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Management of a Coronally Advanced Lingual Flap in Regenerative Osseous Surgery: A Case Series Introducing a Novel Technique

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One of the crucial factors in the success of guided bone regeneration procedures is the correct management of the soft tissues. This allows for stable primary wound closure without tension, which can result in premature exposure of the augmentation area, jeopardizing the final outcome. The use of vertical and periosteal incisions to passivate buccal and lingual flaps in the posterior mandible is often limited by anatomical factors. This paper reports on a series of 69 consecutive cases introducing a novel surgical technique to release and advance the lingual flap coronally in a safe and predictable manner.
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Volume 31, Number 5, 2011
505
Management of a Coronally Advanced
Lingual Flap in Regenerative Osseous
Surgery: A Case Series Introducing a
Novel Technique
Marco Ronda, MD, DDS*
Claudio Stacchi, DDS, MSc**
The effectiveness of guided bone
regeneration (GBR) procedures
to promote horizontal and verti-
cal bone regeneration has been
well documented.1–9 Moreover, the
stability of regenerated bone and
its favorable response under func-
tional loading have been demon-
strated.10–13 The ideal goal of this
therapy has shifted from regener-
ating sufcient bone to place im-
plants to reconstructing hard and
soft tissues similar to the prepatho-
logic condition. Vertical GBR is a
technique with great potential, but
it is very demanding for surgical
skills. The careful management of
the soft tissues is key to the success:
Obtaining and maintaining primary
closure of the ap during healing is
necessary to prevent contamination
and infection of the membrane, an
event that always compromises
the augmentation procedure.14,15
Maintaining closure of the ap over
nonresorbable membranes is even
more challenging when compared
to other augmentation procedures
(eg, bone grafting, split crest tech-
niques) because expanded polytet-
rauoroethylene separates the ap
One of the crucial factors in the success of guided bone regeneration
procedures is the correct management of the soft tissues. This allows for
stable primary wound closure without tension, which can result in premature
exposure of the augmentation area, jeopardizing the nal outcome. The
use of vertical and periosteal incisions to passivate buccal and lingual aps
in the posterior mandible is often limited by anatomical factors. This paper
reports on a series of 69 consecutive cases introducing a novel surgical
technique to release and advance the lingual ap coronally in a safe and
predictable manner. (Int J Periodontics Restorative Dent 2011;31:505–513.)
*Private Practice, Genova, Italy.
** Contract Professor, Department of Biomedicine, University of Trieste, Trieste, Italy.
Correspondence to: Dr Marco Ronda, Piazza Brignole 3/8, 16122 Genova, Italy;
fax: +39 010 583435; email: mronda@panet.it.
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The International Journal of Periodontics & Restorative Dentistry
506
from the underlying periosteal vas-
cularization, depriving it of an im-
portant blood supply. Numerous
studies have suggested a variety
of clinical protocols for the man-
agement of soft tissues.16–21 In this
paper, a novel technique for the
coronal displacement of the lingual
ap is described and its clinical ef-
cacy to obtain and maintain pri-
mary closure on the augmentation
area for the entire healing period
evaluated.
Method and materials
Fifty-two patients requiring dental
implants in the posterior mandi-
ble were enrolled in this study. Of
these, 38 (73.1%) were women and
14 (26.9%) were men, with an age
range from 25 to 79 years (mean,
50.9 ± 12.1 years). Twenty patients
were light smokers (38.5%) and
32 were not smokers (61.5%). The
inclusion criteria were mandibu-
lar partial edentulism (Applegate-
Kennedy Class I or II) involving the
premolar/molar area and an as-
sociated presence of crestal bone
height < 7 mm coronal to the man-
dibular canal. General exclusion
criteria were acute myocardial in-
farction within the past 6 months,
uncontrolled coagulation disorders
or metabolic diseases, radiotherapy
to the head or neck region within
the past 24 months, treatment with
intravenous bisphosphonates, psy-
chologic or psychiatric problems,
heavy smoking (> 10 cigarettes/
day), and alcohol or drug abuse.
The local exclusion criterion was the
presence of uncontrolled periodon-
tal disease. All patients signed a
written informed consent form.
At the initial visit, all subjects
underwent clinical examination
with periapical and panoramic ra-
diographs. A prosthetic evalua-
tion with a diagnostic wax-up was
accomplished, and a computed
tomography (CT) scan with a tem-
plate was created to plan implant
surgery. A total of 69 sites in the
posterior mandible were treated by
insertion of dental implants associ-
ated with vertical bone augmenta-
tion procedures.
