VOLUME 44 NUMBEP 1 JANUAPY 2013 25

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PERIODONTOLOGY
CASE REPORT
A 34-year-old Japanese woman presented
at tno Dopartmont o Poriodontology, Ninon
University School of Dentistry, Tokyo,
Japan. Her chief complaints were the poor
esthetic appearance and hypersensitivity of
her maxillary right canine. She did not
smoke and was systemically healthy.
After initial treatment that included oral
hygiene instruction and scaling and root
planing, a preoperative re-examination was
performed. The midbuccal aspect of the
The connective tissue graft (CTG) and coro-
nally advanced ap (CAF) have been shown
to be predictable procedures for single-tooth
root coverage.
1
However, each technique
has some advantages and disadvantages.
The CTG technique results in excessive soft
tissue thickness and poor color blending
with neighboring gingival tissue
2
and
requires an additional donor site. In contrast,
the CAF technique compromises esthetics
by coronally shifting the mucogingival junc-
tion.
3
Furthermore, CAF-treated sites showed
a signicant apical shift of the gingival mar-
gin compared with CTG-treated sites.
4
A bidirectionally positioned ap tech-
nique in a single-tooth recession was pro-
posed to take advantage of both the CTG
and CAF.
1
Private Practice, Iwano Dental Clinic, Tokyo, Japan; former-
ly, Faculty, Department of Periodontology, Nihon University
School of Dentistry, Tokyo, Japan.
2
Assistant Professor, Department of Periodontology, Division
of Advanced Dental Treatment Dental Research Center, Nihon
University School of Dentistry, Tokyo, Japan.
3
Professor and Chair, Department of Periodontology, Division
of Advanced Dental Treatment Dental Research Center, Nihon
University School of Dentistry, Tokyo, Japan.
Correspondence: Dr Shuichi Sato, Department of
Periodontology, Nihon University School of Dentistry, 1-8-13,
Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8310, Japan. Email:
sato-su@dent.nihon-u.ac.jp
Bidirectionally positioned ap surgery:
A case report with 3-year follow-up
Yoshihiro Iwano, DDS, PhD
1
/Shuichi Sato, DDS, PhD
2
/
Koichi Ito, DDS, MSD, PhD
3
A new technique to cover recessions to take advantage of connective tissue grafts and
coronally advanced aps is proposed. A 34-year-old woman presented with a 2-mm
ClassI recession on the buccal aspect of her maxillary right canine. A full-thickness ap
was placed coronally to cover the exposed root, and a partial thickness ap was posi-
tioned apically. Complete root coverage was obtained, and the width of keratinized tissue
had increased from 2 to 4 mm at the 6-month postoperative visit. These clinical outcomes
were maintained for 3years. This single surgical approach benets from obtaining not only
complete root coverage but also increasing width of keratinized tissue, without requiring a
second surgical site. (Quintessence Int 2013;44:2528)
Key words: connective tissue graft, coronally advanced ap,
Miller Class I recession
Fig 1 A 34-year-old woman presented with a 2-mm
Miller Class I recession on the buccal aspect of her
maxillary right canine.
26 VOLUME 44 NUMBEP 1 JANUAPY 2013
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Fig 2 Trapezoidal partial
and full-thickness pedicle
faps were refected.
Fig 3 A horizontal releas-
ing incision was made in the
periosteum at the base of the
full-thickness fap, and the
fap was then positioned
1 mm coronal of the CEJ to
cover the exposed root and
sutured.
Fig 4 The partial thickness
fap was positioned apically
and sutured.
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Fig 5 Complete root coverage was obtained, and
the width of keratinized tissue increased from 2 to 4
mm after 30 months.
maxillary right canine exhibited the following
baseline clinical parameters: 2-mm reces-
sion depth (Miller Class I recession), 4-mm
recession width, and 2-mm width of keratin-
ized tissue (Fig 1). The patient provided
signed informed consent prior to the surgery.
After local anesthesia with a solution of
2% xylocaine and 1:80,000 epinephrine,
thorough root debridement was performed
with hand instruments to obtain a smooth,
dotoxihod suraoo. No root oonditioning
was used. An intracrevicular partial thick-
ness incision was made with a no. 15c
blade and extended with two horizontal
partial thickness incisions 2 mm above the
cemento enamel junction (CEJ) in the papil-
lae. Two releasing partial thickness vertical
incisions were then made over the muco-
gingival junction, and a trapezoidal partial
thickness pedicle ap was reected. Two
horizontal full-thickness incisions were
made 3 mm apical of the rst horizontal
incisions and extended with an intracrevic-
ular full-thickness incision. Two releasing
full-thickness vertical incisions were then
made over the mucogingival junction. A
secondary trapezoidal full-thickness pedi-
cle ap was reected in the same manner
as the partial thickness ap (Fig 2). After a
horizontal releasing incision was made in
the periosteum at the base of the full-thick-
ness ap, the ap was positioned 1 mm
coronally of the CEJ to cover the exposed
root and was then sutured with a 5-0
absorbable suture (Fig 3). The partial thick-
ness ap was positioned apically and
sutured with a 5-0 absorbable suture
(Fig 4).
Following surgery, the patient suspend-
ed mechanical tooth cleaning for 2 weeks.
The patient was instructed to rinse for 1
minuto witn moutnwasn (Listorino, MoNoil-
PPC) twice daily for 2 weeks to prevent
postsurgical infection. Anti-inammatory
drugs were prescribed for 7 days.
Thereafter, she was placed on a mainte-
nance program with follow-up visits once
every 3 months for approximately 30
months. A clinical examination was per-
formed at the 6-month postoperative visit.
Poot oovorago was oomploto, and tno widtn
of the keratinized tissue had increased from
2 to 4 mm. Probing pocket depth was
1 mm, and there was no bleeding on prob-
ing. These clinical outcomes were main-
tained for 3 years (Fig 5).
DISCUSSION
Using a periosteal pedicle ap, a stable
graft with an inherent blood supply and the
strong regenerative potential of the perios-
teum were created. Use of the periosteum
to cover the exposed root surface prevent-
ed necrosis and provided more complete
root coverage. However, the elevation of
partial thickness aps can be difcult to
QUI NTESSENCE I NTERNATI ONAL
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achieve, particularly in patients with thin
ap thickness.
Placement of the full-thickness ap
1 mm coronal of the CEJ likely conveyed an
advantage. Some researchers have shown
that complete root coverage following CAF
procedure was inuenced by the surgical
positioning of the ap relative to the CEJ.
5
Leaving a portion of the graft exposed
resulted in a greater increase of keratinized
tissue. The present technique was a modi-
cation of the CTG technique, in which a
coronal portion of the CTG was left uncov-
ered during surgery. A CTG with a retained
epithelial collar contributed to keratinized
width gain during the initial stage of healing.
While this is only a case report, it may
indicate an effective surgical approach for
clinicians to obtain not only complete root
coverage, but also increased width of kera-
tinized tissue in a shallow Class I recession.
It does not require a second surgical site.
Further studies with more cases are needed
to conrm the outcome of this surgical tech-
nique.
REFERENCES
1. Cortellini P, Tonetti M, Baldi C, et al. Does placement
of a connective tissue graft improve the outcomes
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Clin Periodontol 2008;36:6879.
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M. Bilaminar techniques for the treatment of reces-
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Clin Periodontol 2003;30:862887.
3. Trombelli L, Tatakis DN, Scabbia A, Zimmerman
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