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Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 41-44

Screw-Assisted Soft Tissue Stabilization – A Paradigm Shift in Flap Fixation: A Case Series With a 3 Months Follow-Up

1 Private Practice, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Periodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran

Date of Web Publication13-Jul-2018

Correspondence Address:
Hoori Aslroosta
Department of Periodontics, School of Dentistry, Tehran University of Medical Sciences, North Karegar Street, Post code: 14399-55991, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/denthyp.denthyp_59_17

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Background: The final step in oral surgeries, proper positioning of the soft tissue, is considered as a major determinant of the clinical outcome. Different suturing anchors suffer fundamental flaws when they are supposed to guarantee the adequate flap fixation. This study aimed at proposing “screw assistant soft tissue stabilization” (SASS) as an alternative method for the conventional suturing techniques. Materials and Methods: A total of seven teeth in six healthy patients underwent surgical crown-lengthening by apically positioned flap technique. Surgical miniscrews were utilized for flap stabilization instead of periosteal sutures that are conventionally designed for soft tissue apical positioning. The widths of keratinized gingiva (KG) and the distance between gingival margin and cemento-enamel junction (GM-CEJ) were measured at baseline and 3 months after surgery. Results: All areas healed uneventfully. A significant increase in GM-CEJ distance without a significant change in the widths of KG was observed. Conclusion: The SASS technique seems to be able to fixate the flaps predictably and efficiently in lateral, apical, or coronal directions. In comparison, with traditional suturing techniques, it donates more comfort to both surgeons and patients. The advantages are of paramount importance in areas with limited surgical access and loose alveolar mucosa.

Keywords: Crown lengthening, surgical flaps, suture anchors

How to cite this article:
Moayer A, Aslroosta H, Akbari S. Screw-Assisted Soft Tissue Stabilization – A Paradigm Shift in Flap Fixation: A Case Series With a 3 Months Follow-Up. Dent Hypotheses 2018;9:41-4

How to cite this URL:
Moayer A, Aslroosta H, Akbari S. Screw-Assisted Soft Tissue Stabilization – A Paradigm Shift in Flap Fixation: A Case Series With a 3 Months Follow-Up. Dent Hypotheses [serial online] 2018 [cited 2023 Mar 22];9:41-4. Available from:

  Introduction Top

To secure the soft tissue flaps in a proper position is a critical prerequisite for success in conducting surgical procedures. This stability has to be maintained until the wound has endured adequate healing to withstand displacement triggered by functional forces.[1] The surgical objectives direct the appropriate position of flap margin, which could be either placed in its original position or displaced apically, coronally, or laterally.[1] Various suturing techniques have been evolved to afford soft tissue stabilization, which is necessary to expedite clot formation, reduce scar formation, and enhance esthetics.[1],[2],[3] The technique known as apically positioned flap (APF) was introduced by Nabers (1954) and was modified by Friedman.[4] Parallel with the development of oral implant dentistry, apically positioned flap has been widely used for increasing the width of the keratinized tissue around implants. It has also been applied in peri-implant resective surgeries. Research has shown that the rebound of soft tissue margin, which is normally observed after APF, is related to inappropriate postsurgical position of flap margin.[5] Different methods have been described to maintain the displaced flap in its new position. Interrupted sutures, mattress sutures,[6] periosteal sutures,[7] and periodontal dressing have been proposed for the fixation of flap margin position. Furthermore, the use of a removable healing plate has been advocated to prevent mucosal regrowth.[8] The more shallow the vestibule is, the more difficult the apical positioning. This leads to more cases of relapse in surgical outcomes, particularly in posterior mandible, due to presence of a loose alveolar mucosa, narrow keratinized mucosa, and absence of a suitable periosteum for suturing. The moot question −why not rely on bone as the most secured structure in periodontium to fixate the flap. In other words, the alveolar bone could be considered as an improved and more stable anchoring system to manage the positioning of flaps. This could be best achieved by making use of extra-short self-drill miniscrews to directly attach the flap to the alveolar bone.

What follows represent some cases, treated by the above-mentioned technique.

