Clin Adv Periodontics - 2022 - Kashani - Incision Free Coronally Advanced Flap With Subepithelial Connective Tissue Graft

Received: 17 September 2020 Accepted: 23 January 2022
DOI: 10.1002/cap.10195
C A S E S T U DY
Incision-free, coronally advanced flap with subepithelial

connective tissue graft placed by the molar or canine access
(MOCA) technique: 13 case series
Hooshang Kashani1 Manali V. Vora2,5 Ryutaro Kuraji3,4 Hoorshad Fathi-Kelly1

Trung Nguyen1 Beniel Tamraz1 Christine Tran1 Yvonne L. Kapila1
1
Department of Orofacial Sciences, University of
California San Francisco, School of Dentistry, San Abstract
Francisco, California, USA Introduction: Root coverage procedures are not always predictable, and
2
Center for Tobacco Control, Research and outcomes depend on several factors. This technique provides a predictable
Education, University of California, San Francisco, alternative to managing facial gingival recessions.
California, USA
Case Series: A new grafting technique is introduced that requires no incisions
3
Department of Life Science Dentistry, The
Nippon Dental University, Tokyo, Japan
at the recipient site, thereby preserving the integrity of the local blood supply
4
to optimize the healing process. The graft is placed through the gingival sulcus
Department of Periodontology, The Nippon
Dental University School of Life Dentistry, Tokyo,
via a molar or canine access (MOCA) approach, and there is minimal tension on
Japan the coronally advanced flap through use of suspension sutures. Thirteen non-
5
Division of Periodontology, University of smoking patients, between the ages of 27 and 57, with Cairo RT1 facial recession
Connecticut, School of Dental Medicine, were studied, with a follow-up period of 1–60 weeks. This paper explains the
Farmington, Connecticut, USA step-by-step technique and highlights 13 cases.
Conclusion: Complete root coverage was achieved in all 13 cases, although
Correspondence
Yvonne L. Kapila, Department of Orofacial
one case showed initial altered healing. While MOCA is technique sensitive, it
Sciences, University of California San Francisco, provides optimal root coverage results. With no incisions at the recipient site,
School of Dentistry, 513 Parnassus Ave., S616C, there is no uneven texture or scar formation, and healing proceeds with minimal
Box 0422, San Francisco, CA 94143, USA.
Email: Yvonne.Kapila@ucsf.edu
interruption.
KEYWORDS
Gingival recession, plastic surgery, tissue grafts, tissue transplantation
Why is this case series new information?

∙ MOCA is a unique approach to introduce grafts into non-incised sites of
recession that can be one, two, or three teeth away at molars or canines.
∙ Non-incised approach minimizes interruption to blood supply.
∙ Coronally advanced flaps are secured in place with composite-fastened suspen-
sion sutures for tension-free flap closure.
What are the keys to successful management of these cases?
∙ Good quality and quantity of connective tissue graft
∙ Early diagnosis and treatment of recession
∙ Expert surgical technique
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Clinical Advances in Periodontics published by Wiley Periodicals LLC on behalf of American Academy of Periodontology.
Clin Adv Periodontics. 2023;13:11–20. wileyonlinelibrary.com/journal/cap 11

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12 KASHANI ET AL.
What are the key limitations to the success of these cases?

∙ The quality of the donor site is variable among patients.
∙ A technique-sensitive approach
∙ Advanced recession might warrant a second surgery.
BACKGROUND no incisions at the recipient site and thereby preserves