Surgical protocol
All surgeries and postoperative visits
were conducted by a single opera-
tor. Under local anesthesia (4% ar-
ticaine with epinephrine 1:100,000;
Septanest, Ogna), a full-thickness
crestal incision was performed in
the keratinized tissue from the dis-
tal surface of the more distal tooth
to the retromolar pad, continuing
the incision in the mandibular ra-
mus for 1 cm, and nishing with a
releasing incision on its lateral sur-
face. To preserve the lingual nerve
when approaching the second mo-
lar area, the blade was inclined ap-
proximately 45 degrees with the tip
in a vestibular direction, and the ex-
ternal oblique ridge was used as a
marker for the incision going distally
and buccally, bearing in mind that
the ramus of the mandible ares
up laterally and posteriorly. When
there was a tooth still present pos-
terior to the augmentation area,
the incision continued 5 mm distal
from it before performing the re-
leasing incision.
The ap design was continued
intrasulcularly on both vestibular
and lingual sides of the mesial por-
tion of the ap. Buccally, it involved
two teeth before nishing with a
vertical hockey stick releasing inci-
sion.22 Lingually, it involved one
tooth to the gingival zenith and
then continued horizontally in a
mesial direction for 1 cm in the
kera tinized tissue. A full-thickness
vestibular ap was elevated and,
after isolating the mental nerve, re-
leased with a longitudinal perioste-
al incision avoiding the mental
foramen area. This slight horizontal
cut, performed using a new blade,
was extended from the distal to the
mesial releasing incisions covering
the entire length of the ap. On the
lingual side, a full-thickness muco-
periosteal ap was elevated until
reaching the mylohyoid line. Then,
using a blunt instrument (eg, a
Pritchard elevator), it was localized
a connective tissue band continu-
ing with the epimysium of the my-
lohyoid muscle (Fig 1). This band,
usually located in the rst molar
area, is 1 to 2 cm wide in a mesio-
distal direction and is inserted into
the inner part of the lingual ap ap-
proximately 5 mm from the crest in
an apical direction. The blunt in-
strument was inserted below the
connective band, and, with gentle
traction in the coronal direction,
this muscular insertion was de-
tached from the lingual ap (Figs 2
and 3). The vertical augmentation
procedure was then performed
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Volume 31, Number 5, 2011
507
using a titanium-reinforced ex-
panded polytetrauoroethylene
Gore-Tex membrane (W.L. Gore)
with a composite bone graft. The
grafting material consisted of a 1:1
mixture of mineralized bone al-
lograft (Puros, Zimmer) and autog-
enous bone harvested from the
external oblique ridge with bone
scrapers (Safescraper, Meta).
The implant site prepara-
tions were made using twist drills
and nalized in the last portion
over the mandibular canal with an
OT4 piezoelectric insert (Piezosur-
Fig 1 Cross-sectional anatomical drawing of the rst molar region showing the insertion of the mylohyoid muscle into the lingual ap and
its relations with other anatomical structures of the area.
Fig 2 Detachment of the mylohyoid muscle insertion from the lin-
gual ap was accomplished by applying gentle traction with a blunt
instrument in a coronal direction.
Fig 3 Cross-sectional anatomical drawing of the rst molar region
representing the situation after detachment of the muscular inser-
tion from the lingual ap.
Muscular insertion into the lingual ap
Mylohyoid muscle
Sublingual gland
Wharton duct
Lingual nerve
Hypoglossus nerve
Lingual artery
Submandibular gland
Facial artery
Submandibular lymphnode
Facial vein
Lingual vein
Muscular insertions
after detachment
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The International Journal of Periodontics & Restorative Dentistry
508
gery, Mectron). Implants were then
placed (Spline Twist and Tapered
Screw-Vent, Zimmer) and left to pro-
trude from the original bone level
for the amount of planned vertical
regeneration (Fig 4). After multiple
perforations of the cortical bone,
performed using an OP5 piezo-
electric insert, the composite graft
was positioned and the membrane
was adapted and xed with lingual
and buccal xation tacks (Micropin,
Omnia). The mucoperiosteal aps
were tested for their passivity and
their capability to be displaced to
cover the augmentation area com-
pletely. A double line of suturing
was performed: Horizontal mattress
sutures were used for close contact
between the inner connective por-
tions of the aps, then multiple in-
terrupted sutures (Gore-Tex CV5,
W.L. Gore) followed (Fig 5).
