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The Modified Apically Repositioned Flap to Increase the Dimensions of Attached Gingiva: The Single Incision Technique for Multiple Adjacent Teeth

João Carnio, DDS, MS* It is commonly accepted that Paulo M. Camargo, DDS, MS** attached gingiva protects the peri- odontium. The keratinized nature of the epithelium, along with the dense bundles of collagen fibers that are firmly inserted to and/or to underlying bone, serves as an effec- tive barrier against physical trauma This article describes a surgical technique directed at increasing the dimensions of caused by toothbrushing; it also facil- attached gingiva over multiple adjacent teeth. The described technique is a varia- itates plaque control.1 In cases of pro- tion of the modified apically repositioned flap (MARF) technique previously pro- gressive in areas posed. The MARF technique uses one single horizontal incision within keratinized tissue, elevation of a split-thickness flap, and suturing of the flap to the perios- that are deficient in attached gingiva, teum in an apical position. Periosteum is left exposed in the area between the ini- therapy aiming at establishing an ade- tial horizontal incision and the coronal margin of the flap. The full perimeter of the quate zone of attached gingiva con- exposed periosteal area is completely surrounded by keratinized tissue. fers stability to the Therefore, keratinized epithelial cells migrate over the periosteum during wound position.2 Moreover, the presence of healing, resulting in the formation of keratinized attached tissue in the area of the attached gingiva has been shown to previously exposed periosteum. The advantages associated with this surgical play a role in the maintenance of gin- technique include its simplicity: It employs one single horizontal incision, gener- gival health around teeth where the ates minimal morbidity since it does not involve any palatal donor tissue, and pro- restoration margin is located subgin- vides predictable gingival color match. (Int J Periodontics Restorative Dent givally3,4 and on teeth that are being 2006;26:265–269.) moved orthodontically out of the alveolar envelope.5–7 Although much controversy exists regarding the need to increase the *Adjunct Professor and Director of Postgraduate Program in Periodontics, State University dimensions of attached gingiva,2 of Londrina School of Dentistry, Londrina, Paraná, Brazil; Private Practice, Londrina-Paraná, Brazil. mucogingival surgical procedures con- **Associate Professor of Periodontics; Division of Associated Clinical Specialties; University tinue to be frequently employed in the of California, Los Angeles, School of Dentistry; Los Angeles, California. practice of periodontics, and various

Correspondence to: Dr João Carnio, Rua Pistoia 245 – Jardim Canadá, Londrina-Pr. techniques have been described in the 1,8 86020-450 Brazil; e-mail: [email protected]. literature for that purpose. Among

