flap advancement: practical techniques to attain tension ...flap advancement: practical techniques...

Flap Advancement: Practical Techniquesto Attain Tension-Free Primary ClosureGary Greenstein,* Benjamin Greenstein,† John Cavallaro,* Nicholas Elian,* and Dennis Tarnow*

Background: Primary and tension-free closure of a flap isoften required after particular surgical procedures (e.g.,guided bone regeneration). Other times, flap advancementmay be desired for situations such as root coverage.

Methods: The literature was searched for articles thataddressed techniques, limitations, and complications asso-ciated with flap advancement. These articles were used asbackground information. In addition, reference informationregarding anatomy was cited as necessary to help describesurgical procedures.

Results: This article describes techniques to advance mu-coperiosteal flaps, which facilitate healing. Methods are pre-sented for a variety of treatment scenarios, ranging fromminor to major coronal tissue advancement. Anatomic land-marks are identified that need to be considered during surgery.In addition, management of complications associated withflap advancement is discussed.

Conclusions: Tension-free primary closure is attainable.The technique is dependent on the extent that the flap needsto be advanced. J Periodontol 2009;80:4-15.

KEY WORDS

Alveolar ridge augmentation; oral surgical procedures.

Flap advancement is required aspart of certain surgical procedures(e.g., ridge augmentation) to at-

tain tension-free primary closure alongthe incision line. Flap advancement mayalso be an integral part of other surgicalprocedures, such as root coverage.When coapting flaps, coronal position-ing of mucogingival tissues facilitateshealing by primary intention, which issuperior to healing by secondary inten-tion.1 Primary closure results in de-creased discomfort and faster healingand is critically important in attainingdesired objectives (e.g., bone regen-eration). Failure to attain tensionlessclosure may result in a soft tissuedehiscence along the incision line thatcan cause a poor outcome and/or post-operative complications. Numerous in-vestigators2-6 have made contributionswith regard to procedures and the un-derstanding of biologic benefits derivedfrom coronally advanced flaps. Thisarticle builds on that information anddescribes several techniques to achievepredictable tension-free primary closureof surgical wounds. In addition, thefollowing subjects are discussed: histol-ogy of incised tissues, concerns aboutanatomic structures in specific sectionsof the mouth, basic surgical principles,and complications associated with theseprocedures.

HISTOLOGY OF INCISED TISSUES

The term ‘‘oral mucous membranes’’ re-fers to the lining of the oral cavity thatcommunicates with the outside.7 Mucous

* Department of Periodontology and Implant Dentistry, New York University College ofDentistry, New York, NY.

† Private practice, Freehold, NJ.

doi: 10.1902/jop.2009.080344

Volume 80 • Number 1

4

membranes consist of two layers: surface epitheliumand an underlying lamina propria.7 Below the laminapropria is the submucosa that attaches the laminapropria to the underlying subjacent structures. Duringoral surgical procedures, epithelium and connectivetissue are usually incised from the oral epithelium in-ward. Incontrast,when releasingflaps toattainprimaryclosure, the tissues are penetrated in reverse order.First the periosteum is surgerized, followed by the sub-mucosa and possibly part of the muscle layer. Incisioninto the epithelium is avoided.

When executing flap advancement, it is advanta-geous to think microscopically with respect to the tis-sues being incised. The first layer to be penetrated isthe periosteum, which is like a cellophane coveringthat surrounds the bone. It is a thin wrap of dense con-nective tissue that consists of two layers.8 The innercambium stratum contains progenitor cells andSharpey’s fibers, which insert into the bone. The outerfibrous layer is innervated and contains blood ves-sels.8 The periosteum is several cells thick (up to0.375 mm); it is bound down and is not very flexiblebecause of the lack of elastic fibers.8

The next tissue stratum to be entered is the sub-mucosa, which consists of varying densities andthicknesses of connective tissue. Within the submu-cosa there are strands of densely grouped collage-nous fibers and loose connective tissue containingadipose, small mixed glands, blood vessels, andnerves.8 In general, the submucosa is loosely tex-tured and contains numerous elastic fibers. It is firmlyattached to the buccinator muscle in the cheek areaand the orbicularis oris adjacent to the lips. In the for-nix, the mucosa is loosely attached to the underlyingstructures. When flaps are advanced, gingiva and lin-ing mucosa (e.g., cheek and vestibule) are coronallypositioned.

REGIONAL ANATOMIC CONSIDERATIONSWHEN EXECUTING FLAP ADVANCEMENT

Posterior MaxillaFlap advancement in the posterior maxilla is a rela-tively safe procedure that can be accomplished withminimal complications. Branches of the infraorbitalartery emerge from the infraorbital foramen and anas-tomose with subdivisions of the facial and buccal ar-teries.9 These blood vessels are located within thetissue of the cheek, which is 10- to 19-mm thick(mean thickness, 15 mm).10 The posterior superioralveolar artery is surrounded by a lot of tissue, andthe transverse facial artery courses anteriorly betweenthe parotid duct and the inferior border of the zygo-matic arch and rests on the masseter muscle.9 It is im-probable that these blood vessels, which are locatedwithin the tissues, would be damaged during properlyexecuted flap-advancement procedures. The parotid

duct (Stensen’s duct) traverses anteriorly over themasseter muscle and turns at a right angle at the sec-ond molar to pierce the buccinator into the mouth.11

The duct is distant to the flap release site and is un-likely to be injured during flap releases. In general,branches of the facial (motor nerves) and trigeminalnerve (sensory nerves) are located deep within thetissues and are not prone to being damaged whencoronally positioning tissues. However, prior to flapadvancement in the maxillary premolar region, it isprudent to palpate the inferior aspect of the infraor-bital ridge and determine the location of the infraor-bital notch. The infraorbital canal is ;5 mm inferiorto the notch, and an imaginary straight line drawn ver-tically through the pupil helps to identify the usual lo-cation of the infraorbital canal.12 Flap release mustremain distant to this structure to avoid injuring theinfraorbital nerve and its terminal branches.13 If surgi-cal procedures are close to the foramen, it is prudentto isolate the nerve prior to creating releasing inci-sions into the submucosa to avoid it. Accessory infra-orbital foramina have been detected in 11.5% ofpatients.14 In general, it is advisable not to incisetoo deeply into the tissues, because it is unknown pre-cisely where branches of the blood vessels and nervesreside.

