Advanced Flap Procedure Research Articles

Coronally advanced flap with and without connective tissue graft in root coverage procedure: A Case Series

Objective: This paper aims to report the outcome of the coronally advanced flap with and without connective tissue graft in the root coverage procedure. We intend to explain the importance of connective tissue graft in coronally advanced flap surgery. Methods: Two patients with gingival recession required surgical intervention to get root coverage and improve aesthetics. Both patients were treated with a coronally advanced flap. We combined the coronally advanced flap with a connective tissue graft for the first patient's maxillary left second incisor and canine; meanwhile, we only did the coronally advanced flap for the second patient's maxillary right canine and first premolar. Results: Surgical intervention was done for both patients with good results. For the first patient with a connective tissue graft, we noticed increased thickness on the keratinized gingiva and gained 1 mm of root coverage. Meanwhile, we got full root coverage for the second patient. In this article, a patient with a connective tissue graft was observed for six months, and a patient without a connective tissue graft was observed for two years. In both cases, we noticed stable and good results. Conclusions: Coronally advanced flap procedure can be a reliable treatent for root coverage in the tooth with gingival recession. An additional connective tissue graft combined with a coronally advanced flap can increase keratinized tissue thickness.

Evaluation of Postoperative Complications Following Modified Coronally Advanced Flap as Root Coverage Procedure - A Prospective Clinical Study.

Root coverage procedures are very technique sensitive and require patients' compliance for successful treatment outcomes. Post operative complications can influence patients' acceptance of treatment and compromise further periodontal maintenance. The aim of this study was to evaluate the frequency and severity of complications after a modified coronally advanced flap procedure. A total of 78 modified coronally advanced flap procedures were performed in 42 patients for root coverage. Duration of surgical procedure, history of smoking, gender, and age were recorded for each patient. A questionnaire was given to every patient to fill in at first post operative week regarding their experience of postoperative pain, swelling, and bleeding. Pain and duration of surgery had a correlation (OR: 1.05, P < 0.05). Post operative bleeding was significantly correlated with duration of surgery (OR: 1.03, P < 0.05). Current smokers experienced post operative swelling (P < 0.05). However, post operative pain in current smokers was not significantly different (P > 0.05) as compared to nonsmokers. Descriptive statistics were expressed as mean and standard deviations. Odd's ratio was obtained to evaluate risk indicators for moderate to severe types of complications. P < 0.05 was considered as significant. The duration of the surgery, long duration, and the presence of smoking can increase the frequency and severity of post operative complications.

Efficiency of the new modified inverted Y cleft lift advancement flap in primary and recurrent sacrococcygeal pilonidal sinus disease with low-lying tracts near the anus

Propose This study aimed to assess the efficiency of the new modified inverted Y cleft lift procedure, utilizing an advancement flap technique with off-midline primary wound closure for patients with lower pits of the sinus near the anus. Patients and methods This prospective case series was conducted from September 2018 to September 2020. Forty patients with sacrococcygeal pilonidal sinus disease with lower pits near the anus presented either as new cases or recurrent cases. All patients were offered the new modified inverted Y cleft lift advancement flap procedure and were followed up for 48.5 months (range, 21–57 months). Patients were evaluated in terms of operation time, postoperative complications, recurrence rate, return-to-work time, and cosmetic satisfaction. Results The average age was 27.4 years (range, 16–52 years); 29 (72.5%) patients were male and 11 (27.5%) were female. The mean operating time was 25 min (range, 22–45 min) and the mean length of hospital stay was 0.8 days (range, 0.4–2 days). Primary healing occurred in 35 (87.5%) patients. Complete healing for complicated wounds (five patients) was achieved in an average of 21 (14–60) days. Two (5%) patients developed a superficial wound infection, four (10%) patients experienced a seroma, and five (12.5%) had partial dehiscence (some complications observed in the same patient). There was no case of deep infection, hematoma formation, or complete dehiscence. Conclusion This series proved that the new modification inverted Y cleft lift flap reconstruction is an effective operative procedure for primary and recurrent pilonidal sinus cases with pits located very close to the anus, associated with low complication and recurrence rates. What does this paper add to the literature? This paper discusses a new modification to the modified cleft lift procedure named the inverted Y flap procedure, achieving off-midline primary wound closure in patients with a difficult situation with lower pits of the sinus very close to the anus, for pilonidal disease either primary or recurrent.