the integrity of the local blood supply, which optimizes
The dental literature is replete with articles on various the healing process. This approach also facilitates graft
grafting techniques for root coverage. While these tech- placement via the use of the gingival sulcus of an adjacent
niques have been constantly modified and improved, the tooth, and places minimal tension on the flap by using
amount of root coverage varies substantially between a suspension suturing technique. Specifically, the tech-
cases. Among existing techniques, a coronally advanced nique relies on placing the graft via either molar or canine
flap using the patient’s own connective tissue provides access, hereby known as the “MOCA technique.” Molar
maximum root coverage and represents the gold standard and canine gingival margin areas are large, and thereby
of grafting.1 However, even with this technique, complete are easy entry points for introduction of more delicate
root coverage is not always possible. and friable graft tissues into sites of recession. This paper
The unpredictable outcome of root coverage surgeries explains the technique step by step and highlights its use in
are a function of several variables, including clinical attach- 13 cases.
ment loss, defect dimensions, periodontal phenotype,
and tooth malpositioning. Defect width, height, shape,
and characteristics are important parameters to consider. CLINICAL PRESENTATION
Several classification systems have been developed to cat-
egorize recession defect characteristics to help determine Thirteen patients, between the ages of 27 and 57, pre-
potential outcomes of treatment.2–5 Anatomic factors, sented to a private practice (San Francisco and Palo Alto,
including variations in the soft tissue of the mucogingival CA, USA) from January 2014 to December 2021 (Table 1). All
defects, health and thickness of the remaining gingiva, 13 cases were non-smokers, five were male and eight were
the amount of keratinized gingiva, and the depth of the female. The cases treated had Cairo RT1 gingival recession
vestibular fornix, can affect the outcome.6–8 Adequate on either anterior or posterior teeth. A presurgical evalu-
length, width, and thickness of the donor tissue are crucial ation, detailed oral exam, oral prophylaxis or scaling, and
for maximum root coverage.1 It is important to choose a root planing were completed on each patient, and carious
donor site with sufficient tissue, like the hard palate, maxil-
lary tuberosity,9 or edentulous ridges (see Supplementary
Figure S1 in online Clinical Advances in Periodontics). A TA B L E 1 Patient demographics and defect measurements
posterior palatal graft can contain glandular tissue, which Pre-op Post-op
should be dissected and excluded from the graft. Other- gingival gingival Root
wise, it may compromise graft take by blocking diffusion recession recession coverage
Case Age, depth depth obtained
of plasmatic fluids from the recipient site.10 The surgeon’s no. sex Tooth # (mm) (mm) (%)
skills, patient compliance, and patient factors that may
1 38 F 9 4 0 100
affect healing processes, like smoking, are also factors that
impact root coverage.11,12 A critical factor in obtaining 2 39 M 6 4 0 100
coverage is the condition of the flap. 3 33 M 11 3.5 0 100
Incision-less techniques for root coverage include the 4 55 M 11 4 0 100
tunneling13 and vestibular incision subperiosteal tunnel 5 38 M 6 5 0 100
access (VISTA).14 In the tunneling technique, incisions are 6 28 F 27 3.5 0 100
minimized by utilizing sulcular incisions for creating a tun-
7 31 F 21, 22 3, 5 0 100
nel. However, this intrasulcular approach limits access for
both graft placement and flap advancement and increases 8 43 F 11 4 0 100
the risk of traumatizing the sulcular tissue, and therefore, 9 51 M 5, 6, 7 3, 4.5, 2 0, 0, 0 100
increases the risk of an unfavorable outcome. The tech- 10 36 F 11 5 0 100
nique discussed in this paper overcomes the limitations 11 55 F 11 3 0 100
of previous tunneling and VISTA techniques by allowing 12 27 F 6 3 0 100
an incision-less approach with remote access points if
13 57 F 30 4 0 100
required. We introduce a grafting technique that requires
CLINICAL ADVANCES IN PERIODONTICS 13
F I G U R E 1 Molar or canine access (MOCA) technique, molar approach. (1a) A half Hollenbach is used to prepare the bed in an apico-coronal
direction by puncturing the mucosa above the apex of the adjacent teeth. (1b) The puncture is performed at the muco-buccal fold and, using the same
instrument, the entire area including the gingival margin is lifted in a coronal direction. (1c) The adjacent papillae are lifted in a corono-lingual direction
into the interproximal space using excavators. (1d) The graft is sutured at one end and introduced through the gingival margin of the molar and gently
maneuvered over to the site of the recession. (1e) The graft is further adjusted in its intended position, and sutures are placed on the other end of the
graft in a sling fashion toward the lingual. (1f ) The graft is sutured in place with a sling suture on the lingual. (1g) The buccal flap is coronally advanced
and secured in place with a composite button on the buccal aspect of the tooth.
lesions, if any, were treated before soft-tissue augmenta- incision leads to a split thickness type flap and the depth
tion. Realistic expectations were established, and verbal of this incision develops the thickness of the graft. The
consent was obtained for the proposed procedure. second incision is at the same location and length as the
first, except that it is placed as perpendicular to the alveolar
process as possible. The third incision, a beveled incision,
CASE MANAGEMENT is longer than the width of the graft and it is placed on
the anterior border of the graft, based on the needed graft
The amount of gingival recession depth from the cemento- length. The fourth incision, exactly like the third incision,
enamel junction (CEJ) was determined and noted for each is made to separate out the posterior part of the graft.
case (Table 1).3 For the molar approach (molar entry point The graft is then separated from the alveolar process very
for graft), a half Hollenbach is used to access and prepare gently using a medium-size curette or periosteal elevator.
the bed of an adjacent recession defect (i.e., premolar) in The concave surface of these instruments is facing the
an apico-coronal direction using a full thickness approach alveolar bone to avoid mechanical stress on the graft.
(Figure 1). For the canine approach, the same instrument The fifth incision releases the graft from its base. The
is used to gain access from the gingival margin of the corono-apical orientation of the graft is noted so that the
canine and the entire area is released and lifted in a coronal cervical part of the graft lays at the CEJ of the recession
direction (Figure 2). Next, the adjacent papillae are lifted area.
in a corono-lingual direction into the interproximal space For grafts placed on maxillary teeth, molar access is used
using excavators. During papillary lifting, extreme caution to introduce the graft into the recession area involving the
should be exercised in avoiding papillae separation, partic- molars, premolars, or canine areas. For recession involving
ularly when papillae are thin. Bed preparation is considered the central or lateral incisors and when canine access is
complete when the recipient site’s gingival margin is eas- not possible, the graft is introduced through the upper
ily coronally advanced beyond the CEJ in a tension-free central incisors. For the mandibular teeth, molar, premolar,
fashion. or canine access is used to introduce the graft into the
For harvesting the graft, a small surgical blade is used, recession area that could be found on canines, premolars,
and mapping is performed by sounding with a periodontal and incisors. Although the title of this technique is termed
probe. The size of the graft is measured on the recipient “MOCA,” the graft can be introduced at other sites with
site. The palate is outlined prior to the harvesting process, wide entry access points; however, molar and canine entry
marking out incisions as detailed below (see Supplemen- points are preferred due their wide entry access.
tary Figure S2 in online Clinical Advances in Periodontics). Using a 4.0 chromic gut suture, the mesial and distal
The first incision is placed 3 mm apical to the gingival corner of the graft is sutured in a sling fashion without
margin, and it follows the contour of the palate in an tying the suture. The graft is gently placed and positioned
anterior–posterior and apical direction (see Figure S2). This on the recipient site by entering the sulcus. The graft is
14 KASHANI ET AL.
F I G U R E 2 Molar or canine access (MOCA) technique, canine approach. (2a) A half Hollenbach is used to prepare the bed in a corono-apical direction
with access obtained through the gingival margin of the canine. (2b) The graft is sutured at one end, and sutures are introduced through the gingival
margin of the canine. (2c) The sutured graft is gently introduced through the gingival margin of the canine and maneuvered over to the site of the
recession. (2d) The graft is further adjusted in its intended position, and sutures are placed on the other end of the graft in a sling fashion toward the
lingual. (2e) The graft is sutured in place with a sling suture on the lingual. (2f ) The buccal flap is coronally advanced and secured in place with a
composite button on the buccal aspect of the tooth.
F I G U R E 3 Case 1. (3a) Recession with rolled or festooned gingiva (McCall’s festoon) of #9. (3b) Pre-insertion of the graft; even though the graft looks
large, there were no difficulties in submerging the graft through the sulcus area of #9. (3c) The mesial and distal of the graft is sutured with a sling suture,
and the gingival margin is advanced coronally and secured with a suspending or hanging suture embedded in composite. (3d) The 3-week post-op
healing. (3e) Six-month post-op shows complete root coverage.
F I G U R E 4 Case 2. (4a) Presurgical view of #6; the etiological factors include position of the canine and aggressive toothbrushing. (4b) One-week
post treatment. (4c) Three weeks post treatment; the denuded root has been covered. (4d) Three months post treatment, the recipient site is healed, and
the results show complete root coverage.
F I G U R E 5 Case 3. (5a) There is severe erosion on the buccal of #11. Comparing the position of #11 with #12 reveals the prominent position of #11,
which predisposed it to recession. (5b) Immediately post operation, the sutured flap had a whitish-pink hue due to retraction tension of the lip; however,
without retraction there was no tension. (5c) Three weeks later, it is notable that oral hygiene needs improvement. (5d) Six months post treatment.
16 KASHANI ET AL.
F I G U R E 6 Case 4. (6a) Canine #11 in prominent position with significant recession. There was no enamel erosion. (6b) Eight weeks post operation
showing complete root coverage; Figure 1B shows the graft tissue that was used in this case.
F I G U R E 7 Case 5. (7a) The discolored portion of the root on #6 was hard (not decayed) and was conditioned prior to grafting. (7b) Three months
post treatment reveals complete root coverage, and it is notable that oral hygiene needs improvement.
F I G U R E 8 Case 6. (8a) Pre-op showing lack of keratinized gingiva on the buccal of #27. (8b) Two weeks post op; exposed portion of the graft may be
due to high content of elastic fibers as in the graft seen in Figure 1A. Patient was given an end-tufted toothbrush and was instructed to brush gently
without traumatizing the recipient site. (8c) Eight weeks later, #27 shows thick mature tissue and complete root coverage.
then held in position by a periosteal elevator at the CEJ CLINICAL OUTCOMES