Concerning the palatal aspect of the posterior max-illa, the anatomic structures that need to be respectedduring palatal surgery are the greater palatine foramenand the greater palatine artery. The artery emergesfrom the foramen and crosses the palate anteriorly.The foramen is found halfway between the osseouscrest and the median raphe and is usually located pal-atally inthemaxillarysecond-andthird-molarregion.15

Therefore, when extending a flap with partial-thicknessdissectionson the palatal aspect, it is advisable tooper-ate mesial to the second molar. Furthermore, when do-ing procedures in this region, the height of the palatalvault should be evaluated to determine how large a flapcan be elevated without encroaching on the palatal ar-tery. It is prudent to leave 2 mm between the artery andthe depth of the surgical incision.16 The following infor-mationhas been reported with respect to the location ofthe artery in relation to the cemento-enamel junction:low vault (flat) = 7 mm; average palate = 12 mm; andhigh vault (U-shaped) = 17 mm.16

Anterior MaxillaIn the anterior region of the mouth, the superior labialartery is located between the mucous membrane andthe orbicularis muscle.9 It is not apt to be injured dur-ing flap-advancement procedures.

Posterior MandibleThe buccal artery is found on the outer wall of the buc-cinator muscle and is not usually in danger of beingincised during routine flap advancement.9 Similarly,

J Periodontol • January 2009 Greenstein, Greenstein, Cavallaro, Elian, Tarnow

5

other nerves (e.g., motor and sensory nerves) lie deepwithin the tissue and are not in jeopardy of beingdamaged. Conversely, the three branches of the men-tal nerve emerge from the mental foramen and mustbe managed carefully to avoid harming them duringflap manipulations.17 If the flap needs to be advancedin the mental foraminal region, the location of themental foramen needs to be identified radiographi-cally.

Flap advancement adjacent to the mental forami-nal area can be accomplished in several ways. Oncea full-thickness mucoperiosteal flap is elevated pastthe mucogingival junction, wet gauze can be usedto push back the flap (a periosteal elevator can beused to push the gauze) until the roof of the mental fo-ramen is exposed. The use of gauze helps to avoidnerve damage. Flap elevation results in two muscles(depressor anguli oris and depressor labii inferiorus)being reflected.18 After the roof of the foramen islocated, the periosteal elevator is used mesially anddistally to the foramen to push the flap several milli-meters apically past the inferior border of the mentalforamen. The periosteal elevator is used to release thefull-thickness flap apical to the mental nerve, therebytotally isolating it. At this juncture, the base of the flapcan be released without injuring the nerve. It is alsopossible to execute a split-thickness flap in this regionto isolate the mental nerve prior to advancing the flap.However, with this technique there is increased risk forinjuring branches of the nerve within the soft tissue.Another method for advancing the flap in this regionthat is preferred by the authors is presented when in-cision designs are described.

With regard to flap release on the lingual side of themandible, if buccal flap advancement is inadequate toattain primary closure over a graft site, then additionalcoverage can be obtained by releasing the lingual flapto the mylohyoid muscle. Wet gauze can be pushedwith the periosteal elevator to accomplish blunt dis-placementof the tissue. If additional flapadvancementis needed, the mylohyoid muscle can be dislodgedfrom its origin on the mylohyoid ridge. Starting at thedistal aspect of the flap, a finger can be inserted underthe periosteum to push part of the mylohyoid muscleoff the bone.

When operating on the lingual aspect of the mandi-ble, the flap needs to be carefully retracted to avoidlingual nerve damage and transient pressure-tractioninjuries. The lingual nerve is usually found 2 mm hor-izontally away from the lingual plate of bone and 3 mmapical to the bony crest.14 However, its positionvaries: the nerve was reported to contact the corticalplate 22% of the time,19 and it was at or coronal to thecrest of bone lingual to the mandibular third molar15% to 20% of the time.20 Accordingly, it is prudentnot to create vertical releasing incisions on the lingual

aspect of the posterior mandible. Furthermore, toavoid injuring the lingual nerve distal to the secondmolar, it may be advantageous to release the flap inthis region on the buccal side of the retromolar padarea.20

Anterior MandibleIn the buccal region, nerves and blood vessels (e.g.,inferior labial nerve and artery and mental nerveand artery) are within the tissues and are protectedby the submucosa.4,21 However, on the lingual as-pect, caution must be exercised when reflecting or re-leasing a flap, because the submental and sublingualarteries may enter accessory foramina through thelingual plate.22 Bleeding can be excessive if these ves-sels are damaged.

