APICALLY-LATERALLY POSITIONED FLAP

(HATTLER PROCEDURE)

When no adequate donor for a laterally positioned pedicle flap is present, this
procedure of limited usefulness may be used when gingival color and texture match
are necessary esthetically. It is a variation of the laterally positioned flap in which
the papillae are utilized as donor tissue in combination with an apically positioned
flap. If a papilla of adequate dimensions is available adjacent to the tooth to be
grafted, a partial thickness dissection may be used to create a broader band of
attached gingiva. Very often this surgical technique is performed in combination
with other periodontal procedures. The entire flap is positioned apically one-half
tooth width mesially or distally, so that the papillae rest on the midradicular
surface of the teeth just coronal to the alveolar bone crest.

INDICATIONS
1) To create a broader band of attached gingiva
2) To improve esthetics when a laterally positioned pedicle flap is not available.

CONTRAINDICATION
1) A deep gingival groove in the papilla
2) Inadequate papillary dimensions
3) A shallow vestibule

SURGICAL TECHNIQUE
1) Local anesthesia
2) A partial-thickness intrasulcular dissection is begun using a No 15 scalpel blade.
3) The interproximal papillae are then partially dissected and maintained (4 to
5mm in length)
4) A "C" releasing incision is used mesially to the most mesial papilla. This incision
is not extended down to bone. It is extended apically beyond the mucogingival
junction into the alveolar mucosa to permit adequate mobility of the flap.
5) The entire partial thickness flap is positioned apically and shifted one-half tooth
width mesially or distally. The papillae are placed either at the gingival margin or
over the adjacent tooth or just coronal to the alveolar bone crest.
6) The total papillary dimension, 4 to 5mm in length, is maintained and positioned
apically and laterally to the desired position
7) The interproximal areas are left covered by periosteum and will heal by
secondary intention without any residual bone loss. New attached gingiva and
papillae will form
8) In case of some overlapping tissue surface, a small amount of gingiva can be
removed from the flap.
9) Once the apically-laterally positioned flap is positioned, be sure there is no
tension on it
10) A periosteal vertical mattress suture is recommended to stabilize the flap
11) Apply digital pressure for 5 minutes and a surgical dressing for 7 days.

REFERENCES
1) Hattler A.B.: Mucogingival Surgery-Utilization of Interdental gingiva as
attached gingiva by surgical displacement.
Periodontics, 5:126,1967
2) Fedi Jr. P.F.: Management of soft tissue: Mucogingival procedures. In Fed Jr.
P.F. "The periodontic syllabus 1985. Lea and Febiger Philadelphia Pa chapter 15;
120-129.