Laterally Stretched Flap™

Copyright © 2018 Instituto Carranza, Buenos Aires

The Laterally Stretched Flap™ is a surgical technique developed by Prof. Dr. Nelson Carranza and his team at the Carranza Institute (1). It is aimed at reducing the exposed portion of the graft in non-displaced flap approches, increasing its vascular supply and stability.

It comprises two main technical variants, the Laterally Stretched Tunnel Flap, and the Laterally Stretched Envelope Flap

Before beginning

Determine the tooth or teeth to be treated. Maximum is limited by the expected lenght of the graft. Usually one to four lower anterior teeth are treated simultaneously, though only one or two deep/narrow recessions will receive the laterally stretched flap, while the remaining adjacent recessions will be treated with a non-displaced (tunnel/envelope) approach.

LSF TUTORIAL.002 — Typical case scenario: One deep/narrow recession (Miller class 2) with adjacent shallow/narrow recessions (Miller class 1).

Laterally Stretched Tunnel Flap

This variant is based on the traditional tunneling techniques (2-3):

1) After intracrevicular incisions are made, a partial thickness tunnel is prepared with tunneling instruments. Facial areas of thin tissue, especially around the recession to be stretched, should be elevated in a full thickness fashion to ensure flap integrity and resistance. The tunnel should extend more than 5 mm laterally and apically until suffucient stretching can be achieved by gently moving the tissues with an atraumatic tissue plier. Beyond the mucogingival junction, a partial periosteal release may be accompanied by a partial submucosal release to liberate muscle tension from the flap. Root surfaces are planed and treated with EDTA for 60 seconds.

LSF TUTORIAL.003

2) A graft of sufficient length to cover all teeth to be treated should be harvested from the palate. The graft is harvested following the Carranza’s Double Blade Grafting Concept (4), which ensures a predictable and homogeneous width of 1mm or 1.5mm.

3) The graft is inserted into the prepared envelope with sling sutures in the usual manner, and secured at both ends.

LSF TUTORIAL.004

4) The anchoring sutures shall be left with some slack to allow the lateral displacement of the tunnel flap.

LSF TUTORIAL.005

5) With the graft secured in its position, lateral stretching of the flap is performed with double-cross and/or simple sutures beginning from the apical extent of the recession and preoceeding coronally. Care must be taken that the needle only engages the flap but no the graft. Sutures are left in place 15 to 20 days post op.

LSF TUTORIAL.006

Laterally Stretched Envelope Flap

The Laterally Stretched Envelope variant is based on the traditional envelope flap technique (5). It was originally developed to treat deep/narow Miller class 3 recessions, but can be applied very successfully to Miller class 1 and 2 recessions.

1) Intracrevicular incisons are made involving the teeth to be treated, and connected interdentally by a horizontal incision at the base of the papillae.

LSF TUTORIAL.008

2) A partial thickness envelope flap is elevated using tunneling instruments. Facial areas of thin tissue, especially around the recession to be stretched, should be elevated in a full thickn fashion to ensure flap integrity and resistance. The envelope flap should extend laterally and apically until suffucient stretching can be achieved by gently moving the tissues with an atraumatic tissue plier. Beyond the mucogingival junction, a partial periosteal release may be accompanied by a partial submucosal release to liberate muscle tension from the flap. Root surfaces are planed and treated with EDTA for 60 seconds.

LSF TUTORIAL.009

3) Recipient bed is finalized by stretching the flap towards the deep/narrow recession and securing it with double-cross and simples sutures.

LSF TUTORIAL.010

4) A graft of sufficient length to cover all teeth to be treated should be harvested from the palate. The graft is harvested following the Carranza’s Double Blade Grafting Concept , which ensures a predictable and homogeneous width of 1mm-1.5mm.

5) The graft is easily inserted into the prepared envelope. Holding sutures may be placed at the ends of the graft, but sufficient slack should be left to allow lateral flap displacement.