MEDICATION ASSESSMENT PRIORTO SURGERY

A thorough medical history should be taken prior tooral surgical procedures. Any medications that thepatient is ingesting that can interfere with clottingshould be reviewed (e.g., aspirin, antiplatelet medica-tion, and warfarin). After consultation with the pa-tient’s physician, if possible, aspirin and antiplateletmedication should be stopped 7 days before surgery,and other non-steroidal anti-inflammatory drugs(e.g., ibuprofen) ought to be discontinued 2 to 5 daysbefore procedures.23 It is prudent to have a patientstop using these products prior to surgery to eliminatetheir effect on platelets, whose turnover time is 7 to 11days.23 However, surgical procedures are often per-formed when patients are taking antiplatelet medica-tion or aspirin on a daily basis. If there are concernsabout a patient’s clotting ability, then an internationalnormalized ratio should be obtained. Warfarin shouldalso be stopped 3 days prior to surgery.23 In addition,several herbal drugs and vitamins may increasebleeding time: garlic, ginseng, gingko biloba, ginger,fish oils, and vitamin E.24 Patients should refrain fromusing herbal drugs before surgery. In general, prior toaltering a patient’s medications, it is advisable to con-sult with their physician to determine that this can bedone safely.

BASIC SURGICAL PRINCIPLES(10 BASIC RULES)

There are a number of important surgical tenets thatapply to flap-advancement procedures.

1. Plan the flap design in advance of all procedures.In this regard, it is suggested that flaps be reflected atleast one tooth beyond what is necessary to facilitatealtering the surgical plan if required. Bear in mind thatlong incisions heal as rapidly as short ones.25

2. Flap design simplicity should be a key goal, andunnecessary complexity should be avoided.

Flap Advancement Volume 80 • Number 1

6

3. If possible, the base of the flap should be widerthan its coronal aspect to maintain optimal vascularity.

4. When vertical releasing incisions are used, theincised tissue is actually a pedicle flap. This pediclecontains the flap’s vascular supply; therefore, whencreated, it should always include submucosa, whichcontains blood vessels. To ensure that the flap has ad-equate vascularity, its length-to-width ratio should notbe >2.5:1.25 In addition, vertical releasing incisions,when used to mobilize a flap, can help to avoid induc-ing recession in adjacent healthy areas.

5. The time that tissues are exposed and desiccatedaffects the amount of postoperative edema. There-fore, procedures should be performed efficiently to re-duce operative time.

6. Attain primary closure without tension on the inci-sion line. In this regard, an advanced flap that has beenproperly prepared for closure should be able to lie pas-sively 3 to 5 mm beyond the original incision line.

7. Keep the tissues moist at all times; after a longprocedure, hydrate the flap and stretch it out.

8. Manage tissues gently; it results in less swellingand discomfort. Keep the periosteal elevator on thebone at all times; suctioning should be done on bonein a sweeping motion to avoid irritating the soft tissues.

9. Be mindful of vital structures at the site undergo-ing surgery and the adjacent tissues.

10. Snug sutures into place, but do not tie themtightly, because it can result in pressure necrosis.Use a combination of mattress and interrupted suturesto ensure optimal closure. Mattress sutures are usedto resist muscle forces on the flap. Use a modified sur-geon’s knot for the interrupted sutures (two throwsclockwise, one counterclockwise, and one moreclockwise knot). A surgeon’s knot does not ordinarilyhave the third throw.26

AMOUNT OF BUCCAL FLAP ADVANCEMENTREQUIRED IS BASED ON COMPLEXITY OF THESURGICAL PROCEDURE

Minor Flap Advancement (several millimeters)Elevate a full-thickness flap (periosteum included)apically to the buccal vestibule and extend the releasemesially and distally under the periosteum beyond theboundaries of the flap (Figs. 1A through 1C). This al-lows some advancement of the elevated tissues. How-ever, it usually does not permit positioning the flapmany millimeters over the lingual or palatal incisionline. This technique works well in the buccal vestibule.A split-thickness dissection beyond the apical and lat-eral extent of the original full-thickness mucoperios-teal flap can be used as an alternative technique toadvance a flap in areas where vital structures arenot present (e.g., mental nerve) or when decorticationis not required as part of a guided bone regeneration(GBR) procedure.

Moderate Flap Advancement (3 to 6 mm)In conjunction with a horizontal incision across theedentulous area, create two vertical releasing inci-sions on the buccal aspect: one mesial and one distalto the field of surgery as part of the initial flap design(Figs. 2A and 2B). Elevate a full-thickness flap andextend it apically to the vestibule (Fig. 2C). In the pre-maxilla area, tissue elevation is usually extended tothe anterior nasal spine (piriform rim) when doing aGBR procedure. The vertical releasing incisions willfacilitate flap advancement. However, this still maynot release the flap enough to achieve coronal posi-tioning of several millimeters over the lingual or pala-tal incision line. To test the extent of the flap release,use a toothed tissue forceps and stretch the flap to de-termine whether it can be lengthened to attain ten-sionless closure. A simple test to ascertain if there isno tension on the advanced tissues is to extend it ontothe palatal or lingual tissue and release it, if it remainsin place then the flap is tension-free.

