The International Journal of Periodontics & Restorative Dentistry © 2017 by QUINTESSENCE PUBLISHING CO, INC. PRINTING of TH

The International Journal of Periodontics & Restorative Dentistry

Use of the Modified Apically Repositioned Flap Technique to Create Attached Gingiva in Areas of No Keratinized Tissue: A Clinical and Histologic Evaluation

João Carnio, DDS, MS1 Minimal or absent attached gingiva Paulo M. Camargo, DDS, MS, MBA2 increases susceptibility to gingival Perry R. Klokkevold, DDS, MS3 recession.1–4 One of the goals of Yi-Ling Lin, DDS, DMSc4 periodontal therapy is therefore pre- 3 Flavia Q. Pirih, DDS, PhD dictable creation or augmentation of the zone of attached gingiva to pro- The complete absence of keratinized attached gingiva on the buccal surface tect the underlying periodontium of a tooth can make the area more susceptible to gingival recession. The and prevent or halt the progression modified apically repositioned flap (MARF) technique is an effective procedure of gingival recession. A consensus to increase the dimensions of attached gingiva in areas that present with report published by the American some existing keratinized tissue. The objective of this case report is to present long-term clinical and histologic evidence that the MARF technique can be Academy of Periodontology Regen- used to create attached gingiva in areas that lack keratinized tissue. Int J eration Workshop suggested that Periodontics Restorative Dent 2017;37:363–369. doi: 10.11607/prd.2824 a minimum width (apicocoronal) of 2 mm of keratinized tissue is needed to maintain gingival health.5 Two main surgical procedures have been proposed to increase the zone of keratinized tissue and attached gingiva: the free gingival graft (FGG) and the modified apically repositioned flap (MARF). When the FGG and MARF techniques were compared, both resulted in statistically and clinically significant increases in the apicocoronal dimensions of keratinized tissue and 1Visiting Researcher, Section of Periodontics, UCLA School of Dentistry, attached gingiva.6 While the FGG Los Angeles, California, USA; Private Practice, Londrina, Brazil. is the best established procedure 2 Professor, Tarrson Family Endowed Chair in Periodontics and Associate Dean of for gingival augmentation in areas Clinical Dental Sciences, UCLA School of Dentistry, Los Angeles, California, USA. 3Associate Professor, Section of Periodontics, UCLA School of Dentistry, with complete absence of keratin- Los Angeles, California, USA. ized tissue, it carries many possible 4Associate Professor, Section of Oral Pathology, UCLA School of Dentistry, drawbacks, including technical dif- Los Angeles, California, USA. ficulty, the creation of a palatal do-

Correspondence to: Dr Joao Carnio and Dr Flavia Q. Pirih, UCLA School of Dentistry, nor area, substantial postoperative Section of Periodontics, 10833 Le Conte Avenue, CHS 63-015, discomfort, and unpredictable color Los Angeles, CA 90095, USA. Fax: (310) 206-3282. match.7 The MARF technique has Email: (Dr Carnio) [email protected]; (Dr Pirih) [email protected] shown promising results as a mo- ©2017 by Quintessence Publishing Co Inc. dality of mucogingival surgery for