Amoxicillin/clavulanate potas-
sium (875 + 125 mg) and ibuprofen
(600 mg) were prescribed twice a
day for 1 week. Patients were also
instructed to rinse twice a day with
a 0.2% chlorhexidine solution and
to avoid mechanical plaque remov-
al in the surgical area until sutures
were removed. Sutures were re-
moved 10 to 12 days after surgery.
Postsurgical visits were scheduled
at 15-day intervals to check the
course of healing and to verify pri-
mary wound closure in the postop-
erative period. Successful primary
closure was dened as complete
coverage of the membrane for at
least 6 months after the augmen-
tation procedure. Any membrane
exposure was considered a loss of
primary closure and a failure for the
aims of this study.
Statistical analysis
The chi-square test was performed
to analyze nonparametric data
obtained in this study (SPSS 16.0,
IBM).
Fig 4 Implants inserted in place and left to protrude 8 mm from
the original bone level. The membrane is already xed on the lin-
gual side and some cortical perforations are visible.
Fig 5 Primary closure of the aps over the augmentation area with
two lines of sutures.
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Volume 31, Number 5, 2011
509
Results
A total of 69 consecutive vertical
GBR procedures were performed in
this study, with the contextual inser-
tion of 187 implants. The amount
of required vertical regeneration
around implants ranged from 1.1 to
12 mm (mean, 5.2 ± 1.8 mm). The
distribution of the surgical sites by
maximum amount of vertical re-
generation required per site is sum-
marized in Table 1. There were no
dropouts during the entire observa-
tion period. Coronal displacement
of the aps was sufcient to obtain
a complete and passive coverage in
all 69 augmented sites. During the
postoperative period, there were
no recorded hemorrhagic prob-
lems or neurosensory changes. No
evidence of adverse local or sys-
temic side effects was observed in
65 sites throughout the study; in 4
sites, although primary closure of
the aps was perfectly maintained,
there were signs of infection in the
augmented zone (swelling and pu-
rulent exudate) during the rst 2
weeks after surgery. In these cases,
membranes and implants were im-
mediately removed (overall failure
rate, 5.8%). Three of the 4 unsuc-
cessful sites were in smokers (11.1%
failure in the smokers group, 2.4% in
the nonsmokers group). The higher
failure rate in the smokers group re-
sulted in a statistically signicant dif-
ference (P < .001).
No membrane exposure was
observed in any patient during the
entire healing period (Fig 6). Six
months after surgery, the mem-
branes were removed, and im-
plants were connected with healing
abutments (Figs 7 and 8).
Discussion
GBR procedures have evolved
greatly over the last 15 years, al-
lowing for predictable implant
placement in horizontally and ver-
tically augmented ridges.7–13 The
success of this technique is depen-
dent on strict observation of the
surgical protocols. A crucial factor
is to achieve and maintain primary
closure of the aps for the entire
healing period. Flap management
has to fulll two main requirements:
It must allow for complete and pas-
sive coverage of the augmented
zone without any residual tension,
and it must be safe for the adjacent
anatomical structures.
The handling of the soft tissues
has been analyzed in numerous
studies,17–24 but most of them are
focused on the management of the
Table 1 Distribution of surgical sites by amount of vertical
augmentation required
Vertical regeneration No. of sites
< 3 mm 0
3–6 mm 42
6.1–9 mm 24
> 9 mm 3
Total 69
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The International Journal of Periodontics & Restorative Dentistry
510
palatal ap. Coronal displacement
of the lingual ap, essential to GBR
in the posterior mandible, has been
well described7–9,22: After full-
thickness elevation beyond the my-
lohyoid line, a slight mesiodistal in-
cision of the periostium was
performed to advance the ap cor-
onally. This technique is very effec-
tive but, in unexperienced hands,
could be potentially harmful for the
delicate anatomical structures of
the oor of the mouth. The surgical
technique of the coronally ad-
vanced lingual ap presented in
this study is fundamentally based
on the separation of the lingual ap
and the underlying muscular struc-
tures in the molar area. From anato-
my, it is known that the most
posterior portion of the mylohyoid
muscle arises from the lingual tuber-
osity, just below the retromolar pad.