If vertical incisions do not facilitate optimal tissueadvancement, hold the flap under tension with a tissueforceps (e.g., Adson tissue forceps), and score the peri-osteum with a new scalpel blade close to the base ofthe flap from the distal to mesial aspect, laterally acrossthe whole flap (Fig. 2C). It is important to maintain di-rect vision of the surgical field when executing incisionsto ensure their effectiveness. Use the scalpel blade tocut into the periosteum 1 mm deep (Fig. 2C). The bevelon a #15 blade is 1 mm wide, and the periosteum is<0.5 mm thick; therefore, the bevel of the blade canbe used as a guide as to how far to insert the scalpelblade. When the flap is held under tension, release ofthe flap will be felt upon incising the periosteum. To at-tain further tissue advancement, insert a closedbluntedscissor (e.g., Metzenbaum scissor) or a hemostat intothe incision line (Fig. 2D). The instrument is held ver-tically, and it is opened ;5 mm, thereby stretchingapart the two sides of the incision line. Once again,the tissue forceps are used to advance the flap to deter-mine whether it can be positioned past the incision line(Fig. 2E). Scoring the periosteum can be repeated 3 to5 mm away from the initial periosteal fenestration (thiscan be done several times) to achieve additional flapmovement. The scissor or hemostat can be used alongeach incision line. Because this surgical manipulationcan result in additional bleeding, it is advantageous toaccomplish flap advancement prior to placement ofgraft materials and barriers.

Major Flap Advancement Required ( ‡7 mm)If buccal vertical releasing incisions and periosteal fen-estrations do not provide enough flap advancement toachieve tensionless primary closure, it is necessary tocut deeper into the submucosa. In this regard, clini-cians should also be aware that once the muscle layer


7

Figure 1.A) Minor flap advancement. Initial photograph of teeth #20 and #21. Periosteum has been elevated mesially and distally beyond the width ofthe sulcular incision. B) Envelope flap advanced several millimeters. C) Healing after 8 weeks. Roots are covered, and there is a band of attachedkeratinized gingiva adjacent to the teeth.

Figure 2.A) Moderate flap advancement. Initial photograph of teeth #6 through #11. B) Full-thickness buccal mucoperiosteal flap with vertical releasingincisions elevated teeth #6 through #11. C) Periosteal fenestration executed several millimeters coronal to the base of the flap. D) Hemostat used tostretch apart the incision line. E) Tissue forceps used to hold the flap and advance it palatally. F) Collagen barrier placed over the bone graft.G) Primary tension-free closure of the flap. H) Healing after 12 weeks.


8

is incised, the patient experiences increased morbiditywith regard to swelling, hemorrhage, and discomfort.Therefore, this is done only when necessary. Further-more, if the decision to cut deeper into the submucosabecause of the extent of the required tissue advance-ment was made prior to initiating the procedure, thenthe 1-mm-deep periosteal fenestrations are replacedby the following technique.

Figure 3 illustrates major flap advancement as partof a GBR procedure. After the initial incisions and afull-thickness mucoperiosteal flap is elevated, the fol-lowing steps are used to attain ‡7 mm of flap advance-ment. Hold the flap in tension with toothed tissueforceps or college pliers. Then, on the distal aspectof the flap, several millimeters coronal to its base, in-sert a new scalpel blade 3 to 5 mm into the tissue,

Figure 3.A) Major flap advancement. Initial photograph of teeth #6 through #11. B) Distal to maxillary canines, vertical releasing incisions are extendedinto the buccal vestibule. C) Full-thickness mucoperiosteal flap elevated to the anterior nasal spine. D) Collagen barriers are positioned prior to placinga bone graft. E) Coronal to the base of the flap, execution of a periosteal fenestration and a deeper incision several millimeters into the tissue. F) Bonegraft material placed adjacent to the buccal plate of bone and at the crest of the ridge. G) Periosteal sutures from the base of the buccal flap to thepalatal flap are used to hold several bioabsorbable barriers in place. H) Tension-free primary closure was attained and the temporary bridge neededto be adjusted to provide room for the graft material and barriers. I) Healing after 1 week. No dehiscence is present. J) A connective tissue graft wasused to reconstitute the buccal vestibule 6 months after the bone graft was placed. K) Shrinkage of the bone graft necessitated using pink porcelain toattain an esthetic result in the final prosthesis.


9

penetrating the periosteum into the muscle layer. Areleasing incision is made in a single sweeping mo-tion, cutting distal to mesial across the whole flap.The blade (use a new blade) is inserted, and the tis-sues are incised with a motion that parallels the bone,thereby avoiding perforating the flap on the buccal as-pect, i.e., the incision is not made perpendicular to theflap, it is oblique to the outer surface of the flap. Deter-mine if adequate tissue advancement has beenachieved. If it has not achieved the desired objective,then additional flap release must be provided using ei-ther of the following methods. Stretch the incision apartwith a scissor or hemostat. If that does not supply de-sired flap advancement, then incise deeper into themuscle tissue in the first incision line or create anotherincision 3 to 5 mm coronal to the first one. When doinga large GBR augmentation, the second incision is oftenrequired to attain primary closure. If extensive flap re-lease is necessary (incising more deeply into the mus-cle layer), place your finger on the epithelial surface ofthe skin so that you can feel if the scalpel blade is ap-proaching the skin surface. In addition, further exten-sion of vertical releasing incisions can help to attainadditional flap advancement. However, the authorsprefer not to create ‘‘cut back incisions’’ because it isdesired to keep the base of the pedicle flap as wideas possible to maintain an optimal blood supply.

Some clinicians use incisions at the end of the ver-tical releasing incisions to enhance flap advancement.Sclar27 recommended cut back incisions at the baseof the vertical incisions, thereby creating 45� to 60�horizontal incisions toward the center of the flap(Fig. 4). In addition, curvilinear releasing incisionswere used. He made the following recommendations:start the vertical releasing incision in the mucco-buccalfold one tooth width away from the surgical site; a split-thickness dissection should be executed; and when the

mucogingival junction is reached, a full-thickness flapis elevated, and the incision courses over to the surgi-cal site.