  Materials and Methods Top

Presurgical phase

All patients received proper plaque control instruction as well as supra and subgingival scaling. The surgeries were performed when the appropriate plaque index (≤25%) was achieved.[9]

Surgical approach

Patients had been referred for surgical crown-lengthening. Prior to the surgery, the patients brushed their teeth using 0.2% chlorhexidine-digluconate mouthwash solution for 60 s. Subsequent to the gain of adequate anesthesia, intrasulcular incisions were prepared on the buccal side to preserve the maximum amount of keratinized gingiva (KG) [Figure 1]. To adjust the KG on the lingual aspects, the appropriate submarginal internal bevel incision or sulcular incision was provided. Soft tissue flaps were designed to include the intended tooth and two adjacent teeth on each side to facilitate the flap displacement in the apical direction.[10] After the flap reflection, the surgical site underwent ostectomy and osteoplasty to provide positive or flat bone architecture with adequate sound tooth structure for restorative purposes and more apical formation of biologic width.[5] The flap margins were positioned at the crest of the alveolar bone, and they were fixed using self-drilling 4-mm miniscrews (Ortho Select GmbH, Wurmilingen, Germany). Presence of a screw on buccal and lingual aspects of each interproximal alveolar bone secured the flap tightly to the underlying bone. What merits attention is that the screws are supposed to be inserted in an interproximal bone to avoid any damage to adjacent anatomic landmarks. Furthermore, screws were used for flap fixation at the level of inter-radicular bone in furcation area of mandibular molars. Thereafter, secondary simple interrupted sutures were made to stabilize the interdental papillary portions in the flap margin. Patients were instructed to use 0.12% chlorhexidine mouth-wash for 14 days. The surgical sites were re-evaluated after 7–10 days when sutures and screws were removed.[11] Patients were referred for restorative phase generally after 12 weeks.[12] The distance between cement-enamel junction (CEJ) and gingival margin (GM) was measured immediately before surgery, after flap fixation, and 12 weeks postoperatively before prosthetic preparation. In addition, the width of KG was measured in mid buccal area at baseline and after 12 weeks. UNC-15 periodontal probe was used for all measurements. The similar procedure was also used for esthetic crown lengthening [Figure 2]. Due to undisplaced design of the buccal flap, these patients are not included in clinical measurements. Data were analyzed by SPSS 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.).
Figure 1: (a) The first and second mandibular molar teeth need crown-lengthening. Consider the narrow keratinized gingiva and shallow vestibular depth. (b and c) Subsequent to flap reflection and bone contouring, both buccal and lingual flaps were fixated apically using miniscrews in interproximal bone. (d) Three months after surgical intervention, sound tooth structure adequate for prosthetic purposes is observed. (e) Final restoration

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Figure 2: (a) Six anterior teeth with delayed passive eruption in a 25 years old man. (b) After flap reflection, bony ledges on alveolar bone is present. (c) After proper bone contouring. (d) At the end of the surgery, flap margin has been secured 1 mm coronal to the CEJ. (e) Ten days after surgical intervention, uneventful healing is observed. Note that one of screws that is partially covered with soft tissue, is removed. (f) Three postoperative week, consider the complete resolution of the remained hole. In this session, the other screws were removed

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  Results Top

A total of six patients with seven teeth (all first and second molars) underwent apically positioning of flap, completed the follow-up for 12 weeks before prosthetic reconstruction [Table 1]. No postsurgical complications were reported. Clinical measurements at baseline and 3 months postoperative follow-up are summarized in [Table 2]. A significant increase in GM-CEJ distance was measured after 12 weeks (Wilcoxon signed rank test, P = 0.001). The apico-coronal dimension of the KG was 2.1 ± 0.76 mm preoperatively and 2.01 ± 0.24 after 3 months. No significant difference was detected in dimension of KG (Wilcoxon signed rank test, P > 0.05).
Table 1: Description of patients and individual treated areas

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Table 2: The clinical measurements at baseline and 3 months