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and premolars. The referring dentist Table 1 Clinical Parameters (in mm) at Different Time Points reported that gingival recession had Throughout the Study been increasing in the area. Mandibular Mandibular Mandibular Clinical examination of these Tooth left second premolar left first premolar left canine teeth demonstrated shallow pocket PD depths, minimal clinical inflamma- Baseline 1.5 1.0 0.5 tion, and moderate recession of the 2 mo 1.0 1.0 0.5 2.5 y 1.0 1.0 1.0 gingival margin. There was limited 5 y 1.0 1.0 1.0 keratinized tissue on the first pre- 13 y 1.0 1.0 1.0 molar and canine and a complete RE absence of keratinized tissue and Baseline 1.5 1.0 0.5 attached gingiva on the second 2 mo 1.5 1.0 1.0 2.5 y 1.5 1.0 0.5 premolar (Table 1); and both premo- 5 y 1.5 1.0 0.5 lars had cervical abrasions (Fig 1a). 13 y 1.5 1.5 0.5 Based on the history of aggressive KT tooth brushing and current clinical Baseline 0.0 1.5 1.0 findings, periodontal surgery was 2 mo 2.5 5.0 4.0 2.5 y 2.5 5.0 5.0 recommended to create and/or in- 5 y 3.5 4.0 5.0 crease the zone of keratinized tissue 13 y 3.5 3.5 4.5 and attached gingiva. AG The patient was presented with Baseline 0.0 0.5 0.5 the options of having FGG or MARF 2 mo 1.5 4.0 3.5 2.5 y 1.5 4.0 4.0 treatment. She opted for the MARF 5 y 2.5 3.0 4.0 because of a previous experience 13 y 2.5 2.5 3.5 with a FGG in which postoperative PD = pocket depth, using the gingival margin as reference; RE = gingival recession, using pain and bleeding occurred. The the cementoenamel junction as reference; KT = keratinized tissue as measured between the mucosal (gingival) margin and the mucogingival junction; AG = attached gingiva as patient was informed that the pre- measured between the bottom of the sulcus (pocket) and the mucogingival junction. dictability of treating the second premolar with the MARF was uncer- nonroot coverage because it allows MARF technique performed to in- tain because the surgical technique, the procedure to be performed with crease the apicocoronal dimension as originally described, required the minimal trauma, does not require a of attached gingiva in the absence a minimum of 0.5 mm of attached palatal donor site, generates mini- of marginal keratinized tissue. gingiva. She understood the poten- mal postoperative discomfort, and tial limitations associated with the has better tissue color match pre- MARF and agreed to undergo the dictability.2– 4,7,8 However, to date, Case Report procedure. this technique has only been used The treatment objectives in- in areas with at least 0.5 mm of at- A 41-year-old nonsmoking woman, cluded creating/increasing the api- tached gingiva and has not been in good general health and with cocoronal dimension of keratinized considered in areas where the mar- no contraindications to periodontal tissue and establishing a zone of ginal tissues were composed of surgery, was referred to one of the attached gingiva on the mandibular nonkeratinized mucosa.8 authors’ (J.C.) private practices in left premolars and canine that were Therefore, the goal of this case January 2002 for treatment of a mu- compatible with periodontal health. report is to present long-term clini- cogingival problem on the buccal Prior to the surgical procedure, cal and histologic outcomes of the aspect of the mandibular left canine the patient was given oral hygiene