In contrast, Fugazzotto28 placed horizontal inci-sions, 3 to 4 mm in length, at the apical extent of thevertical releasing incision (in the buccal vestibule),which were directed away from the vertical incisions.Cranin25 created a split-thickness flap past the muco-gingival line as they proceeded apically to release theflap. He avoided incising the periosteum, which doesnot have a lot of give, and attempted to take advantageof the submucosa, which has many elastic fibers thatfacilitate flapadvancement.However, itmay beadvan-tageous not to create a split-thickness flap in areaswhere decortication of bone will be performed becauseit will dictate that the connective tissue be perforatedmultiple times.

SUPPLEMENTAL TECHNIQUES FORFLAP ADVANCEMENT

A practical technique to advance a flap in the posteriormandible that avoids dissecting apical to the mentalforamen or developing a split-thickness flap is illus-trated in Figure 5. First, a full-thickness mucoperios-teal flap is elevated exposing the roof of the mentalforamen. Then, starting on the distal internal aspectof the flap, periosteal fenestration and incision intothe submucosa are initiated as described above. How-ever, in theregionof themental foramen,adome-shaped

Figure 4.Vertical releasing incisions with cut back incisions at 45� to 60� madeat the base of the flap. The horizontal incision is brought across themucogingival junction to the edentulous site.

Figure 5.Periosteal fenestration is executed buccal to the mental foramen afterthe location of the foramen is identified.


10

incision is created around the foramen (Fig. 6). Ap-proximately 3 mm distal to where the nerve emerges,the incision is curved coronally to within 3 mm of theflap margin. The incision at this coronal level is ex-tended mesially 3 mm beyond the mental foramen,before it is carried apically to the level of the initial in-cision. As a rule of thumb, if the measurement fromthe base of the flap to within 3 mm of the coronal mar-gin is called distance A (e.g., 6 mm), then the width ofthe dome-like incisions initiated on each side of the fo-ramen is 1/2 A (e.g., 3 mm) (Fig. 6). It is recognizedthat the exact position of the branches of the mentalnerve are unknown; therefore, the incisions coronaland mesial to the mental foramen should not be madevery deep into the tissue.

Figure 7 demonstrates a technique for expandingthe volume of palatal tissues to provide primary cov-erage after a GBR procedure in the posterior maxilla.Palatal manipulation of tissues can be done indepen-dently or as a supplement to buccal flap repositioning.For large ridge augmentations, palatal expansion oftissue reduces the need to greatly advance the buccalflap to attain primary closure. Thus, it may avoid de-creasing the buccal vestibule when the buccal flap isadvanced and circumvents the need for a secondaryprocedure (e.g., free gingival or a connective tissuegraft) to reconstruct the vestibule.

This type of flap was described and diagrammed byFugazzotto28 (Fig. 8). The palatal-advancement pro-cedure involves splitting the palatal tissues (bucco-palatal width in the edentulous area) and rotatingout a pedicle graft. Therefore, caution must be exer-cised not to proceed too far apically on the palate, be-cause the greater palatine artery can be damaged.Furthermore, it is prudent to use the following proce-dure mesial to the second molar, because inadvertentsevering of the artery close to the foramen could resultin its retraction into the foramen, making it impossibleto ligate or directly compress it.

First, an incision is made mid-crestally on the eden-tulousridge,andthebuccalflapiselevatedasdescribedpreviously (Fig. 8A). Then the tissue covering the ridgeis elevated, and a full-thickness flap is extended towardthe median raphe. The amount of extension is dictatedby the size of the vault, which reflects the position oftheartery.Then,onthe internalaspectof theflap,closeto its base, coronally directed vertical incisions aremade (mesial and distal of the desired length of thepedicle flap that extend halfway through the flap(bucco-palatally) (Fig. 8). The apical extension ofthe two incisions is connected by a horizontal incision,which also extends halfway though the flap (Fig. 8B).Next,startingatthehorizontalincision,thescalpelbladeisbrought incisally,splittingtheflap, leavingthecoronal2 mm of palatal gingiva intact (Fig. 8C). The dissectedtissue (inner flap) is rotated to the buccal aspect,thereby providing a large segment of tissue to coverthe surgical site (Fig. 8D). This procedure shouldonly be performed when the palatal tissue is thick(‡4 mm).

SUTURING

Prior to suturing, the midline of an elevated flap shouldbe positioned to ensure the tissue is being properlyplaced. For instance, in the premaxilla, the midlineof the flap should line up with the nasopalatine papilla.Initially, it is advantageous to place a stitch (inter-rupted or a horizontal mattress suture) at the midpointof the flap to maintain its orientation. Then the verticalreleasing incisions, at their junction with the horizontalincision, are brought together with an interrupted

Figure 7.The underside of the palatal tissue is split bucco-lingually (width) in anapicocoronal direction. Then a pedicle flap is rotated buccally to provideadditional flap advancement.

Figure 6.In the area of the mental foramen, a dome-shaped incision is madearound the foramen. If the distance from the base of the flap to within3 mm of the coronal margin is 6 mm (A), then the dome-like incisionsmade on each side of the foramen is 1/2 A (e.g., 3 mm).


11

stitch. Next, the horizontal incision is closed with a fewinterrupted or mattress sutures. Mattress sutures canbe used to provide resistance to muscle pull (e.g., or-bicularis oris, mentalis, or buccinator). Subsequently,interrupted stitches are used to attain primary closurealong the horizontal suture line. Finally, the remainderof the vertical releasing incisions are closed with inter-rupted stitches. The authors prefer to use polyglactin910sutures‡ because they maintain 40% of their tensile

strength at 21 days.29 Expandedpolytetrafluoroethylene sutures§

also can provide prolonged tensilestrength.Aftersuturing,applypres-sure for 10 minutes (bleeding timeis between 2 and 9 minutes)30 toobtain a fibrin clot; this preventspooling of blood under the flap.