Further, in the molar region, it is lo-
cated very close to the attachment
of the mucous membrane to the
mandible; in the premolar region,
the attachment drops suddenly to a
lower level, giving a distinct step in
the line of origin.25 These anatomi-
cal factors suggest that the close
contact between the mylohyoid
muscle and the lingual ap in the
molar area is an important limitation
in obtaining coronal displacement.
For this reason, the detachment of
the mylohyoid insertion in the molar
zone allows the lingual ap addition-
al extended movement in the coro-
nal direction, enhancing its mobility
greatly (Fig 9). The separation be-
tween the muscle and ap was ob-
tained using a blunt instrument by
applying gentle traction force in a
coronal direction to the connective
tissue, continuing with the epimy-
sium of the mylohyoid muscle with-
out endangering local anatomical
Fig 6 (left) At 6 months, primary closure was perfectly
maintained, and soft tissues appeared healthy.
Fig 7 At removal, the membrane was stable and perfectly adher-
ent to the crest. The regenerated tissue covered the implants, lling
the space delimited by the membrane completely.
Fig 8 Occlusal view of the implants with healing abut-
ments; the height and thickness of the crest were restored
satisfactorily.
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Volume 31, Number 5, 2011
511
Fig 9a Coronal displacement of a lingual ap measured in the mesial
portion after full-thickness elevation until the mylohyoid line (10 mm).
Fig 9b Coronal displacement of the same ap measured in the distal
portion after full-thickness elevation until the mylohyoid line (15 mm)
Fig 9c Detachment of the muscular insertion from the ap obtained
with gentle traction in the coronal direction using a blunt instrument.
Fig 9d Enhancement in coronal displacement of the ap measured
in the mesial portion (19 mm) after detachment of the muscular inser-
tion. Compare to Fig 9a (baseline).
Fig 9e Measurement of coronal advancement obtained in the distal
portion of the ap (29 mm) after detachment of the muscular inser-
tion. Compare to Fig 9b (baseline).
a
c
b
d
e
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The International Journal of Periodontics & Restorative Dentistry
512
structures (eg, lingual nerve, lingual
artery, sublingual gland). Further-
more, with this technique, the lin-
gual ap is elevated only until the
mylohyoid line and not beyond, as
proposed previously,22 providing ad-
ditional protection to the underlying
anatomical structures.
Primary closure of the ap was
maintained in all cases considered
in this study. The four early infec-
tions were likely a result of intra-
operative contamination of the
composite bone graft with bacteria
present in saliva.26 Moreover, the
data seem to conrm, in accor-
dance with the literature,27–29 that
smoking could be a signicant risk
factor that can jeopardize the out-
come of regenerative procedures.
Conclusions
In this case series, the authors in-
troduce a novel technique to cor-
onally advance the lingual ap in
regenerative surgery. In the cases
considered, the proposed surgical
management of the lingual ap re-
sulted in a 100% success rate in the
maintenance of soft tissue primary
closure for a period of 6 months
postoperatively. Moreover, this sur-
gical approach allows for safe dis-
placement of the lingual ap. The
use of blunt instruments and the
elevation limited to the mylohy-
oid line minimize the possibility of
potential damages to the delicate
anatomical structures of the oor of
the mouth.
Acknowledgments
The authors wish to thank Prof Massimo Si-
mion for his precious teaching and sharing
his broad experience and knowledge in the
eld of regenerative techniques. In addition,
grateful thanks are extended to Mrs Laura
Grusovin for her anatomical drawings.
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... N generated a lower rate of dehiscence and that in turn, stress greater than 0.1 N increased the percentage of dehiscence significantly. In recent years various articles have been published on the manipulation of flaps to prevent dehiscence and achieve primary wound closure, although their evidence is limited given that they refer only to standard case studies [12,[17][18][19]. Jensen & Terheyden (2009) consider that another of the variables that could cause dehiscence is the morphology of the block. ...
... These clinical conclusions are in line with our mathematical findings, as we obtained 75% more Von Mises stress in the suppositions with 0.20 N stress applied to the incision (right-angled and rounded angled) when compared to the lowest suture tension applied (0.05 N). It is worth remembering that to achieve primary wound closure with no tension during the healing process it is necessary to prevent contamination and infection of the graft and, ultimately, protect the bone regeneration process [12,13,18]. ...
... It is necessary to bear this factor in mind, as complications of the regeneration can also be due to a fenestration of the soft tissue at this level [53]. Looking at the analysis of the stress distribution map, the bone block with right angles showed a greater amount of stress at both a crestal and apical vestibular level in the area in contact with the microscrew [18]. In our study, the bone block was fixed with microscrews which were modelled with surgical steel, as affirmed by the studies [11,12,54]. ...