The International Journal of Periodontics & Restorative Dentistry

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 365 instruction with a soft-bristled tooth- brush and received professional prophylaxis. Following administration of local anesthesia with lidocaine contain- ing epinephrine at a concentration of 1:100,000, a horizontal beveled incision was made approximately a b 0.5 mm into the attached gingiva extending from the mesial aspect of the mandibular left lateral incisor to the distal aspect of the mandibular left first premolar. As there was no attached gingiva present on the second premolar, the incision was made in nonkeratinized mucosa, leaving approximately 2 mm of marginal c d tissue collar intact (Fig 1b). A split- Fig 1 MARF procedure on the mandibular left premolars and canine. (a) Clinical appearance at baseline. Note the complete absence of keratinized tissue on the second thickness flap was then elevated and premolar. (b) Initial incision after application of Schiller solution. Note the approximately sutured to the periosteum approxi- 2 mm of nonkeratinized mucosa left intact on the buccal side of the second premolar. (c) MARF at the end of the suturing procedure. (d) Clinical appearance of the treated area mately 3 mm apical to the initial in- 2 months after the MARF procedure; the buccal aspect of the second premolar presented cision with 5-0 chromic gut (Fig 1c). with 2.5 mm of keratinized tissue and 1.5 mm of attached gingiva. A moist gauze pad was applied to the surgical area for 5 minutes with gentle digital pressure to maintain the flap in close contact with the un- At 2 months postsurgically, the 2 months postoperative remained derlying periosteum. A noneugenol patient presented with a substantial similar. Some creeping attachment9 periodontal dressing was applied to increase in the dimensions of kera- occurred on the mandibular left ca- treated teeth and surrounding soft tinized tissue and attached gingiva nine with the gingival margin return- tissues. Postoperative care consist- in the area when compared to base- ing to its baseline level. ed of 0.12% chlorhexidine rinses for line (Table 1, Fig 1d). In particular, Although the apicocoronal di- 4 weeks and analgesic medication the mandibular left second premolar mension of attached gingiva on the (ibuprofen 600 mg every 6 hours) that did not have any keratinized tis- buccal surface of the mandibular left as needed for pain. The patient was sue prior to the surgical procedure second premolar was improved, it advised to avoid chewing on the left presented with 2.5 mm of keratin- was not judged to be adequate to side and to refrain from brushing ized tissue and 1.5 mm of attached stabilize the position of the gingival and flossing the area during the first gingiva; the sulcus depth was 1 mm margin (< 2 mm).10 As a preventive 4 postoperative weeks. During this and gingival recession remained un- measure, a second MARF proce- period, the patient received profes- changed (Table 1, Fig 1d). There was dure to further increase the zone of sional follow-up care on a weekly a 0.5-mm increase in gingival reces- attached gingiva was proposed and basis, as previously described.6 The sion on the mandibular left canine was accepted by the patient. periodontal dressing was removed (Table 1, Fig 2a). In brief, under local anesthesia, at the 1-week postoperative evalu- Examination of the area 2.5 a horizontal beveled incision was ation. Healing following the surgical years after the surgery revealed that made from the distal side of the procedure was uneventful. the clinical parameters observed at mandibular left first premolar to the

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Fig 2 Second MARF procedure on the mandibular left second premolar. (a) Clinical appearance 2.5 years after the first MARF procedure. (b) Second MARF procedure on the second premolar. The flap was secured to its apical position with isobutyl cyanoacrylate.

a b

Fig 3 Clinical appearance of the treated area with a focus on the mandibular left second premolar at 5 years after the first and 2.5 years after the second MARF procedures. (a) The second premolar presented with 3.5 mm of keratinized tissue and 2.5 mm of attached gingiva. (b) The biopsy was retrieved from the buccal aspect of the tooth.

a b

distal side of the second premolar At 5 years after the initial surgery, men was fixed in 10% formalin and and the flap was apically positioned. the patient and referring dentist de- submitted for histologic processing. A marginal tissue collar of approxi- cided to extract the mandibular left Sections of the represented area mately 2 mm remained in its original second premolar to replace that measuring 5 mm were stained with position (Fig 2b). Gentle pressure tooth and the first and second molars hematoxylin-eosin, and the distal was applied for 5 minutes, and iso- with an implant-supported prosthe- portion of the biopsy, which cor- butyl cyanoacrylate was used to sis. From a periodontal standpoint, responded to the midfacial aspect immobilize the flap. Postoperative the second premolar was stable and of the tooth where no keratinized instructions were given as described had a good periodontal prognosis. tissue was present, was examined above. Healing was uneventful. This treatment plan was developed under light microscopy. The histo- At 5 years after the initial MARF by the referring dentist after deter- logic analysis suggested that the procedure and 2.5 years after the mining that the edentulous area cor- specimen was composed of strati- second surgery, further increase in respondent to the first molar did not fied squamous epithelium overlying keratinized tissue (from 2.5 mm at present with adequate bone volume fibrous connective tissue. The free 2.5 years to 3.5 mm at 5 years) and for placement of an implant fixture marginal gingiva exhibited mild, attached gingiva (from 1.5 mm at and the patient did not want to go patchy inflammation, which was 2.5 years to 2.5 mm at 5 years) were through an extensive ridge augmen- within normal limits. A layer of para- observed on the buccal aspect of tation procedure. Since the second keratin was present in the epithelium the mandibular left second premo- premolar was going to be extracted from the mucogingival junction to lar. No changes in pocket depth or by the referring dentist, the patient the gingival margin. Microscopically, gingival recession were observed consented to have a soft tissue bi- the tissue appeared normal (Fig 4). as compared to the 2.5-year evalu- opsy taken from the buccal aspect At 13 years after the initial ation prior to the second MARF proof the tooth. Under local anesthesia MARF procedure, the patient re- cedure (Table 1, Fig 3a). The results (Fig 3b), a full-thickness specimen turned for examination of the left obtained at 2.5 years were stable (4 mm apicocoronal by 2 mm me- mandibular first premolar and ca- (Table 1). siodistal) was retrieved. The speci- nine. At the clinical examination, it