POSTOPERATIVEMEDICATIONS

After large augmentation proce-dures, the patient usually is pre-scribed an antibiotic (e.g.,amoxicillin, 500 mg, three timesa day for 1 week), a mouthrinse(e.g., 0.12% chlorhexidine gluco-nate), and an analgesic. If thereis a high degree of concern that apatient may swell excessively,consideration is given to providinga dose pack of methylpredniso-lone (4-mg tablets, #21). The pa-tient takes six tablets on the daybefore surgery and subsequentlytakes one less pill each day forthe following 5 days. The majordisadvantage of prescribing a ste-roid is that it may mask an infec-tion. Furthermore, the use of thisdrug is not recommended if the pa-tient has a fungal infection. Othermedical conditions in which ste-roids may be contraindicated in-clude heart disease, liver disease,kidneydisease,human immunode-ficiency virus infection, high bloodpressure,pepticulcer,osteoporosis,myasthenia gravis, herpes eyeinfection, low levels of thyroid hor-mone (hypothyroidism), diabetes,tuberculosis, mental/mood dis-orders, seizures, recent infection,allergies, pregnancy, and breast-feeding.31

HEALING TIME

The time for wound repair subsequent to surgery is tis-sue-specific: epithelium, after a 12-hour lag time: 0.5to 1 mm daily,32 connective tissue: 0.5 mm daily,33

and bone: 50 mm daily (1.5 mm per month).34 Aftersuturing, a mucoperiosteal flap adheres to bone(or soft tissue flap) by a fibrin clot (0 to 24 hours).

Figure 8.Diagram of steps to attain palatal flap advancement. A) Palatal tissue is reflected. B) A horizontalincision is made at the base of the flap on its inner aspect. The depth of the incision isapproximately one-half the bucco-palatal flap thickness. C) A scalpel is employed to split theinternal aspect of the flap apico-coronally. D) The internal aspect of the flap is rotated out,thereby lengthening and extending the palatal flap. Reproduced with permission from theAmerican Academy of Periodontology.28

‡ Vicryl sutures, Biosense Webster, Diamond Bar, CA.§ Gore-Tex sutures, W.L. Gore & Associates, Flagstaff, AZ.


12

After 1 week, the clot is replaced by granulation tis-sue. In 2 weeks, the flap is attached to bone via imma-ture collagen fibers.35 However, healing may bedelayed because the barrier can interfere with vascu-larization of the flap. If a particulate graft was placed,4 to 6 months is needed for graft calcificationbefore an implant should be placed,36 and followinga cortical block graft, 4 to 5 months is needed for heal-ing.37

It is possible that biologics, such as platelet-richplasma, may enhance results with regard to the rapid-ity of soft tissue healing. However, it was decided tolimit this technique article to discussions about softtissue management and not to address agents thatmay affect results.

COMPLICATIONS

Undersizing Flap AdvancementWhen doing a procedure such as a ridge augmenta-tion, a common error is to underprepare the flap,which results in failure to achieve tensionless closure.If the tissue is not adequately released, primary clo-sure will not be attained or too much tension will needto be placed on the sutures in an attempt to close thewound. This can result in suture necrosis and a dehis-cence along the suture line. To avoid this dilemma, itis advantageous to prepare the flap for advancementprior to placing bone grafts and barriers. The size ofthe projected augmentation in width and height deter-mines how far the tissue needs to be advanced. In gen-eral, the buccal flap should be able to be displaced 3 to5 mm over the palatal/lingual tissue before even start-ing a large GBR procedure. To accommodate the aug-mentation, additional flap advancement may berequired, and the final releasing of the tissue shouldbe done if needed after the bone and barriers are inplace.

Shrinkage of the augmented ridge after a GBR pro-cedure is commonplace. Clinicians should expectnon-uniform shrinkage in height and width, rangingfrom 39.1% to 76.3%.38 Therefore, the augmentationmust be initially overbuilt. Furthermore, the height ofthe augmentation should be dictated by the desiredheight of the interproximal tissue at the future restoredsite and not by the anticipated mid-buccal contour.

Ecchymosis and EdemaSwelling can begin minutes to hours after surgery andcontinue for 48 to 72 hours before it peaks.39,40

Edema may not extend equally in all directions fromthe injured site. A possible reason for this is that mus-cle attachments, fascia, and structures, such as bone,guide swelling.41 The above tissue alterations cancause discomfort and reduced function. After surgery,patients should apply ice for 10 minutes on and 10minutes off until retiring that evening.42 Ecchymosis

may appear adjacent to the surgery, or it may befound at the inferior aspect of the jaw or even on thechest. Ecchymoses do not affect the results and donot require therapy. They may be disconcerting tothe patient, and reassurance may be needed. In gen-eral, avoidance of penetrating too far into the sub-mucosa when making incisions to facilitate flapadvancement helps to reduce the amount of postop-erative swelling and bleeding.