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Edentulism produces resorption of alveolar bone processes, which can complicate placement of dental implants. Guided bone regeneration techniques aim to recover the volume of bone. These treatments are susceptible to the surgical technique employed, the design of the autologous block or the tension of the suture. These factors can relate to major complications as the lack of primary closure and dehiscence. The present study, using finite element analysis, aimed to determine differences in terms of displacement of the oral mucosa, transferred stress according to Von Mises and deformation of soft tissue when two block graft designs (right-angled and rounded) and two levels of suture tension (0.05 and 0.2 N) were combined. The results showed that all the variables analyzed were greater with 0.2 N. Regarding the design of the block, no difference was found in the transferred stress and deformation of the soft tissue. However, displacement was related to a tendency to dehiscence (25% greater in the right-angled/chamfer design). In conclusion different biomechanical behavior was observed in the block graft depending on the design and suture tension, so it is recommended to use low suture tension and rounded design. A novel finite element analysis model is presented for future investigations.
... Risk factors for this complication are, among others, suturing technique, suture material, and flap design (10)(11)(12). Non-resorbable membranes are widely employed in vertical ridge augmentation procedures (13,14). These barriers are particularly susceptible to wound dehiscencies, because membrane exposure usually leads to contamination, thus compromising the final results (15). ...
... These barriers are particularly susceptible to wound dehiscencies, because membrane exposure usually leads to contamination, thus compromising the final results (15). In vertical augmentations performed in the posterior area of the mandible, where soft tissues are thin, and flap borders need to be stretched, membrane exposure might be more common (14)(15)(16). Therefore, optimal soft tissue management is required to achieve a primary closure of the flap without tension and to prevent infection of the membrane and the underlying material (10,17). ...
... If premolars were present, a sulcular incision in the buccal side and in the second premolar in the lingual side was carried out. Finally, a buccal vertical releasing incision of 9 mm (beyond the mucogingival junction) was performed, and a lingual vertical releasing incision of 4 mm at the mesial side of the second premolar (14,22). Then a full-thickness flap was raised both buccally and lingually. ...
Article
Background: One of the most frequent complications in guided bone regeneration (GBR) is wound dehiscence, which compromises treatment outcomes. Thus, primary tension-free suture is essential to avoid wound dehiscence. The purpose of this study was to compare the extension of 2 different mandibular flaps in human cadaveric specimens, and to measure the size of the supraperiosteal blood vessels. Material and methods: Five freshly unfrozen human cadaveric specimens were used. Arteries and veins were marked and bilateral classical lingual flaps (extending from the second premolar to the retromolar area) were prepared. In one side, the mylohyoid muscle was detached to increase the coronal extension of the flap. An implant drill was used to measure the extension of the flap after exerting 30 g of traction, before and after detaching the mylohyoid muscle. The size of the largest vascular structures of the flap was measured using a periodontal probe. Results: The classical flap extension was 5.99 mm (95% confidence interval (CI): 5.08 to 6.90), while the coronally advanced flap extension with mylohyoid muscle detachment was 14.96 mm (95%CI: 10.81 - 19.11). A statistically significant difference was found between the 2 groups (p= 0.0002), with a mean extension difference was 8.97 mm (95%CI: 5.02 to 12.91). The mean largest artery had 0.20 mm of diameter (95%CI: 0.15 - 0.26). Conclusions: The detachment of the mylohyoid muscle from the lingual flap allows to significantly increase its extension by 2.5 times. The superficial arteries found in the lingual flap have a small diameter (around 0.2mm).
... 11 In order to overcome these drawbacks, other techniques that avoid injury to the periosteum have been proposed, with the aim of preventing periosteal fenestrations. These include the double flap incision (DFI), 11 the coronally advanced lingual flap (CALF), 12 and the modified periosteal releasing incision (MPRI). 13 It was hypothesized that these other techniques of flap advancement may lead to superior bone gain when compared to the PRI. ...
... 13 In group 4 (CALF), the flap was advanced on the buccal aspect using the classic PRI, while on the lingual aspect the mylohyoid muscle was detached to allow lingual advancement. 12 Decortication was performed on the crestal and buccal parts of the ridge using a low-speed surgical round bur under copious irrigation 16 (Fig. 1). ...