A comparative study of cyanoacrylate-based tissue adhesive and surgical sutures on marginal flap stability following coronally advanced flap

IntroductionThe present study evaluated the biomechanical characteristics of cyanoacrylate-based tissue adhesive (TA) compared to surgical sutures in coronally advanced flap (CAF) procedures using an ex-vivo model.Material and methodsThirty-six half-pig mandibles were divided into three groups, n=12 each: (I) CAF fixed with sutures (sling and tag suture technique), (II) CAF fixed with TA, and (III) CAF fixed with sutures and TA. At mandibular premolars, gingival recession defects extending 3 mm apical to the cemento-enamel junction (CEJ) were created. CAF procedures were performed using a split-full-split approach, with coronal advancement of the flap to 1 mm above the marked CEJ and stabilization according to the respective groups I–III. Marginal flap stability against pull-of forces (maximum tensile force) was measured with a universal material testing machine until the CEJ became visible.ResultsThe comparison between groups I–III demonstrated a significantly increased maximum tensile force for the TA (II) compared to the suture group (I) (p<0.001). A significantly increased maximum tensile force was found for the suture and TA (III) compared to the suture group (I) (p<0.001). There was also a significantly increased maximum tensile force in the suture and TA (III) compared to the TA group (II) (p<0.001).ConclusionThe results suggest that cyanoacrylate-based TA can increase marginal flap stability compared to sutures in CAF procedures.Clinical relevanceCyanoacrylate-based TA can be considered a useful and valuable adjunct to conventional suturing techniques in periodontal plastic surgery, especially in cases where high flap stability is required. The results of this ex-vivo study can only be transferred to the clinical situation with limitations. Clinical long-term follow-up data must be generated.

Influence of ternion of soft tissue attributes on gingival recession and root coverage outcome – A retrospective analysis

The independent influence of Keratinized Tissue Width (KTW) and Gingival Biotype (GB) on root coverage outcomes have been reported over the years. These parameters along with Recession Depth (RD) might act as a triad and assessing this ternion would be beneficial in determining prognosis and devising treatment plan for gingival recession. The aim of this retrospective analysis is to evaluate a possible association between KTW, GB and RD and their influence on Gingival Recession and root coverage outcome.45 isolated gingival recession defects were assessed for KTW (&amp;#60;2mm, &amp;#62;2mm), GB (thin vs thick) and RD (1-4mm). Primary outcome was to establish an association between the above-mentioned parameters. Secondary outcome was to find the percentage Root Coverage (%RC) obtained after coronally advanced flap procedure. To evaluate the relationship of KTW vs GB, GB vs RD and KTW vs RD, chi-square test was used. To analyse the intra-parametric correlation and the association between all three parameters, Pearson correlation test and ANOVA were carried out respectively.The Chi-square test results revealed a statistically significant association of p&amp;#60;0.03 for the relationship of KTW vs GB and GB vs RD and p&amp;#60;0.001 for KTW vs RD. Pearson correlation test showed a positive correlation between KTW and GB (.320), negative correlation between GB and RD (-.046), and KTW and RD (-.136). ANOVA showed a p-value of 0.041 inferring that any change in KTW and GB significantly influenced RD. Sites with &amp;#60;2mm KTW, thin GB and deeper RD, which can be referred to as negative ternion, exhibited 43.8% mean RC while sites with &amp;#62;2mm KTW, thick GB and shallow RD, which can be referred to as positive ternion had 94.7% mean RC. There is a definitive association between Keratinized Tissue Width, Gingival Biotype and Recession Depth. A ternion of these parameters greatly influences the outcome of root coverage procedures.

Advancing Surgical Education: A Comprehensive Systematic Review with Meta-Analysis and Novel Approach to Training Models for Local Skin Advancement Flaps.