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these surgical techniques, Carnio and formed by the blade and the portion Periodontal dressing is applied to Miller9 have described the modified of the gingival surface coronal to the the wound during the first postopera- apically repositioned flap (MARF) to blade. Therefore, the blade makes tive week. Postoperative care consists increase the zone of attached gingiva contact with periosteum at a point of 0.12% rinses for 4 around a single . The MARF pre- slightly apical to the alveolar crest. In weeks and analgesic medication sents some advantages over other the mesiodistal direction, this initial (ibuprofen 600 mg every 6 hours) as techniques, including low morbidity horizontal incision should be parallel to needed for pain. The dressing is (because it does not involve any palatal the mucogingival junction so that removed at 1 week postoperatively; donor tissue) and a predictable color approximately 0.5 mm of gingiva mechanical of the surgi- match. Furthermore, the steps remains along the coronal portion of cal area in the form of brushing and involved in the MARF technique are the whole flap. The gingiva present flossing is not initiated until the begin- simple, and the surgical procedure can coronal to the initial incision remains ning of the fifth postoperative week. be conducted expeditiously, with lim- intact around the teeth. The mesiodis- At 6 to 8 weeks postoperatively, ited chair time for the patient and the tal extension of the initial horizontal an increase in the apicocoronal dimen- operator. incision is determined by the number sion of the attached gingiva, corre- In the way it was originally of teeth involved in the procedure and sponding to the area where perios- described,9 the MARF technique is should be extended by at least one teum was left exposed, is typically indicated in the augmentation of half tooth mesially and distally of the observed (Figs 1c, 2, and 3). attached gingival dimensions around areas in which gingival augmentation a single tooth. The purpose of this arti- is desired. This extension will allow for cle is to describe a variation of the apical repositioning of the flap without Discussion MARF as a surgical technique to aug- the use of vertical releasing incisions. ment the dimension of the attached A split-thickness flap is elevated The increase in the dimensions of gingiva around multiple adjacent with a no. 15 blade, and the dissection attached gingiva using the MARF tech- teeth. is extended in the apical direction as far nique as presented in this article offers as deemed necessary. The further api- considerable advantages over other cal the dissection is carried out, the mucogingival surgery techniques, as Surgical technique wider the net gain in attached gingival previously stated. The MARF tech- dimensions. A dissection 5 to 6 mm in nique allows the clinician to control At the time of the surgical procedure, an apical direction is usually sufficient. the width of keratinized tissue to be areas in which the MARF is intended to The flap is then moved apically and created. This control is a function of the be used should present with minimal secured to the periosteum with inter- ability to suture the flap at any desired or no gingival inflammation, physio- rupted U-shaped sutures using 6-0 gut apical position, depending on the logic sulcus depth, and at least 0.5 (Fig 1b). requirements of each case. From the mm of attached gingiva. Following With a moist 22 gauze, gentle standpoint of patient comfort, the administration of local anesthesia with digital pressure is applied to the sur- MARF does not require palatal donor lidocaine containing epinephrine at a gical area for 3 to 5 minutes to main- tissue, which is associated with high concentration of 1:100,000, a hori- tain the flap in close contact with the morbidity and the possibility of post- zontal beveled incision is made with a underlying periosteum. At the end of operative bleeding, as observed in no. 15 blade approximately 0.5 mm the surgical procedure, inspection of cases treated with a . coronal to the mucogingival junction the exposed periosteal area should The MARF technique is also simple, into the attached gingiva (Fig 1a). This reveal a thin, homogenous layer of and its surgical procedures can be exe- initial horizontal incision is performed periosteum with no movable tissue cuted expeditiously, minimizing chair at an angle of 30 to 45 degrees, (neither elastic nor muscular fibers). time for the patient and the surgeon.

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Horizontal Beveled incision beveled incision

Periosteum layer Band of kertatinized tissue in the coronal portion of the flap

Fig 1 Modified apically repositioned flap technique.

Fig 1a (top left) A single horizontal beveled incision is made 0.5 mm coronal to the mucogingival junction. New area of attached gingiva Fig 1b (top right) The flap is apically positioned to the desired level and secured with periosteal sutures.

Fig 1c (right) Final result after healing, showing an increase in the apicocoronal dimension of the attached gingiva.

Finally, the color match generally val tissue remains in contact with the the buccal mucosa tend to generate obtained with the MARF technique is teeth, whereas the apical portion excessive bleeding and are con- very predictable, as the newly formed becomes part of the flap. Preservation traindicated in the mandibular pre- tissue consistently blends well with the of keratinized tissue around the teeth molar/molar area in cases of limited adjacent gingiva. in the process of flap elevation is buccal depth and high location of the The main requirement to make important because that tissue protects mental foramen. the MARF a feasible surgical means of the crestal bone from being resorbed, After the flap has been positioned increasing the dimension of the which would initiate or increase gingi- apically and sutured, the periosteal attached gingiva is the need for at least val recession. area is left exposed. According to 0.5 mm of presurgical attached gingiva The MARF technique as described Karring and coworkers,10 the main fac- in the apicocoronal direction. The exis- in this article does not require vertical tor determining the nature of the tence of this minimal amount of releasing incisions for flap mobiliza- epithelial surface that will develop over attached gingiva in the surgical area tion. The mesiodistal extension of the the exposed periosteum is the origin allows for the use of a flap design that initial horizontal incision by at least one of the epithelial cells that will migrate incorporates a horizontal beveled inci- half tooth in each direction provides over the wound. The surgical wound sion that separates the gingival tissue the flap with adequate mobility for api- created with the MARF technique is in two segments: coronally, the gingi- cal repositioning. Vertical incisions into completely surrounded by keratinized

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Fig 2a Presurgical view of the mandibular Fig 2b A horizontal incision is made 0.5 Fig 2c Clinical view of the surgical area 1 right canine, premolars, and first molar, mm coronal to the mucogingival junction, week postoperatively. showing a narrow band of attached gingiva. followed by elevation of a split-thickness flap, which is apically positioned and sutured, leaving periosteum exposed.