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  Discussion Top

The formation of a stable blood clot and its organization is the sine qua non for a wound to withstand tensile forces.[3] Moreover, the preservation or addition of keratinized attached gingiva is a critical consideration that dictates the final position of flap margin. Secured apical flap positioning could meet both objectives.[13] The suturing techniques have been designated primarily to stabilize and maintain the soft tissue flap margin in a proper position until the healing process provides adequate tissue strength against the functional forces. Four anchoring structures are used in oral surgeries.[3] The first anchor is the movable vestibular connective tissue, which provides the least secured soft tissue stabilization. Periosteum is the second type of anchors, used for the stabilization of movable soft tissue in displaced flaps, pedicles, and free mucosal grafts. Attached masticatory mucosa provides a reliable anchorage for mucosal grafts and flaps, designed with vertical releasing incisions[3],[14] Implant supported restorations and teeth are the most stable anchorages ever used. The tooth anchorage whereby the sutures are bounded to facial surfaces of teeth have been advocated for coronal flap displacement.[15] However, it is of no noteworthy benefit for apical flap positioning. The presence of a loosely attached connective tissue and the absence of sufficient vestibular depth make it more difficult to conduct the flap management. Such limitations are generally faced in posterior regions of mandible.[4] This paper was an effort made to propose the bony structures as the most secured anchorage for flap stabilization.

Using chrome-cobalt alloy tacks, Seibert tacked the gingival flap to the alveolar bone.[16] Notwithstanding the favorable results, some drawbacks were reported. They had to push the tacks (using a plier) subsequent to drill a hole into the dense alveolar bone. This made the procedure more complicated. Furthermore, two patients were reported with cases of fistula after the removal of tacks, which disappeared by the next week. A number of studies on traumatology and orthopedics have also reported soft tissue fixation using bio absorbable fixation devices and have proved that such technique could treat ligaments and meniscal injuries more safely and quickly than the former suturing techniques.[17],[18],[19]

The present study experienced the application of screws (for the same clinical purposes) as a reliable method to increase convenience and speed compared with conventional suturing techniques. When it comes to surgical ease, periosteal sutures urge the flap partial splitting that could result in limited access to bone contouring. Moreover, since it is not recommended to conduct splitting and preparing vertical incisions in the lingual flap, screw-assisted flap displacement could be alternatively used to facilitate such a procedure. Akin to the traditional apical flap positioning, this alternative method could preserve the keratinized attached gingiva. Furthermore, up to 3 months’ postsurgery, there was a beneficial effect on clinical parameters. All patients had a desirable amount of exposed sound tooth structure as a result of the increase in clinical attachment level. At the beginning of the study, there were some concerns about necrosis and abscess formation (in piercing points) following the screw fixation in papillary region of flap margin. However, none of the patients experienced such complications during early healing period. Uneventful soft tissue healing without scar formation was another benefit of screw-aided soft tissue stabilization. This advantage could suggest the technique as a simple and esthetically pleasing method of soft tissue management in crown lengthening procedures within the esthetic zone. In terms of comfort, patients reported no pain or a mild pain relieved using non-steroidal anti-inflammatory drugs (NSAIDs).

Furthermore, screws were retrieved after 7–10 days without the need for local anesthesia. This step brought no discomfort to patients even in screws that are partially covered by the soft tissue. Seibert reported fistula formation in two patients.[16] This could be related to less biocompatibility of chrome-cobalt alloy tacks replaced by the titanium miniscrews in the present study. Furthermore, they used an invasive method for fixation of tacks.

Also, there were concerns how the remaining holes on the gingiva would repair without scar tissue formation once the screw had been removed. Fortunately, it did not pose a major problem. The holes disappeared until the 3rd or 4th postsurgical weeks [[Figure 2]f]. Screw-aided soft tissue stabilization could be a valuable alternative for sutures applied to a broad spectrum of periodontal surgeries. Surgical techniques requiring careful soft tissue positioning (for instance, crown lengthening surgeries in posterior regions of mandible as well as anterior parts of maxilla) would benefit from screw fixation. To keep pace with the developments in implant dentistry, it could be advantageous to start repositioning of soft tissue flaps in apical, coronal, and lateral directions designated as either full or split thickness flaps.

