In this surgery, in the posterior region of the third quadrant a vestibular and lingual flap is repositioned apically – a procedure that would be contraindicated if there was not enough keratinized gingiva. First, a paramarginal incision is performed on the buccal side following the tooth shape and creating new papillae. In the next step, Professor Wachtel prepares a split flap towards the vestibular area. Not removing periosteum from the bone surface is important for the success of this surgery since later the flap needs to be fixed at the periosteum to remain in the intended apical position. In contrary, on the lingual side a full thickness flap is prepared after the paramarginal incision in order to avoid any damage of the lingual artery and nerve.
However, due to the anatomy in this region the lingual flap does not move coronally but rather stays in the desired apical position. In the interdental area, the incisions cross each other so that new papilla tips are created parallel to the original ones. Following an intrasulcular incision all the tissue within the incision lines as well as excess interdental soft tissue has to be thoroughly removed. Once the mobilization of the buccal and lingual flap is completed, the alveolar ridge is reshaped and smoothened using a round diamond burr.
The flaps are fixed applying vertical mattress sutures, which in the buccal area are guided from the mobile part of the flap through the attached areas of the periosteum. The fixation of the buccal split thickness flap to the underlying periosteum ensures the apical positioning. A connection to the full-thickness lingual flap can be established through the interproximal spaces.