Performing local skin flaps is a challenging task that requires cognitive and technical skills to design flaps with proper orientation to avoid distorting normal anatomy. Junior trainees need adequate exposure to gain confidence and expertise in such procedures. This article systematically reviews the literature's different local skin advancement flap training models and describes a new, easy-to-use training model. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane, Web of Science, and Google Scholar databases were searched from their inception until August 2022 for articles about local skin advancement flap training models. The meta-analysis results were pooled across the studies using a random-effects model and presented as a weighted mean difference with a 95% confidence interval (95% CI). Out of 773 reviewed articles, 18 were included in the systematic review, and four reported enough data to be included in the meta-analysis. Rhomboid and Z-plasty flaps were the most commonly taught flaps by training models. The most commonly used training models were synthetic-based, followed by animal-based models. The training models significantly increased the trainees' confidence and expertise regarding local skin flap procedures (p<0.00001) for both domains. Training models, per our reported data, significantly improve the trainees' confidence and expertise in performing local skin advancement flap procedures; continuous efforts in developing and establishing new, simple-to-use, and effective training models are strongly encouragedto further improvement of surgical education and enhance the trainees' surgical skills.

(002) Neuroproliferative Vestibulodynia as a Cause of Persistent Genital Arousal Disorder: A First-Ever Case Series

Abstract Introduction Persistent Genital Arousal Disorder (PGAD), a condition of unwanted, unremitting feelings of genital arousal, is associated with significant morbidity including catastrophizing, depression, anxiety, and/or suicidal ideation. There are multiple diverse triggers of PGAD that may originate in one or more of five regions in a patient: end organ, pelvis/perineum, cauda equina, spinal cord, and/or brain. Regarding the contributions to PGAD in the end-organ region, it is hypothesized that vestibulodynia may be a trigger for PGAD. The vestibule has unique sensory qualities, as this region receives sensory innervation from branches of both the somatic pudendal and visceral pelvic nerves. Objectives Neuroproliferative vestibulodynia is a disorder of excess deposition of mast cells with resultant excess c-afferent nociceptors in the vestibule. To the best of our knowledge, vestibulodynia, specifically neuroproliferative vestibulodynia, has not been reported in the literature as a cause of PGAD. The purpose of this study was to report on four women with lifelong PGAD suspected of having neuroproliferative vestibulodynia. Methods These women underwent: i) a detailed biopsychosocial assessment including sex therapy and diagnostic testing, evaluation of baseline PGAD intensity, vulvoscopy, cotton swab testing of the vestibule, PGAD intensity post-cotton swab test, and vestibular anesthesia testing (VAT); ii) treatment by complete vestibulectomy with vaginal advancement flap reconstruction; iii) staining of vestibular tissue with CD 117 (for mast cells) (Figure 1) and PGP 9.5 (for nerves) (Figure 2) and iv) measurement of clinical outcome with patient global impression of improvement. The VAT was performed with a topical anesthetic carefully applied to the vestibule between Hart’s line and the hymen. Complete anesthesia was assessed by cotton swab testing. Pre- and post-VAT intensity levels were compared. Results These patients had lifelong PGAD with a history of frequent masturbation at a very young age and feelings of catastrophizing, depression, anxiety, and/or suicidal ideation. Three patients had experienced sexual trauma, eating disorders, and had stressful relationships with family members. All four used various SSRI medications for depression/anxiety disorders and PGAD management from a young age. The youngest patient presented at 13 years with a presumptive diagnosis, primarily based on VAT, of neuroproliferative vestibulodynia. Surgery was delayed until she stopped growing at age 18. The other three presented at ages 20, 24, and 24. All four had full, although temporary, resolution of PGAD symptoms post-VAT. Each underwent a complete vestibulectomy with vaginal advancement flap procedure; the mean age at time of surgery was 22 +/− 3 years. Stained vestibular tissues showed in excess of 20 mast cells and nerves per high power field, consistent with neuroproliferative vestibulodynia. Curiously, post-operatively, none of the patients required the usual post-op opioid pain medications typical of patients undergoing vestibulectomy. While all four still experience mild PGAD symptoms when stressed, their PGAD symptoms are very much improved post-op with significant symptom resolution, with a mean follow-up of 11 months, range 4 – 26. Conclusions This is the first case series to document that neuroproliferative vestibulodynia is a treatable cause of PGAD, although more research is needed. Disclosure No.