The International Journal of Periodontics & Restorative Dentistry

Fig 4 Hematoxylin-eosin histology of the gingival specimen. (a) Biopsied gingiva tissue at ×2 magnification (Aperio Imagescope). (b) View at ×20 magnification of the green box GM area selected from (a). Parakeratin is present in the epithelium coronal to the mucogingival junction. The red line indicates the nonkeratinized epithelium and the blue line shows the parakeratinized epithelium. (c) View at ×20 magnification of the yellow box selected from (a). Parakeratin is present in the epithelium covering the marginal gingiva. MGJ = mucogingival S junction; GM = gingival margin; S = sulcular epithelium; J = junctional epithelium. J

MGJ

1 mm 100 μm 100 μm a b c

was discovered that the second pre- periodontium from external trau- molar was still present. The patient matic injuries.2 had decided to wear a removable Since the introduction of the partial denture to replace the first term mucogingival surgery in the and second molars as opposed to 1950s, various procedures have an implant-supported restoration to been used to correct problems as- replace all three teeth, and the re- sociated with the lack of attached sults obtained with the two surgical gingiva.10 One of the first surgical Fig 5 Clinical appearance of the treated procedures were sustainable on the techniques to establish wider zones area 13 years after the initial MARF second premolar and first and sec- of attached gingiva involved alter- procedure. ond molars (Fig 5). ing the mandibular vestibular depth by repositioning the mucogingival the need for alternative methods to junction in an apical direction.11,12 achieve similar results and avoid un- Discussion To retain or to gain attached gin- wanted side effects.16,17 The MARF, giva, the apically repositioned flap a relatively noninvasive procedure Keratinized tissue that is attached to was proposed.13–15 This technique aiming at increasing the attached the root surface and/or underlying allowed surgeons to increase or pre- gingiva, was recently introduced in bone is a desirable anatomical fea- serve the area of attached gingiva the literature. The advantage of the ture for the maintenance of gingival by moving the marginal gingival tis- MARF in relation to the previously health. If a nonkeratinized soft tissue apically and exposing a variable proposed technique is that preserv- sue margin loosely attached to the band of crestal bone depending on ing the marginal gingival tissue col- root is present, it may enhance the how much attached gingiva was de- lar in its original position enables an development of soft tissue reces- sired. However, the postoperative increase in attached gingiva without sion, serve as a weak barrier against discomfort, great amount of bone additional loss of attachment and biofilm, and impede adequate oral resorption, and loss of attachment more favorable postoperative com- hygiene, and it may not protect the related to this procedure suggested fort to the patient.

