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PERIODONTAL SURGERY
Sem ilunar Coronally Repositioned Flap
A Minimally Invasive Technique for Predictable
Management of Gingival Recession
Abdul Ahad, M.D.S.; Shazra Tasneem, B.D.S.; Arundeep Kaur Lamba, M.D.S.
ABSTRACT
Gingival recession in anterior teeth not only catches
the eyes of a dentist, it also is of concern to the patient.
The goal of the periodontist in such cases is not limited
to relieving the offending condition, but also to achiev­
ing optimum aesthetics. While planning the treatment
of gingival recession, it is important to consider the
predictability of various techniques. This report de­
scribes a successful case of semilunar coronally repo­
sitioned flap in Miller’s Class I recession defects on
maxillary central incisors.
Gingival recession is defined as the migration of gingiva apically
with resultant root exposure. It stems from loss of periodontal
connective tissue fibers along the root surface. There could be
multiple factors responsible for recession, like inflammatory peri­
odontal disease, or a local irritating factor, like chronic trauma.
Other causes could be malaligned teeth, a prominent root con­
vexity, abnormal frenal pull, or toothbrush-induced trauma.1
Factors like bone dehiscence and insufficient width of keratin­
30 J U N E /J U L Y 2 0 1 8 ■ The New York State Dental Journal
ized gingiva may also predispose a person to gingival recession.2
Gingival recession commonly results in dentinal hypersensitivity,
root caries and noticeably poor aesthetic appearance.3
P.D. Miller classified gingival recession into Class I, II, III and
IV, based on the extent of recession relative to mucogingival junc­
tion and interdental bone or soft tissue loss.4 Depending on the
severity of recession, there is a wide range of treatment modali­
ties that have been used for root coverage. These can be classified
broadly into two categories. Free grafts like free gingival graft and
free connective tissue grafts have one major disadvantage. They
involve a donor site, thus increasing patient morbidity. Pedicled
flaps like coronally repositioned flap and lateral pedicled flap have
better patient acceptance, since no additional donor site is in­
volved.5 Semilunar coronally repositioned flap was originally de­
scribed by Tarnow in 1986 for minimally invasive and predictable
management of gingival recession.6
Case Report
A 45-year-old female reported with the chief complaint of reced­
ing gums and sensitivity to cold in her upper front teeth that
had been present for the past three months. There was no other
relevant medical or dental history. She was found to have main-
 T A B LE 1 . P r e - a n d P o s t o p e r a t i v e
M e a s u r e m e n t o f C lin i c a l P a r a m e t e r s

tained good oral hygiene. Miller’s Class I gingival recession in­ Teeth
48 #9
N um bers
volving both maxillary central incisors was observed. Gingival
biotype was thick with adequate width of keratinized gingiva (Fig­ C linical 3 months 3 months
Preoperative Preoperative
Parameters Postoperative Postoperative
ures 1-3). The depth of maxillary labial vestibule was also ad­
Plaque Index 0 .5 0 .5 0 .5 0 .2 5
equate. After Phase I periodontal therapy, a semilunar coronally
repositioned flap was planned to cover the denuded root, all of Bleeding on
Absent Absent Absent Absent
Probing
which was found to be within normal limits. Clinical parameters
of involved teeth, including plaque index, bleeding on probing, Probing
2 mm 1 mm 2 mm 1 mm
Depth
probing depth, clinical attachm ent level, recession depth and
recession width were recorded (Table 1). C linical
Attachment 4 mm 1 mm 4 mm 1 mm
Level
Surgical Technique
Recession
After local infiltration of 2% lidocaine (epinephrine 1:80000), 2 mm 0 mm 2 mm 0 mm
Depth
separate semilunar incisions were made on the labial aspect of Recession
3 mm 0 mm 3 .5 mm 0 mm
both maxillary central incisors, parallel to the free gingival mar­ W id th
gin using a No. 15 blade. Both incisions started from the middle
of the interdental papillae, between the central and lateral in­
cisors, and were joined in the midline. A uniform distance of
2 mm from the gingival margin was maintained through the
extent of incision, to ensure optimal blood supply to the re­ Postoperative Protocol
positioned tissue. This was followed by two separate sulcular The patient was asked to eat a soft diet and to avoid biting using
incisions extending from the mesiolabial line angle to the disto- her front teeth for two weeks. She was also instructed to avoid
labial line angle of each central incisor, sparing the interdental brushing in the operated area for two weeks. Chlorhexidine mouth
papillae. Both incisions were joined by sharp dissection using a rinse (0.2%) and ibuprofen 400 mg tablets were prescribed twice
No. 15 blade (Figure 4). daily for one week.
Semilunar partial thickness flaps, still connected at the in­ Postoperative healing was uneventful. The periodontal dress­
terdental papilla, were then mobilized coronally. Repositioned tis­ ing was removed two weeks after surgery. The patient was then
sue was passively adapted on the denuded root surface (Figure 5). instructed to gently brush the operated area using a roll technique
A moist gauze was used to hold the repositioned tissue against in the coronal direction only for the next month.
both central incisors for 10 minutes. This step facilitated forma­
tion of a uniform thin clot and stabilization of the repositioned Treatment Outcome
tissue. The surgical site was carefully covered with periodontal Complete coverage of the denuded root surface was observed
dressing (COE-PAI<™, GC America Inc., IL) (Figure 6). No sutures three weeks after surgery. After three months of follow-up, 100%
were used in this procedure. coverage was still maintained on both central incisors. Excellent

Figure 1. Preoperative view. Figures 2, 3. M easurem ent of recession depth.