DOP76 Comparison of healing of complex perianal Crohn′s disease fistulas by advancement flap and mesenchymal stem cell therapy

Abstract Background The combination of surgical approach and biologic treatment is the most successful approach to achieve healing of perianal Crohn′s disease (CD) fistulas. Alongside conventional surgical methods (advancememt flap AF), a new method of fistula closure - allogeneic mesenchymal stem cell (MSC) therapy found its way to clinical practice. Methods The aim of a single centre prospective observational study was to compare the healing results of complex perianal CD fistulas by advancement flap and mesenchymal stem cell therapy (by darvadstrosel). 119 consecutive CD patients with complex fistula (95 with anorectal and 24 anovaginal); treated by MSC-darvastrocel in between 2018 to 3/2022. All patients had a long term loose seton drainage and optimized conventional therapy with luminal remission confirmed by colonoscopy. Complete healing was clinically assessed (no visible external opening or a scar without secretion, no inflammation, no subsequent perianal surgery needed within 3 months post index surgery). Results AF group: Duration of luminal CD was 8,84 years (1-38) and perianal CD 4,74 years (0,5-17). Patients underwent 4,22 (1-23) previous perianal surgeries. The follow up was 11,47 months (0,5-48,9). Conservative therapy (biologics and immunosuppressants) was stable for 23,1 months (1-137). Patients did not suffer from anorectal stenosis or rectal inflammation. MSC group: (60 pp. 36F/24M): Duration of luminal CD was 13 years (2-43 years), of perianal CD 7 years (2-23 years). Number of previous perianal surgeries was 8 (3-25). Conservative therapy was stable for 19 months (1-120). Follow up was 12,5 months (5-34). 38,3% (23) of patients had anorectal stenosis, 38,3% patients underwent advancement flap procedure prior, and 62% suffered from chronic inflammation in rectum. Complete healing was achieved in 86,5 % pts in the AF group and 74.1% of those were healed even with vaginal fistulas. Conclusion There was no significant difference in the healing rate of both methods (p= 0,202). AF procedure could be beneficial in vaginal fistulas, where MSC therapy is contraindicated. MSC therapy is useful in the case of chronic changes of rectal mucosa, anorectal stenosis and the presence of 2 internal openings, where AF procedure is not performable. High success rate in both groups may be conditioned by good preparation of patients (multiple previous drainages) and stable luminal disease (stable conservative treatment).

Clinical Assessment of the Effects of Low-Level Laser Therapy on Coronally Advanced Flap Procedure in the Management of Isolated Gingival Recession

The aim of this randomized, controlled split-mouth clinical trial was to assess the effect of LLLT on wound healing after modified coronally advanced flap (MCAF) procedure for treatment of isolated recession-type defects. Fifteen patients with isolated bilaterally symmetrical gingival recessions (Miller’s Class I or Class II, or a combination of both) were enrolled in this study. After a modified, coronally advanced flap technique was implemented, a diode laser (810 nm) with a power of 120 mW irradiated the inner surface of the flap and the outer surface of the flap (low-level laser therapy—LLLT) after suturing for 5 min. This was repeated for the following four consecutive days. Descriptive statistics, a Kruskal–Wallis test and a Mann–Whitney test were performed to analyze the data. A p-value of less than 0.05 was considered statistically significant. The mean recession depth decreased from 3.33 ± 0.9 mm (baseline) to 0.2 ± 0.3 mm (3 months) and 0.4 ± 0.2 mm (6 months) in the test group. The mean recession width decreased from 3.8 ± 0.7 mm (baseline) to 0.2 ± 0.3 mm (3 months) and 0.5 ± 0.3 mm (6 months) in the test group. Due to minimal pain and discomfort, patient acceptability was quite high.

