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
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.
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.
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.
4) The anchoring sutures shall be left with some slack to allow the lateral displacement of the tunnel flap.
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.
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.
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.
3) Recipient bed is finalized by stretching the flap towards the deep/narrow recession and securing it with double-cross and simples sutures.
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.
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.
- 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.
Copyright © 2018 Instituto Carranza, Buenos Aires