LSF TUTORIAL.011

6) The graft is sutured altogether with the flap with a sling suture. This suture can involve one tooth (two papillae) or several teeth. The needle enters from the buccal side engaging the flap-graft-papilla complex, and exits through the base of the lingual papilla surrounding the lingual aspect of the tooth to engage the other papilla in a similar manner.

LSF TUTORIAL.012

CLINICAL EXAMPLES

CASE 1

: Deep/narrow, class 2 Miller recession on tooth #32 will be treated with a Laterally Stretched Envelope Flap. The adjacent shallow/narrow Miller class recession defects will be treated with a «conventional» tunnel approach.

Tunnel Case.002 — Note the extremely thin gingival biotype associated with the recession lesions. The aim of treatment includes covering the recessions and thickening the biotype.

Tunnel Case.003 — A partial thickness tunnel flap is prepared with (modified) tunneling instruments. Perisoteal release is necessary beyond the mucogingival junction to free the muscle attachment. Additional submucosal release is recommended to detach muscle (and frenulum) tension from the tunnel flap.

Tunnel Case.004 — A graft of uniform thickness (1.5 mm in this case) is obtained with the Carranza’s Double Blade Harvesting Technique. The graft contains a portion of lamina propia to provide density and stability and a portion of submucosa to enhance revascularization.

Tunnel Case.005 — Typical Graft. Average size of grafts usually measure 25 mm long. Graft height average 8 mm.

Tunnel Case.006 — Double Blade Graft presented over prepared recipient site

Tunnel Case.007 — Graft insertion with sling sutures

Tunnel Case.008 — Final suturing. Note that additional anchoring sutures are usually needed to hold the graft in place and avoid its tendency to slip apically

Tunnel Case.009 — Postopertaive view at 6 months. Note the excellent color blend and the preservation of the mucogingival line position. The dense connective tissue graft extends apically to the mgj (under the layer of oral mucosa) providing ample tissue thickness and preventing muscle coronal reattachment.

Postopertaive view at 6 months clearly depicts the thickened gingival biotype.

CASE 2

Envelope Case.001 — Deep and narrow Miller class 2 recession defect on tooth #31, with adjacent shallow and narrow Miller class 1 recessions.

Envelope Case.002 — The facial protrusion of the root of tooth #31 rendered an extremely thin biotype and likely contributed to the development of the gingival recession. The aim of the treatment will include root coverage and biotype thickening of teeth #31, #41, and #32

Envelope Case.003 — Partial thickness/full thickness direction of the envelope flap was performed with modified tunneling instruments

Envelope Case.004 — Incisal view of prepared site. Note the full thickness elevation in very thin areas and the partial thickness elevation in the less thin interdental areas.

Envelope Case.005 — Harvested Graft before trimming

Envelope Case.006 — A 1.5 mm double-blade handle was chosen for this case. Note graft uniform thickness. Thinner grafts (1mm) can be harvested as well with the Carranza’s Double Blade Grafting Concept.

CORRECC.001 — Graft presented over the prepared site, before its placement inside the envelope.

Envelope Case.008 — Final suturing of the flap-graft with sling sutures. In this particular case additional suspending sutures were placed to the interdental splinting device.

Envelope Case.009 — Palatal donor area is sutured achieving primary closure after harvesting the graft with the Parallel Blade Technique.

Envelope Case.015 — Postoperative view at 3 years. Tissue colour and thickness are excellent.

Envelope Case.011 — Successful long term results obtained by root coverage and biotype thickening

REFERENCES

Carranza N, Pontarolo C, Rojas MA. Laterally stretched flap with connective tissue graft to treat single narrow deep recession defects on lower incisors. Clin Adv Periodontics. Accepted for publication 11-16-2017
Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: short term results in the treatment of shallow marginal tissue recession. J Periodontol1989;60:316-319.
Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: A clinical report. Int JPeriodontics Restorative Dent 1999;19:199-206.
Carranza N. Harvesting connective tissue grafts from the palate, Instituto Carranza, Buenos Aires. Apple ibooks2014:10-14 https://institutocarranzadotcom.files.wordpress.com/2016/08/harvest-connective-tissue.pdf
Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent 1994;14:126-37.