Comparison of Outcomes in Lateral Sphincterotomy and Anal Advancement Flap in the Treatment of Chronic Anal Fissure

Aim: For the comparison of outcomes in lateral sphincterotomy and anal advancement flap in the treatment of chronic anal fissure. Study Design: Randomized clinical trial Place and Duration of Study: Jinnah Hospital, Lahore from 1st April 2021 to 31st March 2022. Methodology: One hundred patients of age &gt;15 years were enrolled. Patients were defined as preoperative according to the definition of chronic anal fissure. Patients were divided into two groups, 50 patients in each group. The first group underwent lateral sphincterotomy while the second group was operated through anal advanced flap procedure. The wound infection was observed on day third as a post-operative protocol. Anal incontinence was determined post 3 months of surgery by any procedure conducted. Vaizey-scoring was used for determining anal incontinence. Results: The mean age of the patients was 39.5±4.7 years in lateral sphincterotomy group while it was 38.9±5.1 year in anal advanced flap. The highest number of cases was reported between the age group of 15-35 years within both operative procedures. The fissure healing was observed in 88% of lateral sphincterotomy group which lower than the observed values of 96% in anal advanced flap group. The follow up data also showed an increased case of infection and anal incontinence in lateral sphincterotomy group when compared with anal advanced flap cases. Conclusion: Anal advancement flap surgical method is considerably a better treatment method for the treatment of anal fissures. Key words: Pharmacological interventions, Anal fissures, Constipation, Chronic, Sphincterotomy

Hyaluronic Acid as an Adjunct to Coronally Advanced Flap Procedures for Gingival Recessions: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

Previous systematic reviews have reported that coronally advanced flap (CAF) + connective tissue graft (CTG) are the gold standard in root coverage procedures (RCP). Nevertheless, adjunctive treatment with hyaluronic acid (HA) has been proposed to aim at improving clinical outcomes and reducing patient morbidity. The aim of this systematic review and meta-analysis is to compare the use of HA as an adjunctive treatment to CAF procedures in Miller class I and II (recession type 1; RT1) gingival recession (GR) defects treatment with no adjunctive/other treatments. MEDLINE, The Cochrane Central Register of Controlled Trials, Web of Science, Scopus databases and gray literature were searched up to April 2022. The primary outcome variables were mean recession coverage (MRC) and reduction of the recession depth (RecRed). Weighted mean differences and 95% confidence intervals between treatments were estimated using a random-effect mode. From 264 titles identified, 3 RCTs reporting 90 GR defects in 60 patients were included. Overall analysis of MRC and RecRed were 0.27% (p = 0.01) and 0.40 mm (p = 0.45) in favor of CAF + HA compared to CAF alone/CAF + subepithelial connective tissue graft (SCTG), respectively, with a statistically significant difference only for MRC values. Nevertheless, due to the limited number and heterogeneity of the included studies, well-performed RCTs are needed to clarify a potential advantage of HA in RCPs in the future.

The Cleft Lift procedure for pilonidal disease renamed as a rotation and advancement flap procedure (RAF): Insights and technical tips for a successful outcome

IntroductionThe Cleft Lift procedure originally named by Bascom is a derivative of the Karydakis flap procedure for pilonidal sinus disease. The terminology and variations of the name have long confused surgeons and have limited its wide adoption. TechniqueThis technical paper deconstructs the confusing terminology, suggests simple steps for success, and proposes a more descriptive name for the asymmetric flap procedure which has the lowest reported recurrences for all surgical options for pilonidal disease. ResultsThe author has successfully performed the Cleft Lift procedure for pilonidal disease since 2000. In the last consecutive 757 patients treated over 12 years, only 6 patients have required a second operation. This cohort included 287 patients referred with recurrent disease or open wounds from prior pilonidal surgery. A new naming scheme is proposed that more accurately describes the operation. The proposed name is the pilonidal RAF procedure for rotation (around the anus) and advancement (across the natal cleft midline) flap . ConclusionsThe pilonidal RAF procedure is highly successful in treating pilonidal sinus disease with a very low need for additional surgery even in complex recurrent disease.