Fig 2d (left) Clinical view of the surgical area 2 weeks postoperatively.

Fig 2e (right) One-year postsurgical view of the area shown in Fig 2a, revealing a marked increase in the apicocoronal dimen- sion of the attached gingiva.

Fig 2f (left) Two-year postsurgical view of the area, showing stable clinical results.

Fig 2g (right) Iodine solution staining of the gingiva reveals the keratinized nature of the tissue 2 years postoperatively.

tissue. This will prevent the prolifera- in the formation and maturation of ker- aborted or a free gingival graft should tion of nonkeratinized epithelial cells atinized tissue. be placed on the exposure area. originating from the to A potential problem encountered Exposure of a root surface area in the the surgical area. Therefore, the during execution of the MARF is the course of healing may lead to soft tis- epithelial cells migrating from the mar- presence of bony dehiscence in areas sue dehiscence or fenestration. gins of the wound to cover the of a thin . If root expo- However, presurgical detection of the exposed connective tissue are kera- sure occurs during the surgical proce- crestal bone through sulcus probing tinized in nature, which in turn will result dure, the procedure should be will prevent this occurrence.

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Fig 3a (left) Preoperative view of the mandibular left lateral incisor, canine, and first premolar showing a narrow band of attached gingiva.

Fig 3b (right) A beveled horizontal inci- sion is made parallel and slightly coronal to the mucogingival junction.

Fig 3c (left) The split-thickness flap is sutured in an apical position.

Fig 3d (right) Clinical view of the area at 3 years postsurgery. Notice the marked increase in the apicocoronal dimension of the attached gingiva as compared to Fig 3a.

The clinical observations follow- References 6. Wennström JL, Lindhe J, Sinclair F, ing the MARF with respect to the for- Thilander B. Some periodontal tissue reac- tions to orthodontic tooth movement in mation of keratinized tissue have been 1. Wennström JL. Mucogingival therapy. In: Newman M (ed). Annals of . monkeys. J Clin Periodontol 1987;14: confirmed histologically.9 Two biop- Chicago: American Academy of 121–129. sies taken from single teeth treated Periodontology, 1996:671–701. 7. Steiner GC, Pearson JK, Ainamo J. with the MARF at 6 weeks postopera- 2. Consensus report. Mucogingival therapy. Changes of the marginal periodontium as tively showed that the new tissue pre- In: Newman M (ed). Annals of Perio- a result of labial tooth movement in mon- keys. J Periodontol 1981;52:314–320. sented with characteristics of gingival dontology. Chicago: The American Academy of Periodontology, 1996: tissue. 8. Friedman N. Mucogingival surgery: The 702–706. apically repositioned flap. J Periodontol In summary, the MARF technique 3. Maynard JG, Wilson RD. Physiologic 1962;33:328–340. provides clinicians with a simple and dimensions of the periodontium signifi- 9. Carnio J, Miller PD Jr. Increasing the effective tool to increase the dimension cant to the restorative dentist. J Perio- amount of attached gingiva using a mod- of attached gingiva that has several dontol 1979; 50:170–174. ified apically repositioned flap. J advantages over autografts and allo- 4. Nevins M. Attached gingiva—mucogingi- Periodontol 1999;70:1110–1117. grafts. The authors are in the process val therapy and restorative dentistry. Int J 10. Karring T, Cumming BR, Oliver RC, Löe H. Periodontics Restorative Dent 1986;6: The origin of granulation tissue and its of conducting a clinical study to quan- 9–27. impact on postoperative results of muco- tify the clinical results obtained with 5. Coatoam GW, Behrents RG, Bissada NF. gingival surgery. J Periodontol 1975;46: the MARF technique. The width of keratinized gingiva during 577–585. orthodontic treatment: Its significance and impact on periodontal status. J Perio- dontol 1981;52:307–313.

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