while the suture is tied on the palatal or lingual aspect of
the recipient site. The stability of the graft at the recipient Healing was uneventful in 12 out of the 13 cases presented
site is directly related to the level of graft firmness and the here (Figures 3–15). Case 1 showed uneven healing at the
size of the graft. After the graft is secured, the gingival flap surgical site and presented with a groove-like defect at the
(without engaging the graft) is sutured coronally (Figures 3, initial postsurgical evaluation. However, at the 6-month
5, and 11; Cases 1, 3, and 9, respectively) in a hanging or follow-up visit, the recipient area had a normal texture. The
suspended fashion to the buccal aspect of the recipient follow-up for the remaining 12 cases ranged from 1 to 60
tooth via suspensory sling sutures. This is accomplished by weeks, with a mean follow-up of 23 weeks. All 13 cases had
embedding the suture into flowable composite placed on 100% root coverage at final follow-up. None of the cases
the buccal surface of the recipient tooth. presented with scarring at the surgical site.
F I G U R E 9 Case 7. (9a) Pre-op #21 and #22, precise identification of the cemento-enamel junction (CEJ) was based on the differences in the texture
of the enamel and dentin. This patient was going to receive orthodontic treatment. Orthodontic correction of these prominent teeth is necessary to
minimize recurrence of the recession. (9b) Twelve weeks post operation reveals complete root coverage; the patient was scheduled for orthodontic
treatment after completion of this plastic procedure.
F I G U R E 1 0 Case 8. (10a) Patient was interested in treatment of #11 only. The cemento-enamel junction (CEJ) was identified for the purposes of
positioning the gingival margin. Decay was removed from this site on #11, but it did not extend to or involve the pulp. (10b) Fifteen weeks post operation.
F I G U R E 1 1 Case 9. (11a) Pre-op the location of the cemento-enamel junction (CEJ) on #5, #6, and #7 was not clear. In this case the location of the
CEJs was determined by measuring the length of clinical crowns of #10, #11, and #12 where the amount of incisive wear was the same. (11b) A composite
hook is made for keeping the gingival margin coronally. This allows placement of the gingival margin in the desired location. (11c) The graft is inserted to
treat the recession on #5, #6, and #7. The mesial of the graft is on the mesial of #7 and the distal is on the distal of #5. The graft is sutured on the palatal
area with sling sutures, and the gingival margin is coronally advanced to cover the graft. The hook area was filled with composite and rounded and
polished. (11d) The closed flap was positioned coronally above the CEJ without any tension using a suspension suture. (11e) The 6-month postsurgical
image shows complete root coverage of #5, #6, and #7.
18 KASHANI ET AL.
FIGURE 12 Case 10. (12a) There is 5 mm of buccal recession plus mild abrasion on #11. (12b) Fourteen months post op.
F I G U R E 1 3 Case 11. (13a) This patient presented with a Class I Miller recession with erosion and superficial decay on #11. In addition, the papilla
between #11 and #12 had slight interproximal recession. Eight weeks postoperatively there was full root coverage plus improvement of the papilla
between #11 and #12, which is one of the advantages of this technique; assists with papilla fill. (13b) Thirteen months post operation showing stable and
full root coverage.
F I G U R E 1 4 Case 12. (14a) Tooth #6 exhibits Class I Miller recession; the etiology includes the prominent tooth position and a thin periodontal
phenotype. This is the only site of recession in this young female patient, further underscoring that the main reason for the recession is the prominent
root. (14b) Eleven days post operation shows complete root coverage of tooth #6. The patient was instructed to use a toothbrush with two rows of
bristles and a pen or two-finger grip using the Bass technique in order to prevent reoccurrence of the recession.
DISCUSSION base of pedicle flaps.10–12 Prior to the establishment of graft