Comparative Evaluation of Coronally Advanced Flap Procedure in Conjunction with Amniotic Membrane Versus Coronally Advanced Flap with Platelet-Rich Fibrin Membrane in Patients with Miller's Class I and II Gingival Recession Defects

Abstract Introduction Amnion membrane (AM) and platelet-rich fibrin (PRF) have been used as Guided Tissue Regeneration (GTR)-based root coverage procedures in treatment of gingival recession. The objective of the present study was to comparatively evaluate the coronally advanced flap (CAF) procedure in conjunction with AM versus CAF with PRF in patients with Miller's class I and II gingival recession defects (GRD). Materials and Methods The sample size (Miller's Class I and Class II GRD) consisted of 24 patients who were stratified into two groups randomly (12 for each group). Group A patients were treated by CAF with PRF and Group B patients were treated by CAF with AM. Clinical parameters comprising plaque index (PI), gingival index (GI), pocket probing depth (PPD), clinical attachment level (CAL), and GRD were assessed at baseline, 3 months, and 6 months postoperatively. Results The percentage of root coverage obtained in the study groups was 62% and 77%, respectively, for Groups A and B. Statistically significant difference was obtained in the clinical parameters (PPD, CAL, and GRD) of Group B, which was treated by CAF with AM. Conclusion Significant difference was found between Group A (CAF+ PRF) and Group B (CAF+ AM) membrane treated sites in reduction of PPD, gain in clinical attachment level, reduction of GRD from baseline to 3 months and baseline to 6 months, with more significant results seen with Group B.

Treatment of cryptoglandular fistulas with the fistula tract laser closure (FiLaC™) method in comparison with standard methods: first results of a multicenter retrospective comparative study in the Netherlands.

Current surgical closure techniques for sphincter-sparing treatment of high cryptoglandular fistulas in the Netherlands include the mucosal advancement flap procedure (MAF) and ligation of the intersphincteric fistula tract (LIFT). A relatively novel treatment is the fistula tract laser closure (FiLaC™) method. The aim of this study was to investigate the differences in healing and recurrence rates between FiLaC™ and current standard practices. This multicenter retrospective cohort study included both primary and recurrent high cryptoglandular anorectal fistulas, treated with either FiLaC™ or standard methods (MAF or LIFT) between September 2015 and July 2020. Patients with extrasphincteric fistulas, Crohn's disease, multiple fistulas, age < 18years or missing data regarding healing time or recurrence were excluded. The primary outcomes were the clinical primary and secondary healing and recurrence rates. Primary healing was defined as a closed external opening without fluid discharge within 6months of treatment on examination, while secondary healing was the same endpoint after secondary treatment. Secondary outcomes included healing time and complaints. A total of 162 high fistulas from 3 Dutch hospitals were included. Ninety-nine high fistulas were treated with FiLaC™ and 63 with either MAF or LIFT. There were no significant differences between FiLaC™ and MAF/LIFT in terms of clinical healing (55.6% versus 58.7%, p = .601), secondary healing (70.0% versus 69.2%, p = .950) or recurrence rates (49.5% versus 54%, p = .420), respectively. Median follow-up duration was 7.1months in the FiLaC™ group (interquartile range [IQR] 4.1-14.4months) versus 6months in the control group (IQR 3.5-8.1months). FiLaC™ treatment of high anorectal fistulas does not appear to be inferior to MAF or LIFT. Based on these preliminary results, FiLaC™ can be considered as a worthwhile treatment option for high cryptoglandular fistulas. Prospective studies with a longer follow-up period and well-determined postoperative parameters such as complication rates, magnetic resonance imaging for confirmation of fistula healing, incontinence and quality of life are warranted.

Use of Xenogenic Collagen Matrices in Peri-Implant Soft Tissue Volume Augmentation: A Critical Review on the Current Evidence and New Technique Presentation.

