunnel and the coronal placement of the recessed gingival margins completely covers the donor tissue. Due to this the esthetic result is excellent.
• The technique is mostly used for the anterior maxillary area where the vestibular depth is adequate and there is good gingival thickness.
• Main advantage to this technique is thickening of gingival margin as soon as healing is over. The thicker gingival margin is stable and allows the possibility of “creeping reattachment” of gingival margin.

Coronally Advanced Flap Surgical Technique

Following is a step-by-step description of the surgical procedure as outlined by Azzi:

• Step 1: Ask the patient to follow plaque control instruction and careful scaling and root planing is to be done several weeks before starting surgical procedure. Patient should be instructed to rinse for 30 seconds with 0.l2% chlorhexidine gluconate solution.
• Step 2: After adequate anesthesia, the surgical procedure should be performed.
• Step 3: Place composite material stops at the contact points (temporary) to prevent collapse of suspended sutures inside the interproximal spaces before commencing the surgery.
• Step 4: Perform root planing of exposed root surfaces by using Gracey curettes.
• Step 5: Give initial sulcular incision by 15 c and l2 d blades. Small contoured blades and mini curettes are used for creating the recipient pouches and tunnels.
• Step 6: Over the buccal aspect, an intrasulcular incision should be given around the necks of the teeth. Extend the incision to one adjacent tooth both mesially and distally by using 15c blade. This incision maintains both height and thickness of gingival component and enables access beneath the buccal gingiva with help of Gracey curettes. Direct the cutting edge toward the bone for dissecting connective tissue beyond the mucogingival line and freed off the buccal flap from its insertions to the bone around each tooth.
• Step 7: Muscle fibers and any of the remaining collagen fibers over the inner aspect of flap, which prevent buccal gingiva from being moved coronally should be cut by using Gracey curettes.
• Step 8: Papillae should be kept intact and undermined for maintaining their integrity and carefully released from the underlying bone, which allows coronal positioning of the papillae.
• Step 9: An envelope, full thickness pouch and tunnel is created and should be extended apically beyond the mucogingival line by blunt dissection for insertion of free connective tissue graft through intrasulcular incision. Place a saline moistened gauze over the recipient site.
• Step 10: Size of the pouch, which includes the area of denuded root surface should be measured so that an equivalent size donor connective tissue can be taken from the tuberosity.
• Step 11: Create a second surgical site to obtain a connective tissue graft of adequate size and shape to be placed at recipient site. Connective tissue which is harvested from tuberosity area should be contoured to fit inside the recipient tunnel and pouch.
• Step 12: Place a mattress suture at one end of graft which help to guide the graft via sulcus and beneath each interdental papilla. Border of the tissue is gently pushed inside the pouch and tunnel by using tissue forceps and a packing instrument. The graft is pushed from adjacent tooth on one side of the surgical area to adjacent tooth over other side.
• Step 13: Place a mattress suture on one end of graft will help in maintaining the graft in position while the buccal tissue covers the connective tissue graft. This connective tissue graft is anchored to the inner inspect of buccal flap inside interdental papilla region. A vertical mattress suture is used to hold the connective tissue in position beneath the gingiva. The connective tissue graft is completely submerged beneath buccal flap and the papillae.
• Step 14: Complete gingival papillary complex (i.e., buccal gingiva along with underlying connective tissue graft and papillae) should be coronally positioned by using a horizontal mattress suture which is anchored at incisal edge of contact area. Contact areas should be splinted preoperatively to close the interdental contact by using a composite material to prevent the suture from sliding apically interdentally.
• Step 15: Other holding sutures can be placed via overlying gingival tissue and donor tissue to the underlying periosteum to secure and stabilize the donor tissue and the overlying gingiva in a coronal position.

Area should not be covered with periodontal dressing.

Patient should be instructed to rinse daily with chlorhexidine gluconate and to avoid touching the sutures during oral hygiene procedures.

Antibiotics can be administered (amoxicillin 500 mg three times a day) if seemed necessary.