vascularization, the graft survives via plasmatic, transudate,
The survival of soft tissue grafts depends on a variety and diffusive circulation for the first 3 days,10 provided the
of factors, including the type of surgical procedure, the recipient site’s circulation has not been interrupted.
number and type of incisions, such as vertical incisions, A critical part of the graft is the portion that covers the
horizontal incisions, de-epithelization and partial removal denuded root surface. The circulation in this segment of the
of the adjacent papillae, and split-thickness incisions at the graft is maximized by the MOCA technique. Because there
F I G U R E 1 5 Case 13. (15a) Tooth #30 exhibits Class I Miller recession. (15b) Fourteen days after operation shows complete root coverage. (15c) Four
months and 10 days post operation shows complete and stable root coverage.
is no incision aside from the access for tunneling involving CONFLIC T OF INTEREST
the recipient site, this technique provides optimal clinical The authors have no conflicts of interest with any of the
results, as there is no uneven texture or scar formation, materials or topics presented in this report.
and healing proceeds with minimal interruption. One case,
however, did demonstrate interrupted healing. REFERENCES
1. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage pro-
cedures: a systematic review from the AAP Regeneration Workshop. J
CONCLUSION Periodontol. 2015;86(2 Suppl):S8-S51.
2. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of
successful grafting. Periodontics. 1968;6:121-129.
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While MOCA is a technique-sensitive surgical procedure, it tics Restorative Dent. 1985;5(2):8-13.
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at the recipient site, there is no uneven texture or scar for- clinical attachment level to classify gingival recessions and predict
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mation, which promotes healing with minimal interruption.
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of donor tissue can be compromised by the presence of 8. Zucchelli G, Testo T, De Sanctis M. Clinical and anatomical factors
exostoses and quantity of fat and glandular tissue. It is limiting treatment outcomes of gingival recession: a new method to
critical to have sufficient tissue to maximize root coverage predetermine the line of toot coverage. J Periodontol. 2006;77:714-
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to meet patient expectations and provide satisfactory 9. Jung U-W, Um YJ, Choi SH. Histologic observation of soft tissue
outcomes. Early diagnosis and treatment is important, acquired from maxillary tuberosity area for root coverage. J Periodon-
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ACKNOWLEDGMENT graft plus coronally advanced flap in the treatment of maxillary single
We wish to thank all the patients that were part of this case recession-type defects. J Periodontol. 2018(11):1290-1299.
report series and the UCSF Division of Periodontology for 13. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of mul-
its support. tiple adjacent gingival recessions with the tunnel subepithelial
20 KASHANI ET AL.
connective tissue graft: a clinical report. Int J Periodontics Restorative