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Both the MARF and the clas- the end of the follow-up period, muscle attachment. The lack of de- sic FGG18 have been shown to with no additional attachment loss mand for elasticity from the granu- predictably increase the band of having occurred as compared to lation tissue that was developing keratinized tissue and the attached baseline. over the periosteum in the area, gingiva.6,8 As originally described, The clinical outcomes present- which was healing by secondary one of the requirements to make ed 5 years after the first MARF sur- intention, may have induced geno- the MARF a feasible surgical option gery were supported by histologic typic changes to the epithelial cells to increase the gingival dimensions evidence that the tissue formed on that favored immobility and there- was the presence of least 0.5 mm of the buccal aspect of the mandibu- fore keratinization20 (Fig 1c). Finally, attached gingiva. This requirement lar left second premolar was nor- it is reasonable to think that granu- would allow the surgical wound to mal keratinized tissue resembling lation tissue from the periodontal have keratinized tissue surrounding gingiva, composed of stratified ligament may have proliferated cor- its perimeter. It was thought that the squamous epithelium overlying the onally along the root and laterally epithelial cells present on the bor- connective tissue. A layer of kera- as a response to the surgical insult, ders of the wound would migrate tinized epithelium was present from and its development may have in- over the exposed periosteum and the mucogingival junction to the duced the keratinization of the epi- give origin to the newly formed ke- gingival margin. thelial cells over it. This possibility ratinized tissue.8 The reasons keratinized tissue is supported by a series of publica- The uniqueness of the case re- formed after surgical apical repo- tions that demonstrated the ability ported herein is related to the re- sitioning of a nonkeratinized muco- of the periodontal connective tis- sults obtained on the mandibular sal margin remain undetermined. sue to induce the differentiation of left second premolar, which did not One possible explanation is the epithelial cells into keratinized gin- present with clinical evidence of ke- growth of a rapidly dividing group gival epithelium.21–24 On the other ratinized tissue at the beginning of of cells around a more slowly divid- hand, if the granulation tissue origi- treatment. The creation of 2.5 mm ing group of cells. In this case, the nates from the connective tissue of of keratinized tissue and 1.5 mm epithelial cells, which expressed the alveolar mucosa proper a non- of attached gingiva on this tooth keratin, could have migrated from keratinized epithelium develops.23 with the MARF technique after the the mesial and distal aspects of the After the second surgery, the first surgery was unexpected, be- wound and populated the surface wound area, in contrast to the ini- cause it was assumed that a source of the exposed periosteum faster tial clinical situation, was completely of keratinized epithelium was not than other cells that were present surrounded by keratinized tissue. available where the surgical wound around the surgically created area. The increase in keratinized tissue was created. The results obtained This phenomenon is called epiboly. and attached gingiva was expected. with the second surgical proce- It is also plausible that the incision, This is supported by the concept dure were in line with expectations which was initially made below the proposed by Karring et al,23 which for the MARF technique as previ- soft tissue margin, aided in dissi- suggests that the main factor deter- ously published. That the clinical pating the tension that was exer- mining the nature of the epithelial results obtained with two succes- cised by the muscular fibers of the surface that will develop over the sive MARF procedures remained alveolar mucosa onto the marginal exposed periosteum is the origin of stable over 13 years is remarkable. tissue. This might have promoted the epithelial cells that will migrate The keratinized tissue on the buccal the stabilization of the marginal over the wound. aspect of the mandibular left sec- tissue at its new position19 and in- The marginal bone is also a ond premolar had increased from 0 duced changes to the environment, factor in the keratinization pro- to 3.5 mm and the attached gingiva helping the wound healing process cess. The amount of buccal crestal had increased from 0 to 2.5 mm at to occur without interference of bone loss is consistently related to