It is concluded that soft tissue positioning at the end of periodontal surgical procedures could be facilitated using fine delicate screws that are fixated in keratinized tissue of papillary portions of periodontal flaps. It is necessary to investigate the clinical, biologic, and technical considerations of the procedure s in future clinical trials.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Silverstein LH, Kurtzman GM, Shatz PC. Suturing for optimal soft-tissue management. J Oral Implantol 2009;35:82-90.  Back to cited text no. 1
Burkhardt R, Lang NP. Fundamental principles in periodontal plastic surgery and mucosal augmentation − A narrative review. J Clin Periodontol 2014;41(Suppl 15):S98-107.  Back to cited text no. 2
Burkhardt R, Lang NP. Influence of suturing on wound healing. Periodontol 2000 2015;68:270-81.  Back to cited text no. 3
Friedman N. Mucogingival surgery: The apically repositioned flap. J Periodontol 1962;33:328-40.  Back to cited text no. 4
Arora R, Narula SC, Sharma RK, Tewari S. Evaluation of supracrestal gingival tissue after surgical crown lengthening: A 6-month clinical study. J Periodontol 2013;84:934-40.  Back to cited text no. 5
De Sanctis M, Cortellini P, Clauser C, Pini Prato GP. Coronal displacement of the junctional epithelium and attachment gain following apically positioned flap with bone resective surgery in dogs. Int J Periodontics Restorative Dent 1988;8:64-76.  Back to cited text no. 6
Carnio J, Miller PD Jr. Increasing the amount of attached gingiva using a modified apically repositioned flap. J Periodontol 1999;70:1110-7.  Back to cited text no. 7
Soldani F, Eastaugh D, Stirrups D, Foley J. Use of a removable healing plate after exposure of an unerupted incisor with an apically repositioned flap. Br J Oral Maxillofac Surg 2006;44:546-7.  Back to cited text no. 8
Carnio J, Camargo PM, Passanezi E. Increasing the apico-coronal dimension of attached gingiva using the modified apically repositioned flap technique: A case series with a 6-month follow-up. J Periodontol 2007;78:1825-30.  Back to cited text no. 9
Tuan MC, Nowzari H, Slots J. Clinical and microbiologic study of periodontal surgery by means of apically positioned flaps with and without osseous recontouring. Int J Periodontics Restorative Dent 2000;20:468-75.  Back to cited text no. 10
Levy RM, Giannobile WV, Feres M, Haffajee AD, Smith C, Socransky SS. The effect of apically repositioned flap surgery on clinical parameters and the composition of the subgingival microbiota: 12-Month data. Int J Periodontics Restorative Dent 2002;22:209-19.  Back to cited text no. 11
Hempton TJ, Dominici JT. Contemporary crown-lengthening therapy: A review. J Am Dent Assoc 2010;141:647-55.  Back to cited text no. 12
Yeh S, Andreana S. Crown lengthening: Basic principles, indications, techniques and clinical case reports. N Y State Dent J 2004;70:30-6.  Back to cited text no. 13
Moore RL, Hill M. Suturing techniques for periodontal plastic surgery. Periodontol 2000 1996;11:103-11.  Back to cited text no. 14
Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor BB. Int J Periodontics Restorative Dent 2011;31:653-60.  Back to cited text no. 15
Seibert JS. Technique for the stabilization of tissue flaps employing chrome-cobalt alloy tissue tacks. J Periodontol 1961;32:283-9.  Back to cited text no. 16
Nho SJ, Provencher MT, Seroyer ST, Romeo AA. Bioabsorbable anchors in glenohumeral shoulder surgery. Arthroscopy 2009;25:788-93.  Back to cited text no. 17
Janis L, Lam AT, Espiritu T, Ploot E, Husain ZS. A comparison of soft-tissue anchors in tendo achilles reattachment. J Foot Ankle Surg 2001;40:195-207.  Back to cited text no. 18
Rokkanen PU, Böstman O, Hirvensalo E, Mäkelä EA, Partio EK, Pätiälä H et al. Bioabsorbable fixation in orthopaedic surgery and traumatology. Biomaterials 2000;21:2607-13.  Back to cited text no. 19


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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