Article
The aim of this study was to investigate and compare the clinical and radiographic bone gain in guided bone regeneration with titanium mesh, for four different advancement techniques: periosteal releasing incision (PRI), double flap incision (DFI), modified periosteal releasing incision (MPRI), and coronally advanced lingual flap (CALF). Forty patients with a partially edentulous mandible were allocated randomly to four study groups (PRI, DFI, MPRI, CALF; 10 patients in each). Clinical bone gain (primary outcome) and radiographic bone gain were evaluated. In addition, correlations between study variables (clinical and radiographic bone gain, flap advancement, mesh exposure area and percentage exposure, pain, and swelling) were explored. CALF exhibited the highest mean clinical bone gain (4.12 ± 1.37 mm) and PRI the lowest (2.60 ± 1.36 mm); the mean clinical bone gain differed significantly among the groups (P < 0.001). The highest mean radiographic bone gain was seen in the CALF group (3.54 ± 1.65 mm) and the lowest in the PRI group (2.06 ± 1.11 mm); the mean radiographic bone gain also differed significantly among the groups (P < 0.001). The correlation analysis revealed positive correlations between flap advancement and radiographic bone gain (P = 0.003) and between swelling and pain (P = 0.007). An inverse correlation was found between flap advancement and swelling (P = 0.049), mesh exposure area and clinical bone gain (P = 0.022), and mesh exposure percentage and clinical bone gain (P = 0.017). In summary, the highest clinical and radiographic bone gain was observed for CALF, while the lowest was observed for PRI.
... Following local anaesthesia (Articaine Hydrochloride/ Adrenaline) access to the edentulous ridge ridge was performed with a 15C Blade using intrasulcular buccal and lingual incisions from the distal area of tooth 33 till the distal aspect of tooth 37and a mid-crestal incision on edentulous site 35. The area of interdental papilla was carefully dissected in split thickness and 2 flaps (buccal-lingual) were meticulously elevated and further released with a periosteal incision at the buccal side and stretching of the mylohyoid muscle fibres using a periosteal elevator [17] (Figure 6). An alveolar ridge expansion protocol using Densah drills [18] (Versah LLC, Michigan, USA) followed on site 35 for the drilling preparation and an MIS V3 3.9 diameter and 10mm length implant (MIS Implants Technologies, BAR-LEV, Israel) was inserted sub-crestaly with a torque of 25 N.cm. ...
... Following local anaesthesia (Articaine Hydrochloride/ Adrenaline) access to the edentulous ridge ridge was performed with a 15C Blade using intrasulcular buccal and lingual incisions from the distal area of tooth 33 till the distal aspect of tooth 37and a mid-crestal incision on edentulous site 35. The area of interdental papilla was carefully dissected in split thickness and 2 flaps (buccal-lingual) were meticulously elevated and further released with a periosteal incision at the buccal side and stretching of the mylohyoid muscle fibres using a periosteal elevator [17] (Figure 6). An alveolar ridge expansion protocol*using Densah drills [18] (Versah LLC, Michigan, USA) followed on site 35 for the drilling preparation and an MIS V3 3.9 diameter and 10mm length implant (MIS Implants Technologies, BAR-LEV, Israel) was inserted sub-crestal with a torque of 25N.cm. ...
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Vertical ridge augmentation is one of the most challenging procedures in implant dentistry because of the advanced skills required by the operator and the fact that bone augmentation is aimed outside the bony contour, in an environment of reduced blood supply. What is more, the flap management required to ensure soft tissue closure frequently leads to associated comorbidities in terms of swelling and hematomas. For these reasons, and even if autologous onlay block grafts are still the gold standard, new techniques and biomaterials have favored the development of potentially less invasive approaches. The present work evaluates the most recent strategies in vertical ridge augmentation to reduce invasiveness and complications, including diagnostic/treatment planning considerations, surgical techniques, digital tools (eg, customized titanium meshes/membranes or bone blocks), and future trends in the field of tissue engineering and cell therapy.
Chapter
This chapter reviews in a concise manner the different methods of ridge augmentation pointing out the relevant points in the literature and fundamentals of healing with the biological component. In this chapter, the reader will also acquaint on how to approach each procedure as well the different flaps and materials.
