Vascularized Connective Tissue Flap for Bone Graft Coverage
Alveolar defects are characterized by missing soft and hard tissues. It is often necessary to combine secondary procedures to address the soft-tissue component. The authors describe a technique that uses a split-thickness flap design that is placed over the crest of the remaining ridge and extends in a palatal direction. This allows advancement of the flap with its exposed connective tissue over the bone graft and provides restoration of both bone and keratinized tissue. Seventeen patients with defects involving the anterior maxilla who required grafting procedures were including in this study. All patients had an autogenous bone graft (n = 17) combined with osseointegrated implants (n = 41). A split-thickness flap design was used at the time of bone graft placement (primary) in 9 patients and at the time of implant uncovering (secondary) in 8 patients. There were no cases of flap necrosis or dehiscence with exposure of the bone graft. All patients demonstrated an increase in keratinized tissue involving the peri-implant area. An apical repositioned split-thickness flap provides an increased zone of keratinized tissue with improved esthetics and implant maintenance. This technique can be performed simultaneously with the grafting procedure, thus avoiding extensive undermining of the adjacent soft tissue.Abstract
(a) Diagram showing the location of the split-thickness incisions over the alveolar defect. (b) Diagram showing the placement of the bone graft and coverage with the split-thickness flap. Arrows indicate the direction of the flap.
(a) Anterior alveolar defect with congenitally missing lateral incisor. Note the insufficient ridge width places the rootform implants in a proper location. (b) Placement of an onlay block graft harvested from the lateral ramus of the mandible. Note the minimal undermining of the facial tissue. (c) Coverage of the graft with the split-thickness flap. Note the exposed connective tissue providing coverage over the graft. (d) Postoperative result prior to implant placement showing the sufficient amount of attached gingival to obtain optimal anterior aesthetics.
Figure 3. Diagram showing the location of the split-thickness incisions over the grafted ridge. Figure 4. (a) Diagram showing the new keratinized mucosa around dental implant. (b) Anterior maxilla after grafting procedure with insufficient keratinized tissue. The area of incision is shown (black dash) as well as the area of undermining in a split-thickness manner (gray lines). (c) Apical repositioning of the split-thickness flap and placement of implant healing abutments. (d) Four weeks postoperatively with an increase in attached gingival along the facial aspect of the peri-implant region.
Figure 5. Prosthetic restoration after 3-week soft-tissue healing. Figure 6. Three-month radiographic follow-up.
Contributor Notes