The New York State Dental Journal • J U N E / J U L Y 2 0 1 8 31

Figure 4. Sulcular and semilunar incisions joined by No. 15 blade.
color match with adjacent tissue was also observed (Figure 7).
Clinical parameters recorded at the three-month postsurgical
visit are presented in Table 1.
Discussion
Gingival recession is as serious an aesthetic problem as it is a
periodontal concern. There are many possible ways to take care
of a gingival defect, but in choosing among those procedures,
certain things have to be considered in order to predict a success­
ful outcome. There are a set of criteria for calling a root coverage
procedure successful. These include:2
A. Gingival margin should be on the CE] in Miller’s Class I and
Class II recession.
B. Probing depth should not exceed 2 mm.
C. Bleeding on probing should be absent.
D. Color should match adjacent tissue.
The prognosis for root coverage surgeries depends to a large
extent on the amount of gingival recession. For instance, suc­
cess rates for Class I and Class II recession defects are higher and
may boast of 100% success, whereas Class III recession results in
a 50% to 70% success rate, and Class IV shows a meager 0% to
10% success rate.2
Figure 6. Periodontal dressing placed over surgical site.
32 JU N E /JU L Y 2 0 1 8 • The New York State Dental Journal
Figure 5. Partial thickness flop repositioned coronally.
Semilunar coronally repositioned flap is indicated when there
is adequate width of attached gingiva, accompanied by minimal
recession. The procedure involves placing a semilunar incision
parallel to the gingival margin at an optimum distance from the
gingival margin to maintain the vascularity.6 It is a simple pro­
cedure with minimal trauma to the surgical site. Even sutures
are not required, as the clot formed by applying the moist gauze
for 10 minutes facilitates adequate stabilization of the flap. Some
clinicians have also discouraged use of a periodontal pack, as it
may dislodge the tissue.7 However, we found it advantageous, as
a carefully placed pack will protect the surgical site from any kind
of physical, chemical and thermal trauma.
The case presented here could have been managed by vari­
ous other surgical methods to achieve similar results. However,
no other technique is less invasive. A coronally advanced flap re­
quires involvement of a larger area, apart from resulting in re­
duced vestibular depth. A tunnel technique with free connective
tissue graft would require a donor site on the palate. In addition
to patient morbidity, successful outcome with such techniques
also demands more time and clinical expertise.
Given its advantages of being simple, minimally invasive,
maintenance of the initial vestibular depth, flap design that allows
Figure 7. Three-month postoperative view.
for better vascularity and repositioning, absence of scarring, which
may result from vertical incisions, and minimal postop discomfort,
as there is no donor site, this technique appears to be highly useful
in maxillary teeth where gravity reinforces the coronal reposition­
ing of the flap.6,8 The fact that it does not require advanced tech­
nique or instruments or years of experience and expertise, makes
this procedure easy and feasible in even a most basic dental setup.
Conclusion
The case presented here shows that semilunar coronally reposi­
tioned flap remains a periodontal plastic surgical technique of
choice when encountering Miller’s Class I gingival recession de­
fects in maxillary anterior teeth. Case selection, if done properly
and keeping in mind the indications of the procedure, provides
good results, which also meet the patient’s expectations. A
Queries about this article can be sent to Dr. Ahad at aahad.amu@gmail.com.
3. Pini Prato GP, Clauser C, Tonetti MS, Cortellini P. Guided tissue regeneration in gingival
recessions. Periodontol 2000 1995;11:49-57.
4. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent
1985;5:8-13.
5. Wennstrom JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.
6. Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol 1986;13:182-5.
7. Sorrentino JM, Tarnow DP. The semilunar coronally repositioned flap combined with a
frenectomy to obtain root coverage over the maxillary central incisors. J Periodontol 2009;
80:1013-7.
8. Pai BSJ, Rajan SA, Padma R, Suragimath G, Annaji S, Kamath KV. Modified semilunar coro­
nally advanced flap: a case series. J Ind Soc Periodontol 2013;17:124-7.
9. Baker P, Spedding C. The aetiology of gingival recession. Dent Update 2002;29:59-62.
Abdul Ahad, M .D .S ., is senior resident, Deportment of Periodontics, Dr. Ziouddin Ahmad Dentol
College, Faculty of Medicine, Aligarh Muslim University, Aligarh, India.
S hazra Tasneem , B.D .S., is a postgraduate student, Department of Periodontics, Dr. Ziauddin
Ahmad Dental College, Faculty of Medicine, Aligarh Muslim University, Aligarh, India.
A rundeep K aur Lam ba, M .D .S ., is professor and head, Department of Periodontics, Maulana
Azad Institute of Dental Sciences, New Delhi, India.

REFERENCES
1. Peeran SW, Thiruneervannan M, Mugrabi MH. Semilunar coronally repositioned flap. Arch
Int Surg 2013;3:166-8.
2. Shreya D, Jain SJ, Gupta SG, Muglikar SD, Pathan DS. Semilunar coronally advanced flap
technique for root coverage in adjacent teeth in the anterior esthetic zone—a case report.
Austin J Dent 2015;2:1018.

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