Background Vertical bone loss represents a major surgical challenge in the implant treatment of the posterior mandible, due to anatomical factors and technical difficulties. A proper management of the soft tissues is a crucial point for the success in any regenerative procedure: a complete and stable closure of the flaps during the healing is mandatory to prevent contamination and infection and allows for an undisturbed graft healing and incorporation. This prerequisite can be accomplished only if buccal and lingual flap are sufficiently released, in order to obtain a passive coverage of the augmented area, stabilizing it with tension-free sutures. In the posterior mandible, in particular, the use of conventional periosteal incisions is not always sufficient for a proper buccal flap passivation, being often limited by anatomical factors. Aim/Hypothesis This paper reports a series of 76 consecutive cases of vertical guided bone regeneration in the posterior mandible, introducing a novel surgical technique to enhance the coronal advancement of the buccal flap in a safe and predictable way. Material and methods Sixty-four consecutive patients needing dental implants associated to bone augmentation procedures in the posterior mandible were enrolled in this study and treated from February 2010 to June 2013. After raising a full thickness trapezoidal buccal flap, it was passivated with the following procedure: at first a conventional periosteal releasing incision (PRI) was performed, cutting the periosteum in a depth of 1 mm from distal to mesial. The coronal displacement of the flap after PRI was measured with a periodontal probe in three different points of the periosteal incision line (mesial, central and distal). The connective tissue exposed by the PRI in the inner part of the buccal flap, represents the working area where applying the ‘brushing’ technique. Keeping the flap in tension, the blade was used, in the entire working area, with a ‘brushing’ movement in order to interrupt the residual periosteal fibers and to dissect and separate the superficial from the deeper part of the flap. The coronal advancement reached after the ‘brushing’ procedure was measured with a periodontal probe with the previously described modalities. Lingual flap was elevated until reaching the mylohyoid line, and it was released by detaching the insertion of the mylohyoid muscle from the inner part of the flap. Vertical augmentation procedures were then performed using titanium-reinforced d-PTFE membranes and mineralized allograft, contextually to the implants insertion. Results Seventy-six mandibular sites were treated with the insertion of 215 dental implants associated with vertical GBR procedures. The coronal displacement of the buccal flap, after the PRI, varied from 4 to 11 mm (mean 8.4 ± 1.8 mm). After the additional release performed with the ‘brushing’ technique, the buccal flap advancement varied from 10 to 38 mm (mean 21.7 ± 6.3 mm). Mean enhancement in flap release obtained with the ‘brushing’ technique after PRI was 13.2 mm ± 4.8 mm. The healing period was uneventful in 73 sites (96.1%). A small membrane exposure without purulent exudate, occurred in a smoker patient after 18 weeks and was treated with chlorhexidine gel, reaching a satisfactory regenerative result. A membrane exposure with purulent exudate and an abscess without membrane exposure were observed in two smoker patients, leading to a failure of the procedure. In the patients with an uneventful healing period, the membranes were removed after 6–7 months: 209 implants out of 215 resulted clinically osseointegrated (97.2%). Conclusion and clinical implications In this case series the authors introduce a novel technique to increase the coronal advancement of the buccal flap in regenerative surgery. The proposed surgical modifications to the conventional PRI resulted in a 97% maintenance of primary closure over d-PTFE membranes during the healing period. The ‘brushing’ technique allows for a significant enhancement in the coronal displacement of the buccal flap if compared to PRI and double-flap incision.
The ‘brushing' technique: a novel approach for the coronal advancement of the buccal flap
Stacchi C;
2014-01-01
Abstract
Background Vertical bone loss represents a major surgical challenge in the implant treatment of the posterior mandible, due to anatomical factors and technical difficulties. A proper management of the soft tissues is a crucial point for the success in any regenerative procedure: a complete and stable closure of the flaps during the healing is mandatory to prevent contamination and infection and allows for an undisturbed graft healing and incorporation. This prerequisite can be accomplished only if buccal and lingual flap are sufficiently released, in order to obtain a passive coverage of the augmented area, stabilizing it with tension-free sutures. In the posterior mandible, in particular, the use of conventional periosteal incisions is not always sufficient for a proper buccal flap passivation, being often limited by anatomical factors. Aim/Hypothesis This paper reports a series of 76 consecutive cases of vertical guided bone regeneration in the posterior mandible, introducing a novel surgical technique to enhance the coronal advancement of the buccal flap in a safe and predictable way. Material and methods Sixty-four consecutive patients needing dental implants associated to bone augmentation procedures in the posterior mandible were enrolled in this study and treated from February 2010 to June 2013. After raising a full thickness trapezoidal buccal flap, it was passivated with the following procedure: at first a conventional periosteal releasing incision (PRI) was performed, cutting the periosteum in a depth of 1 mm from distal to mesial. The coronal displacement of the flap after PRI was measured with a periodontal probe in three different points of the periosteal incision line (mesial, central and distal). The connective tissue exposed by the PRI in the inner part of the buccal flap, represents the working area where applying the ‘brushing’ technique. Keeping the flap in tension, the blade was used, in the entire working area, with a ‘brushing’ movement in order to interrupt the residual periosteal fibers and to dissect and separate the superficial from the deeper part of the flap. The coronal advancement reached after the ‘brushing’ procedure was measured with a periodontal probe with the previously described modalities. Lingual flap was elevated until reaching the mylohyoid line, and it was released by detaching the insertion of the mylohyoid muscle from the inner part of the flap. Vertical augmentation procedures were then performed using titanium-reinforced d-PTFE membranes and mineralized allograft, contextually to the implants insertion. Results Seventy-six mandibular sites were treated with the insertion of 215 dental implants associated with vertical GBR procedures. The coronal displacement of the buccal flap, after the PRI, varied from 4 to 11 mm (mean 8.4 ± 1.8 mm). After the additional release performed with the ‘brushing’ technique, the buccal flap advancement varied from 10 to 38 mm (mean 21.7 ± 6.3 mm). Mean enhancement in flap release obtained with the ‘brushing’ technique after PRI was 13.2 mm ± 4.8 mm. The healing period was uneventful in 73 sites (96.1%). A small membrane exposure without purulent exudate, occurred in a smoker patient after 18 weeks and was treated with chlorhexidine gel, reaching a satisfactory regenerative result. A membrane exposure with purulent exudate and an abscess without membrane exposure were observed in two smoker patients, leading to a failure of the procedure. In the patients with an uneventful healing period, the membranes were removed after 6–7 months: 209 implants out of 215 resulted clinically osseointegrated (97.2%). Conclusion and clinical implications In this case series the authors introduce a novel technique to increase the coronal advancement of the buccal flap in regenerative surgery. The proposed surgical modifications to the conventional PRI resulted in a 97% maintenance of primary closure over d-PTFE membranes during the healing period. The ‘brushing’ technique allows for a significant enhancement in the coronal displacement of the buccal flap if compared to PRI and double-flap incision.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