Dent. 1999;19(2):199-206. How to cite this article: Kashani H, Vora MV, Kuraji
14. Zadeh HH. Minimally invasive treatment of maxillary anterior gingival
recession defects by vestibular incision subperiosteal tunnel access
R, et al. Incision-free, coronally advanced flap with
and platelet-derived growth factor BB. Int J Periodontics Restorative subepithelial connective tissue graft placed by the
Dent. 2011;31(6):653-660. molar or canine access (MOCA) technique: 13 case
series. Clin Adv Periodontics. 2023;13:11–20.
https://doi.org/10.1002/cap.10195
S U P P O R T I N G I N F O R M AT I O N
Additional supporting information can be found online in
the Supporting Information section at the end of this article.

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Received: 17 September 2020 Accepted: 23 January 2022

Incision-free, coronally advanced flap with subepithelial

Hooshang Kashani1 Manali V. Vora2,5 Ryutaro Kuraji3,4 Hoorshad Fathi-Kelly1

Why is this case series new information?

Clin Adv Periodontics. 2023;13:11–20. wileyonlinelibrary.com/journal/cap 11

What are the key limitations to the success of these cases?

BACKGROUND no incisions at the recipient site and thereby preserves

then held in position by a periosteal elevator at the CEJ CLINICAL OUTCOMES

DISCUSSION base of pedicle flaps.10–12 Prior to the establishment of graft

connective tissue graft: a clinical report. Int J Periodontics Restorative

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