Chapter
Guided bone regeneration (GBR) is the process of replacing lost tissues with elements to restore normal function and structure for ideal three-dimensional placement of dental implants. GBR is based on guided tissue regeneration and has common mechanical and biological principles; their similarities are obvious throughout the evolution of bone regeneration concepts. There are four fundamental biological principles for successful GBR: primary wound closure, adequate blood supply, clot stability, and space maintenance.Microsurgery was introduced in Periodontology in 1992 for the improvement of surgical techniques. It was made possible by the advancements in visual acuity obtained through the microscope. Microsurgery helps develop motor skills by improving surgical capacity, reduces tissue trauma, and contributes to the primary closure of the wound.The proposed use of the microscope in GBR can aid precision in surgical execution. It has been shown that microsurgery contributes to improved healing and treatment outcomes in other areas of Periodontology.This chapter provides a detailed description of GBR techniques using a surgical microscope (MO) along with information on the elements essential for the application of this technology. The principles of magnification and coaxial light and fundamentals of microsurgery are used for the execution of incisions, release of flaps, preparation of the surgical bed, handling of biomaterials, and membrane fixation, complementing the techniques for flap closure and soft tissue management in regenerative therapy.KeywordsBone regenerationMicrosurgeryMicroscopic periodontal surgeryMicrosurgery in bone regeneration therapyMicrosurgery in process augmentationMicrosurgical flapMicrosurgical regenerative therapies
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Purpose of Review The purpose of the present review was to discuss the success and predictability of vertical ridge augmentation (VRA) with the use of guided bone regeneration (GBR). Recent Findings Weighted mean gains in vertical heights of 8.04 mm (distraction osteogenesis), 4.18 mm (GBR), and 3.46 mm (block grafts) were reported for the specific VRA procedures; however, a superior technique was not identified. Summary VRA with GBR is a technique-sensitive procedure with the potential of regenerating significant heights of vital bone, which should be performed by highly experienced clinicians due to the potential for severe complications. Regardless of the technique used for VRA, two important factors for a successful and predictable outcome are (i) the defect morphology and (ii) the proper flap management/advancement to obtain and retain a tension-free primary closure.
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Statement of problem The use of dense polytetrafluoroethylene (dPTFE) membranes in alveolar ridge preservation may help reduce the risk of bacterial contamination and infection, maintaining the soft-tissue anatomy. However, systematic reviews on their efficacy in postextraction sites are lacking. Purpose The purpose of this systematic review and meta-analysis was to assess the efficacy of alveolar ridge preservation with dPTFE membranes when used alone or in combination with bone grafting materials in postextraction sites. Material and methods An electronic search up to February 2021 was conducted by using PubMed, Embase, and the Cochrane library to detect studies using dPTFE membranes in postextraction sites. An additional manual search was performed in relevant journals. Clinical and radiographic dimensional changes of the alveolar ridge, histomorphometric, microcomputed tomography, implant-related findings, and rate of complications were recorded. One-dimensional meta-analysis was performed to calculate the overall means and 95% confidence intervals (α=.05). Results A total of 23 studies, 14 randomized controlled trials, 4 retrospective cohort studies, 3 case series, and 2 prospective nonrandomized clinical trials, met the inclusion criteria. Five studies were included in the quantitative analysis. The meta-analysis revealed that the use of dPTFE membranes resulted in a statistically significant (P=.042) increase in clinical keratinized tissue of 3.49 mm (95% confidence interval [CI]: 0.16, 6.83) when compared with extraction alone. Metaregression showed that the difference of 1.10 mm (95% CI: -0.14, 2.35) in the radiographic horizontal measurements was not significant (P=.082), but the difference of 1.06 mm (95% CI: 0.51, 1.62) in the radiographic vertical dimensional change between dPTFE membranes+allograft and extraction alone was statistically significant (P<.001). Conclusions The use of dPTFE membranes was better than extraction alone in terms of keratinized tissue width and radiographic vertical bone loss.
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A new flap design, the coronally positioned palatal sliding flap, was used to cover barrier membrane placed over implants in one patient, and to provide localized ridge augmentation around implants in another patient. The method is a valid surgical approach because of the favorable risk-benefit ratio. The surgical technique is easy to to perform, and it is possible to obtain a sufficient sliding position of the palatal tissue. This new palatal flap design may be indicated for a variety of periodontal surgical procedures, including guided tissue regeneration and implant surgery.