BleedingA good medical history helps to avoid untoward bleed-ing due to drug-related coagulopathy. Intraoperativehemostasis is usually not a problem if tissues are man-aged gently. Exuberant bleeding can usually be con-trolled with pressure, epinephrine in the anesthetic,and sutures. After surgery, too much activity shouldbe avoided. Postoperative bleeding along the sutureline may be due to the epinephrine in the anestheticwearing off. Pressure for 5 minutes usually resultsin clotting (bleeding time is 2 to 9 minutes).30

Failure to achieve hemostasis dictates that the flapbe reopened. The soft and hard tissues need to be in-spected for bleeding points. Bleeding vessels withinthe flap need to be ligated, and bleeding from nutri-ent vessels within the bone should be obtunded. Theincision needs to be resutured, and coaptation of theflaps should be checked by gently rubbing a peri-odontal probe across the suture line. If a hematomadevelops during the first 24 hours after therapy andcauses discomfort or distorts the flap, it should beevacuated and the wound resutured.

When doing a split-thickness palatal flap, the clini-cian must be prepared to manage accidental damageto the greater palatine artery. If the artery is injured,apply pressure to control hemorrhaging, then take acurved hemostat(s) and clamp the palatal flap adja-cent to where the split of the palatal tissue was made.If the bleeding vessel is visible, ligate it or apply elec-tric cautery. Additional deep sutures may be needed ifthe bleeding vessel is not visible.

InfectionsAfter the first 72 hours, erythema, edema, tenderness,and exudation are indicative of infection. If there issuppuration, a culture should be taken and an antibi-otic prescribed. The presence of fluctuance dictatesthat the area should be incised and a drain placedfor several days.

DehiscenceThe main cause of wound dehiscences is failure toprovide tensionless closure. Other reasons for a de-hiscence are infection, trauma from opposing den-tition, irritation from a removable prosthesis, andhematoma development. If a patient brushes on thesutures prematurely it can result in a dehiscence. If


13

a dehiscence develops, the chance of a successfulaugmentation is reduced. Do not attempt to resuturea dehiscence. Let it heal by secondary intention andmonitor the patient.

NecrosisIf the blood supply to the flap is compromised, it canresult in ischemia and, subsequently, tissue necrosis.If this occurs, it may be due to sutures that were tootight, paracrestal incisions, or poor flap design result-ing in thin tissue margins, thereby excluding an ade-quate blood supply. Increased wound tension couldalso induce necrosis of the flap margins, resulting ina soft tissue dehiscence.

Loss of the VestibuleFlap advancement to cover a large bone regenerationprocedure may result in partial or total loss of the ves-tibule adjacent to the surgical site. Coronal position-ing of the tissue often distorts the topography of thevestibule and alters the mucogingival line with the ad-jacent tissues (Fig. 3H). In extreme cases, the patientmay also feel that the lip is tethered (tied down). Afterthe augmentation has healed, the vestibule needs tobe reconstituted. This can be accomplished in differ-ent ways: a split-thickness flap with tacking of the flapat the level of the vestibule; a subepithelial connectivetissue graft or a free gingival graft may or may not beplaced over the connective tissue bed created by thesplit-thickness flap; or laser therapy. It is appropriateto inform patients in advance that multiple revisionsmay be part of the treatment.

CONCLUSIONS

One of the important factors in achieving successfulGBR is providing tensionless primary closure oversurgical sites. The extent of the bone augmentationis the critical determinant dictating the distance thattissues need to be coronally positioned. This articlereviewed several techniques that can achieve thisobjective. The simplest technique that can providetensionless primary closure should be selected, be-cause it will be associated with the least amount ofmorbidity. Inability to attain closure with a simplermethod does not preclude using more advanced out-lined methods. However, careful consideration needsto be given to the merits of each technique prior toinitiating incisions to avoid creating unnecessarywounds. Clinicians need to make a judgment call asto which technique they believe will provide the opti-mal result. This decision should take into account thesize of the augmentation, elasticity of the patient’s tis-sue, oral musculature, size of the vestibule, operatorexperience and preference, and the patient’s willing-ness to undergo these procedures as opposed to aprosthetic solution with pink porcelain.

ACKNOWLEDGMENT

The authors report no conflicts of interest related tothis study.

REFERENCES1. Mercandetti M. Woundhealing,healingand repair.Avail-

able at: http://www.emedicine.com/plastic/TOPIC411.HTM. Accessed May 10, 2008.

2. Martin M, Gantes B, Garrett S, Egelberg J. Treatmentof periodontal furcation defects. (I). Review of theliterature and description of a regenerative surgicaltechnique. J Clin Periodontol 1988;15:227-231.

3. Ruben MP. Rationale for periosteal fenestration inmucogingival surgery. Quintessence Int Dent Dig1977;8:71-72.

4. Carranza FA Jr., Carraro JJ, Dotto CA, Cabrini RL.Effect of periosteal fenestration in gingival extensionoperations. J Periodontol 1966;37:335-340.

5. Hurzeler MB, Weng D. Functional and esthetic out-come enhancement of periodontal surgery by appli-cation of plastic surgery principles. Int J PeriodonticsRestorative Dent 1999;19:36-43.

6. Bjorn H, Hollender L, Lindhe J. Tissue regeneration inpatients with periodontal disease. Odontol Revy 1965;16:317-326.

7. Orban BJ. Oral mucous membrane. In: Sicher H, ed.Orban’s Oral Histology and Embryology, 6th ed. St.Louis: C.V. Mosby; 1966:213-265.

8. Bevalnder G. Outline of Histology, 6th ed. St. Louis:C.V. Mosby; 1967:10-34.

9. Norton NS, ed. Netter’s Head and Neck Anatomy forDentistry. Philadelphia: Saunders; 2007:177.

10. Possoff A. External thermal applications in postex-traction therapy. J Am Dent Assoc 1955;50:147-156.


12. Bennet CR. Manheim’s Local Anesthesia and Pain Con-trol in Dental Practice. St. Louis: C.V. Mosby; 1974:72.


14. Canan S, Asim OM, Okan B, Ozek C, Alper M.Anatomic variations of the infraorbital foramen. AnnPlast Surg 1999;43:613-617.