The International Journal of Periodontics & Restorative Dentistry

the amount of new keratinized tis- Conclusions 8. Carnio J, Camargo PM. The modified sue created. In other words, areas apically repositioned flap to increase the dimensions of attached gingiva: The sin- where the height of the marginal Despite the limits of a single case re- gle incision technique for multiple adja- bone is reduced have a greater port, this study presents proof of the cent teeth. Int J Periodontics Restorative Dent 2006;26:265–269. likelihood of periodontal ligament principle that the MARF technique 9. Matter J, Cimasoni G. Creeping attach- contribution to the keratinization can induce the creation of keratin- ment after free gingival grafts. J Peri- activity.23 ized tissue and attached gingiva in odontol 1976;47:574–579. 10. Friedman N. Mucogingival surgery. Tex However, the fact that buccal areas that initially present with a non- Dent J 1957;75:358–362. bone was still present at the time keratinized tissue margin. A study 11. Bohannan HM. Studies in the alteration of vestibular depth II. Periosteum reten- of biopsy may negate this rationale with a larger sample size is needed tion. J Periodontol 1962;33:354–359. for the participation of the exposed to determine the success and pre- 12. Bohannan HM. Studies in the alteration periodontal ligament by bone re- dictability of the MARF technique in of vestibular depth I. Complete denuda- tion. J Periodontol 1962;33:120–128. sorption from this area in this regen- treating these clinical situations. 13. Nabers CL. Repositioning the attached eration process (Fig 3b). gingiva. J Periodontol 1954;25:38–39. 14. Ariaudo AA, Tyrrell HA. Repositioning Finally, the dimensions of the and increasing the zone of attached gin- keratinized tissue and attached Acknowledgments giva. J Periodontol 1957;28:106–110. gingiva gained on the mandibular 15. Friedman N. Mucogingival surgery: The apically repositioned flap. J Periodontol left premolars and canine with the The authors reported no conflicts of interest 1962;33:328–340. MARF technique remained stable related to this study. 16. Cohen DW, Ross SE. The double papil- lae repositioned flap in periodontal ther- for 13 years. The patient opted apy. J Periodontol 1968;39:65–70. out of the restorative plan that in- 17. Grupe HE. Modified technique for the cluded a fixed partial denture sup- References sliding flap operation. J Periodontol 1966; 37:491–495. ported by implants and accepted 18. Sullivan HC, Atkins JH. Free autogenous a treatment plan that included . 1 Wennström J, Lindhe J, Nyman S. Role gingival grafts. 3. Utilization of grafts in the treatment of gingival recession. Peri- maintenance of the mandibular of keratinized gingiva for gingival health. Clinical and histologic study of normal odontics 1968;6:152–160. left second premolar and fabrica- and regenerated gingival tissue in dogs. 19. Trombelli L. Periodontal regeneration in tion of a removable partial denture. J Clin Periodontol 1981;8:311–328. gingival recession defects. Periodontol 2. Carnio J, Camargo PM, Passanezi E. In- 2000 1999;19:138–150. The reconstituted tissue in the area creasing the apico-coronal dimension 20. Schmid MO, Mörmann W, Bachmann A. correspondent to the biopsy re- of attached gingiva using the modified Mucogingival surgery. The subperios- teal vestibule extension. Clinical results moval was clinically normal gingiva apically repositioned flap technique: A case series with a 6-month follow-up. 2 years after surgery. J Clin Periodontol in texture, color, and volume and J Periodontol 2007;78:1825–1830. 1979;6:22–32. remained stable for the remaining 3. Wennström JL. Mucogingival therapy. 21. Karring T, Ostergaard E, Löe H. Con- Ann Periodontol 1996;1:671–701. servation of tissue specificity after het- 8 years following the biopsy. Fur- 4. Pini Prato G. Mucogingival deformities. erotopic transplantation of gingiva and thermore, the second premolar was Ann Periodontol 1999;4:98–101. alveolar mucosa. J Periodontal Res 1971; 6:282–293. used as an abutment for a remov- 5. Scheyer ET, Sanz M, Dibart S, et al. Peri- odontal soft tissue non-root coverage 22. Karring T, Lang NP, Löe H. The role of able partial denture with the buccal procedures: A consensus report from gingival connective tissue in determin- clasp crossing the gingiva of that the AAP Regeneration Workshop. J Peri- ing epithelial differentiation. J Periodon- odontol 2015;86(suppl):S73–S76. tal Res 1975;10:1–11. tooth for retention and stability. If 6. Carnio J, Camargo PM, Pirih PQ. Surgi- 23. Karring T, Cumming BR, Oliver RC, Löe the tooth did not have adequate cal techniques to increase the apicocor- H. The origin of granulation tissue and its impact on postoperative results of mu- keratinized tissue and attached gin- onal dimension of the attached gingiva: A 1-year comparison between the free cogingival surgery. J Periodontol 1975; giva, the potential trauma from the gingival graft and the modified apically 46:577–585. partial denture may have increased repositioned flap. Int J Periodontics Re- 24. Wennström J. Regeneration of gin- storative Dent 2015;35:571–578. giva following surgical excision. A clini- the chances of gingival recession. 7. Miller PD Jr. Root coverage grafting for cal study. J Clin Periodontol 1983;10: regeneration and aesthetics. Periodon- 287–297. tol 2000 1993;1:118–127.

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