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1.The structure of the lower molar region of the mouth has been studied in anatomic preparations and in the living subject.2.The retromolar pad contains an extension of the palatine salivary glands and lies over the retromolar triangle of the mandible, overlapping the attachments of the pterygomandibular raphe, the buccinator and superior constrictor muscles, and the lingual tuberosity.3.The pterygomandibular raphe is not palpable in the living mouth; but the masseter muscle when it is tensed, the superficial and deep tendons of the temporalis muscle, and the anterior border of the medial pterygoid muscle when it is stretched can all be distinguished.4.The muscle band described by Fish7 from the work of Garmany, crossing from the mandible to the tongue behind the alveololingual sulcus, was not found.5.The margins of the buccinator muscle attached to the maxilla and mandible are turned in so as to arise nearer the tooth crowns than is commonly believed. The inner cheek pad of soft but dense connective tissue covers the inner surface of the muscle.
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A severely damaged edentulous ridge frequently obviates the placement of dental implants or results in placing them at an angle that compromises the prosthetic restoration. This paper demonstrates the repair of severely resorbed edentulous ridges by a combination of bone allografting and the placement of a barrier membrane. The damaged edentulous ridge is treated first in this two-stage process. The implants are then installed at a second surgery.
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The purpose of this study was to present the surgical procedures and the clinical results of guided tissue regeneration (GTR) treatment aimed at regenerating local jaw bone in situations where the anatomy of the ridge did not allow the placement of dental implants. 12 patients were selected for ridge enlargement or bony defect regeneration. A combined split- and full-thickness flap was raised in areas designated for subsequent implant placement. Following perforation of the cortical bone to create a bleeding bone surface, a PTFE membrane was adjusted to the surgical site in such a way that a secluded space was created between the membrane and the subjacent bone surface in order to increase the width of the ridge or to regenerate bony defects present. Complete tension-free closure of the soft tissue flap was emphasized. Following a healing period of 6 to 10 months, reopening procedures were performed and the gain of bone dimension was assessed. In 9 patients with 12 potential implant sites, a sufficient bone volume was obtained to allow subsequent implant placement. The gain of new bone formation varied between 1.5 and 5.5 mm. In 3 patients, acute infections developed which necessitated early removal of the membranes and no bone regeneration could be achieved. The results of the study indicate that the biological principle of GTR is highly predictable for ridge enlargement or defect regeneration under the prerequisite of a complication-free healing.
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Insufficient bone volume may be a significant problem in connection with dental implants. In this study, a technique based on the principle of guided tissue regeneration was tested for its ability to generate bone tissue around titanium implants. Implants were inserted in tibiae of rabbits. To create a secluded space for osteogenesis and to prevent soft-tissue ingrowth, a porous Teflon membrane was placed around exposed parts of the implant. Where a membrane had been used, the threads of the implant were completely covered with significant amounts of new bone. This study indicates that the membrane technique is a reconstructive surgical method that may be applicable to create new bone around exposed parts of titanium implants in a clinical setting.
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The recommended modifications of soft-tissue management for two-stage implant surgeries have resulted in improved access for implant placement, accommodation of surgical stents, less formation of cicatrix in the vestibules, better control of flap extensions resulting in improved esthetics, and improved tissue quality for long-term peri-implant maintenance and success. The implication of periodontal guidelines to the uncovering procedure of dental implants result in decreased thickness of peri-implant tissues and less pocket formation around the transmucosal sleeves. These modifications contribute significantly to the long-term periodontal maintenance of peri-implant tissues.
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The purpose of this study was to evaluate: (1) the surgical protocol, effectiveness, and reliability for vertical ridge augmentation using a new titanium-reinforced membrane and osseointegrated implants; and (2) the histologic characteristics of the interface between a pure titanium implant and newly regenerated human bone. Five patients received 15 conical Brånemark-type implants in six different surgical sites requiring vertical augmentation. The implants protruded 4 to 7 mm from the bone crest. Pure titanium miniscrews (1.3 x 10 mm) were positioned distally to the implants, protruding 3 to 4 mm from the bone level. The implants and the miniscrews were covered with a titanium-reinforced membrane, and the flaps were sutured. Membranes were removed at the stage 2 surgery after 9 months of healing. Measurements of biopsy specimens showed a gain in bone height from 3 to 4 mm. Histologic examination showed that all retrieved miniscrews were in direct contact with bone. Histomorphometric analysis of bone contact gave a mean value of 42.5 +/- 3.6% for five of the six examined miniscrews. The results suggest that the placement of implants protruding 3 to 4 mm from the top of resorbed bone surfaces may result in vertical bone regeneration to the top of the implant cylinder and that the regenerated bone is able to osseointegrate pure titanium implants.