Biologically guided flap stability:

1. Keratinized tissue height required for the CAF.

2. Critical factors in CAF to obtain CRC.
3. Split-full-split flap modulation.
4. The surgical technique of the CAF in both the test group ( split-full-
split) and the control group ( split ).
5. Clinical parameters of both groups at the baseline and 1 year after
the surgery.
6. The role of the periosteum retention in the split-full-split of CAF on:
a) flap thickness and stability.
B) wound-rupturing forces.
C) early phase of healing and blood clot.

7. Patient’s centered outcomes in test group Vs. control group.

8. Conclusions.

9. at least a 2 mm of keratinized tissue apical to the recession defect

is required for CAF.

2. Critical factors in CAF to obtain CRC:

a. Flap positioning coronal to CEJ.
b. Tension free flap design.
C. Flap thickness which found to be influencing the clinical outcomes
of the CAF.

3. Split-full-split flap modulation on flap thickness ( produced by

inclusion of the periosteum in the central area ) increases the flap
thickness in portion of the flap that will cover the previously
exposed avascular toot surface >> better stability of the flap.
 4. Surgical technique of the CAF :

a) Trapezoidal flap is made by making 2 horizontal incisions and 2

vertical releasing incisions.
B) flap elevation in split-full split :
The surgical papillae created by the horizontal incisions are elevated
with split thickness while the central part apical to the recession is fully
elevated using small Periosteal elevator to expose up to 3-4 mm of bone
apical to bone dehiscence.
Flap elevation in completely split technique:
The whole flap is partially elevated using the blade (15c ) parallel to the
external mucosal surface.

C) In both techniques , the incision is terminated apically to the

mucogingival line by means of split thickness elevation ( split ) to free
flap from muscle tension.

D) when the margin of the flap reached passively 1mm coronal to CEJ of
the affected tooth > the coronal mobilization is considered adequate.
# de-epithelialization of the anatomical papillae to provide the adequate
connective tissue bed ( blood supply ) for the future soft tissue margin
( surgical papillae ).

E) mechanical preparation of only the portion of the root surface relative

to loss of clinical attachment ( in probable sulcus ) using curettes then
application of EDTA for 2 minutes then rinse.

F) Suturing:
1. Start with simple interrupted sutures from the most apical
extension of the vertical incisions and proceed coronally > suture
from the flap margin to the adjacent buccal soft tissue ( in apico-
coronal direction).
2. Sling suture of the flap margin for more stability of the surgical
papillae on the CT bed and precise adaptation of the flap margin
over the convexity of the crown.
 5. clinical parameters after 1year:
Periosteum retention( split-full-split) / test group provides superior
clinical results in terms of complete root coverage ( CRC ) and root
coverage ( RC ) as well as reduction of hypersensitivity and post-
surgical discomfort.
Frequency to obtain CRC in test group was twice as high as in
control group ( completely split)
Significant association between CRC and the thickness of the flap
resulted after elevation.

6. The role of periosteum retention in the Split-full-split of CAF

( test group):

A) flap thickness and stability:

The periosteum included in the flap maintained the entire structure of
the Sulcular area that will cover the avascular root surface >> better flap
stability and consequent better clinical result.

B) the flap thickness also have a role in absorbing/ deflecting any

external interference of the flap ( wound-rupturing forces ) that could be
transmitted to the fibrin clot at the root surface.

C) role in wound healing and clot maturation:

Clot stability and its adhesion on root surface positively influence
the formation of new CT attachment instead of long junctional
epithelium.
So, due to the intrinsic stiffness of the periosteum , greater flap
stability will be achieved.
The periosteum - with its high vascularization- provides an
important source of the endothelial cells ( fibroblasts and
macrophages ) and growth factors.
The availability of these cells in the periodontal wound can
accelerate the phase of new tissue attachment and speed up the
transition of catabolic phase to anabolic phase >> maturation and
stabilization of blood clot.
The periosteum reduces the space for a better blood clot stability
and maturation ( acting as if a connective tissue graft is used with
CAF ).

7. Patient centered outcomes in test Vs. control groups:

Some patients of the control group reported higher discomfort as twice
as high than in test group after 1st week of healing due to >>
Extensive partial thickness elevation in control group resulted in greater
amount of blood clot >> greater difficulty to be reabsorbed in the early
phase of healing.

8. Conclusions: