The document compares and contrasts coronally advanced flap (CAF) and laterally positioned flap (LPF) periodontal plastic surgery techniques. CAF involves advancing the gingival margin over exposed root surfaces and has been shown to significantly reduce recession and clinical attachment level gain, though results are dependent on biotype and brushing habits. CAF alone may be associated with greater apical relapse over time compared to techniques using connective tissue grafts. LPF involves rotating a pedicle flap from an adjacent tooth to cover recession and has also demonstrated recession reduction and clinical attachment gain, with more maintenance of results long term compared to CAF alone. Both techniques have advantages for less experienced clinicians but are less effective than connective tissue grafting

1. Laterally Positioned Flap VS
Coronally Advanced Flap
by Amir Salahuddin
Periodontist and Oral Hygienist

2. Coronally Advanced Flap-Based
Procedures

3. Historical Note
• Historical reports proposing the advancement of the gingival marginal tissue over
an exposed root surface were published initially in 1907 (by Harlan) and 1912 (by
Rosenthal) in the USA.
• However, Norberg may be considered as the first author to describe a clinically
viable technique involving the use of the coronally advanced flap (CAF).

4. CAF modifications
• Increase of the keratinized tissue band with a free gingival graft (FGG) before the surgery of
coronal flap advancement.
• Tarnow described a new flap design, the semilunar coronally advanced flap, to be used in areas
presenting a band of keratinized tissue.
• Zucchelli and de Sanctis proposed the use of a horizontal incision and a split-full-split approach
to create an “envelope flap” with no releasing incisions in order to preserve the maximum soft
tissue thickness above the root exposure.

5. Type of Defect to Be Indicated
• Treatment of localized or multiple Class I GR presenting a width of attached
keratinized tissue (KT) of at least 2 mm and thick periodontal biotype.
• Class III GR may be benefited by this procedure also when adequate amount of
keratinized tissue (similar to Class I) is present.

6. Basics of the Surgical Sequence

10. Implications
for Practice and Clinical Decision-Making on Soft Tissue
Coverage
• The use of CAF alone propitiates significant reductions in recession depth, as well
as CAL gain for Miller Class I single or multiple defects at short term.
• CAF is less technically demanding, faster and less painful than connective graft-
based procedures, and may be better indicated for less experienced clinicians.
• However, long-term maintenance of results seems to be directly linked to the type
of periodontal biotype and tooth brushing habits.

11. • CAF alone may be associated with a great amount of apical relapse of gingival margin
position over time.
• In terms of mean root coverage and complete root coverage achieved, this technique is
less effective than SCTG-based procedures or CAF plus biomaterials (i.e. enamel matrix
derivative, acellular dermal matrix grafts or xenograft matrix grafts).
• Thus, the use of coronally advanced flap alone is better suitable for the treatment of
localized or multiple recession-type defects when SCTG or the above- mentioned
biomaterials could not be used.

14. Laterally Positioned Flap-Based
Procedures

15. Historical Note
• Described in 1956 by Grupe and Warren.
• This technique was based on the preparation of a full-thickness pedicle flap using the soft tissue
(gingiva and mucosa) of a tooth adjacent to the gingival recession and its positioning/rotation
over the exposed root surface in order to cover it.
• later, modifications to the original technique (including papillary tissue-based procedures) were
proposed to reduce the adverse effects related to the donor sites, as well as to improve the
coverage of the recipient site.

16. Between 1964 and 1968, several groups of clinicians/
researchers proposed some changes
1. The use of edentulous ridges adjacent to the recipient site as donor bed.
2. the use of a partial-thickness flap created by sharp dissection to maintain the
donor bed covered by periosteum.

17. Type of Defect to Be Indicated
• Treatment of localized Class I or II GR (Class III may be benefited by this
procedure) adjacent to the donor teeth presenting a width of attached keratinized
tissue (KT) of at least 2 mm and thick periodontal biotype.

18. Basics of the Surgical Sequence

20. Implications
for Practice and Clinical Decision-Making on Soft Tissue
Coverage
• The use of LPF may lead to significant reduction in recession depth and clinical
attachment level gain for Miller Class I and II localized defects, as well as a great
part of the root coverage achieved at short term may be maintained long term.
• Creeping attachment may occur in donor and recipient sites, but the amount of
coronal displacement of the gingival tissue cannot be defined.

21. • By requiring only one surgical site, its use is easier and less painful, and the chair
time is smaller than SCTG, which, in practical terms, may be better indicated for
less experienced clinicians.
• On the other hand, in terms of achieving complete root coverage, this technique is
less effective than SCTG-based procedures, as well as its use is limited to
localized areas, with an adjacent thick periodontal biotype.
• Consequently and despite their clinical advantages, the use of LPF is better
suitable when SCTG could not be used

31. Thank you