15. Sujatha N, Manjunath KY, Balasubramanyam V. Vari-ations of the location of the greater palatine foramina indry human skulls. Indian J Dent Res 2005;16:99-102.

16. Reiser GM, Bruno JF, Mahan PE, Larkin LH. Thesubepithelial connective tissue graft palatal donor site:Anatomic considerations for surgeons. Int J Periodon-tics Restorative Dent 1996;16:130-137.

17. Mraiwa N, Jacobs R, Moerman P, et al. Presence andcourse of the incisive canal in the human mandibularinterforaminal region: Two-dimensional imaging ver-sus anatomical observations. Surg Radiol Anat 2003;25:416-423.


19. Behnia H, Kheradvar A, Shahrokhi M. An anatomicstudy of the lingual nerve in the third molar region.J Oral Maxillofac Surg 2000;58:649-651.

20. Pogrel MA, Goldman KE. Lingual flap retraction forthird molar removal. J Oral Maxillofac Surg 2004;62:1125-1130.

21. Norton NS, ed. Netter’s Head and Neck Anatomy forDentistry. Philadelphia: Saunders, 2007:349.


14

22. Hofschneider U, Tepper G, Gahleitner A, Ulm C.Assessment of the blood supply to the mental regionfor reduction of bleeding complications during implantsurgery in the interforaminal region. Int J Oral MaxillofacImplants 1999;14:379-383.

23. Raucher G. Preoperative evaluation and manage-ment. Available at: http://www.emedicine.com/derm/topic819.htm. Accessed April 27, 2007.

24. Lambrecht JE, Hamilton W, Rabinovich A. A review ofherb-drug interactions. Documented and theoretical.Available at: http://www.uspharmacist.com/oldformat.asp?url=newlook/files/comp/aug00alt.htm. AccessedApril 27, 2007.

25. Cranin AN. Implant surgery: The management of softtissues. J Oral Implantol 2002;28:230-237.

26. Silverstein LH. Principles of Dental Suturing. Mahwah,NJ: Montage Media; 1999:70-75.

27. Sclar AG. Surgical techniques for management ofperi-implant soft tissues. In: Soft Tissue Esthetic Con-siderations in Implant Therapy. Chicago: Quintes-sence Books; 2003:47-51.

28. Fugazzotto PA. Maintenance of soft tissue closure follow-ing guided bone regeneration: Technical considerationsand report of 723 cases. J Periodontol 1999;70:1085-1097.

29. Ethicon. VICRYL. Available at: http://www.ethicon.com/content/backgrounders/www.ethicon.com/www.ethicon.com/vicryl_epi.pdf. Accessed June 11, 2008.

30. Patient UK. Bleeding time. Available at: http://www.mclno.org/webresources/pathman/BT_web/Bleeding_time.htm. Accessed June 20, 2008.

31. MCL Web Resources. Precautions for patients on ste-roids undergoing surgery. Available at: http://www.patient.co.uk/showdoc/40024472. Accessed June 20,2008.

32. Engler WO, Ramfjord SP, Hiniker JJ. Healing followingsimple gingivectomy. A tritiated thymidine radioauto-graphic study. I. Epithelialization. J Periodontol 1966;37:298-308.

33. RamfjordSP, EnglerWO, Hiniker JJ. A radioautographicstudy of healing following simple gingivectomy. II. Theconnective tissue. J Periodontol 1966;37:179-189.

34. Misch CE. Bone augmentation for implant placement:Keys to bone grafting. In: Misch CE, ed. ImplantDentistry, 2nd ed. St. Louis: Mosby; 1999:453.

35. Hiatt WH, Stallard RE, Butler ED, Badgett B. Repairfollowing mucoperiosteal flap surgery with full gingivalretention. J Periodontol 1968;39:11-16.

36. Tischler M, Misch CE. Extraction site bone grafting ingeneral dentistry. Review of applications and princi-ples. Dent Today 2004;23:108-113.

37. Pikos MA. Block autografts for localized ridge aug-mentation: Part II. The posterior mandible. ImplantDent 2000;9:67-75.

38. Simon BI, Von Hagen S, Deasy MJ, Faldu M, ResnanskyD. Changes in alveolar bone height and width followingridge augmentation using bone graft and membranes.J Periodontol 2000;71:1774-1791.

39. Seymour RA, Meechan JG, Blair GS. An investigationinto post-operative pain after third molar surgery underlocal analgesia. Br J Oral Maxillofac Surg 1985;23:410-418.

40. Meechan JG, Seymour RA. The use of third molarsurgery in clinical pharmacology. Br J Oral MaxillofacSurg 1993;31:360-365.

41. Deal DN, Tipton J, Rosencrance E, Curl WW, Smith TL.Ice reduces edema. A study of microvascular perme-ability in rats. J Bone Joint Surg Am 2002;84-A:1573-1578.

42. Greenstein G. Therapeutic efficacy of cold therapyafter intraoral surgical procedures: Literature review.J Periodontol 2007;78:790-800.

Correspondence: Dr. Gary Greenstein, 900 W. Main St.,Freehold, NJ 07728. Fax: 732/780-7798; e-mail: [email protected].

Submitted June 24, 2008; accepted for publication August3, 2008.


15

flap advancement: practical techniques to attain tension ...flap advancement: practical techniques...

Documents