Plastic peri-implant surgical procedures aiming to increase soft tissue volume around dental implants have long been well-described. These are represented by: pedicle soft tissue grafts (rotational flap procedures and advanced flap procedures) and free soft tissue grafts (epithelialized, also called free gingival graft (FGG), and non-epithelialized, also called, connective tissue graft (CTG) or a combination of both. To bypass the drawback connected with autologous grafts harvesting, xenogenic collagen matrices (XCM)s and collagen-based matrices derived from porcine dermis (PDXCM)s have been introduced, as an alternative, in plastic peri-implant procedures. Aim: This review is aimed to evaluate and to critically analyze the available evidence on the effectiveness of XCMs and PDXCMs in soft tissue volume augmentation around dental implants. Moreover, a clinical case with a new soft tissue grafting procedure technique (Guided Soft Tissue Regeneration, GSTR) is presented. Material and Methods: An electronic search was performed on the MEDLINE database, SCOPUS, Cochrane Library and Web of Science. The electronic search provided a total of 133 articles. One hundred and twenty-eight not meeting the inclusion criteria were excluded. Seven articles of human randomized clinical trials were selected. A total number of 108 patients were treated with CTG, and 110 patients with XCM. Results: in peri-implant soft tissue augmentation procedures, XCMs seem an effective alternative to CTGs, associated with lower patient morbidity and lower operative times.

A Modified Suturing Protocol for Tripod Stabilization of Connective Tissue Graft and Coronal Advancement of Tunnel Flap for Treatment of Isolated Gingival Recession.

Preserving a sufficient blood supply and maintaining wound stability during the healing phase are the most crucial factors for success in root coverage procedures. Selecting the surgical technique and suturing protocol used to achieve these goals is therefore indispensable for predictable treatment outcomes. Tunneling flap procedures have evolved as a technical advancement in periodontal plastic surgery, particularly focusing on improving the vascular supply at the surgical site. Along with the development of newer flap designs for recession coverage, several suturing protocols for flap stability have been described. This paper illustrates the use of a modified suturing method for soft tissue graft stabilization in a coronally advanced tunnel flap procedure for the treatment of isolated gingival recession. It allows precise three-dimensional positioning and tripod stabilization of the graft in the tunnel as an independent step, differing from previously described techniques. A modified tissue-supported vertical mattress suture is then placed for coronal advancement and improved wound adaptation. The present authors have found that the proposed suturing protocol achieves successful integration of graft, maximum root coverage, excellent esthetic results, and limited postoperative morbidity. The suturing technique is described in detail with schematic illustrations and clinical cases, and its advantages and potential limitations are discussed.

A Novel Approach of Using Free Buccal Pad of Fat Combined With Modified Coronally Advanced Flap in Treating Localized Gingival Recession: A Technical Note

Background: Various surgical techniques have been proposed for the treatment of gingival recession (GR) in the form of either pedicled or free grafts. The free buccal pad of fat is an easy technique for harvesting a free graft for regenerative purposes and is currently gaining popularity and attention in the field of periodontology. The buccal fat pad is a fat tissue that is used as a novel source of mesenchymal cells (MSC). The aim of the current case report was to assess the efficacy of using a free buccal pad of fat in combination with a modified coronally advanced flap procedure (CAF) in treating localized gingival recession. Methods: A healthy 33-year-old male presented with gingival recession type 1 (RT1) affecting his upper right canine and was suffering from continuous sensitivity. Phase I therapy was performed six weeks before surgery. A modified CAF was raised to expose the recipient site and a free buccal fat pad graft (FBFP) was harvested and sutured in place. Results: The color of the tissues was nearly homogeneous two weeks following the surgical procedure. Maximum root coverage was 66.6% achieved at one month. However, a gradual relapse of 25% was noticed through the follow-up at three and six months postoperatively. Conclusion: The use of the FBFP in combination with a modified CAF can be excluded as a successful regenerative method for treating GR. However, further studies and randomized controlled clinical trials are recommended to confirm the effectiveness of this technique for the treatment of GR in the long term.

Thickness of keratinized tissue as an indicator of success in connective tissue operations

To investigate how keratinized tissue thickness have an impact on clinical outcome of the subepithelial connective tissue graft with coronally advanced flap procedure in Miller Class I defects which previously grouped as having either “thick” or “thin” phenotypes. Recession defects were treated with the same surgical approach in both “thick” (n=18), “thin” (n=19) groups. Plaque index (PI), gingival index (GI), recession depth (RD), recession width (RW) and width of keratinized tissue (WKT) were recorded on baseline, 6. week, 3., 6., 9., and 12. months respectively. Probing depth (PD), clinical attachment level (CAL), thickness of keratinized tissue (TKT) of defects were recorded on baseline, 3., 6., 9. and 12. months. The percentage of root coverage was measured on 3., 6. and 12. months. Palatal mucosa thickness measurements were repeated on 6. and 12. months. Compared to baseline, there was statistically significant decrease in CAL, RD and RW; and a significant increase in PD, WKT and TKT in both groups (p<0,05). TKT was the highest on 3. month, decreased till 9. month and became stable then. According to phenotypes, only defects of thin group's baseline TKT was positively correlated with the amount of thin group's root coverage. Within the results of this study success of root coverage in connective tissue operations is influenced by a threshold thickness of flap in the operation area only in thin phenotype group.

Outcomes of Fissurectomy and Advancement Flap in Management of Chronic Anal Fissure

Chronic anal fissure is a painful linear tear in the mucocutaneous junction of the distal part of the analcanal and involves the full thickness of mucosa, causing severe pain may last even hours after defecation.Usually,it occurs along the midline either anterior or posterior,if it presents off the midline, other pathologymight be associated with. Unhealed anal fissure after 6-8 weeks is defined chronic, with the presence of othercriteria,it unlikely heals with medical treatment, and surgery is mandatory after pharmacological treatmentfailure. Lateral internal sphincterotomy had high healing rate, but unfortunately, with risk of incontinence.Fissurectomywithcomplete excision of the fissure keeping the internal anal sphincter intact,and anadvancement flap of well vascularized tissue is transferred to cover the base of fissure and improve healing.This study mainly aiming to analyze the outcome of fissurectomy with advancement flap procedure in thetreatment of chronic anal fissure and highlight its advantage in terms of healing rate and complicationsespecially anal incontinence.During a period of about 5 years 345 patients (260 males and 85 females), havebeen included in this study and were diagnosed as cases of chronic anal fissure. After administration of localanesthetic,fissurectomywith advanced flap was performed. Patients had been followed up regularly for 6-24months. Data collected and statistical analysesby using SPSS. About 75% ofpatients were males while, 25% were females, their ages were between 20-59 year, most of the patients werein thirties, nevertheless most of the females were in twenties.Mean time for wound healing was 10 days.Whilst complete fissure healing process lasting approximately one month. About 11.9% of the patients takemore than one month to complete healing process. Healing rate was 100% after the follow up period of 6-24months. Recurrence developed only in 2% of the patients. None of the patients developed incontinence,anal stenosis, key hole deformity, necrosis or urine retention. From this study concluded Fissurectomy withadvancement flap in the treatment of chronic anal fissure is cost effective procedure, can be done under LAwith least time-off work, with low complication, low recurrence,and no incontinence.

Anal Advancement Flap versus Lateral Internal Sphenecterotomy for Treatment of Chronic Anal Fissure with High-pressure Anal Canal.

Background: Anal fissure, is an ulcer-like, longitudinal tear in the anal canal squamous epithelium . Nowadays the standard treatment for anal fissure is Lateral internal sphincterotomy (LIS). Anal advancement flap (AAF) procedure is accomplished by transfer of healthy well-vascularized tissue onto the base of the fissure combined with fissurectomy, this improves wound healing and decrease anal stenosis risk.Methods: Forty patients with chronic anal fissure and hypertonic anal sphincter detected by anal Manometry. Allocated randomly into two groups .Lateral internal sphincterotomy group (A) and anal advancement flap group (B) . Objectives : the aim of this study is to compare the outcome of lateral internal sphincterotomy and anal advancement flap in management of chronic anal fissure.Results: A total number of 40 cases (20 cases in each groups). Manometry results showed no significant difference in the preoperative mean resting anal pressure was observed among the two groups. The Mean ± SD for group A was 104.3900 ± 12.93917 and for group B was 107.3900 ± 12.30241 as shown in. the operative time in Group A ranged from 8- 12 minutes with a mean operative time 10.0 ± 1.3 minutes. In Group B, the operative time ranged from 25-41 minutes with a mean operative time 32.0 ± 6.01752 minutes. As regard hospital stay in this study, no difference was found between both groups.Conclusions: In conclusion, anal advancement flap is a comparable procedure for LIS for treatment of chronic anal fissure in hypertonic anal canal.