Best Way to Close a Maxillary Flap without Tension Over the Alveolar Ridge?

I have found that using scissors instead of a blade to release the periosteum gives me better results. Also make your incisions further away from your graft or membrane. Drop a vertical incision if u need to. Use a horizontal matrice suture for better flap adaptation.

Tension free Flap closure has always geen an issue which cann affect the outcome of the graft . The idea of a separate membrane be it collagen or even titanium is neccesitated by most graft materials unsuitability. Simply yhey are not stable or soft cell occlusive , but ,ore recently a few materials have been marketed that are both stable and cell occlusive . Thus the graft becomes its own membrane thus dispensing with the need for a membrane that may hinder healing by denying the critical blood supply from the periosteum . ( Podoropolus 09 , J of Perio ). Now all you need is a site specific flap to retain the periosteal supply to adjant soft tissue where closure is easier , and if still not possible ( recent extraction site ) it is not an issue as the graft is stable and will merely granulate over . After nearly 1,000 cases this may be a way forward. Peter

Sorry about typos , Peter

There are two ways that you can achieve closure in difficult maxiallary graft cases. The first is to perform a sliding palatal flap. There are no vertical releasing incisions on the palatal side. The palatal tissues are undermined two thirds up towards the mid-palate. A split thickness exit is made at that junction and the palatal flap may be moved coronally up to 5mm. Combine this with splitting periosteum on the facial falp and you can advance 15mm or more. If you do not feel comfortable with palatal release, then use PRF membranes to cover the dehisced area. Within 7 days you will have complete epithelial coverage of the graft. RJM

Easiest way is to perform two vertical releasing incisions on the buccal, then horizontally score the periosteum on the underside of the flap with the #15 blade multiple times (take care not to perforate the flap). You'll be amazed how much release you get. This almost always allows for a tension free closure with considerable bulk of graft. If you can't quite get it to stretch completely, you can make up the difference with a membrane, leaving the exposed surface of the membrane. The epithelium will migrate over it to achieve the remaining closure...

Dear O. , Peter is exactly right (Hi peter we met in Luzern this biomaterials day), Having done this procedures in over 1500 implants(with easygraft or easygraft crystal)in the last year, I can certainly say that periostium is the best membrane and if you dont need one is even better. Is Easygraft sold in the U.S.?, if not it soon will be, and then you can take advantage of the polilactide acid "membrane" that is between other things, Bactericide and it allows a full granulation and epithelialization on top of it without migration of the soft tissue cells into the graft. Thats why veneer grafts are now so easy to do and so predictable. Eventhough Petrungaro does it with mineross, it works wonderfully too(the flapless graft)but is even simpler with Easygraft. (as a disclosure you should know that I have no personal or professional relation with degradable solutions, the manufacturer of Easygraft) cheers

hi, what i am doing the last 1 year with great results is to use dermis to cover all these.the last one case was extremely wonderful. i place an immediate implant in 24 (first premolar) and i placed bone graft due to the missing buccal plate and after that i placed a dermis.the flaps where approximated but never had a complete closure. in 3 weeks i had full closure and after 6 months i entry the site i was amazed because i found bone even above the cover screw. i had never had a failure. even better is the autogenous connective tissue graft but very few patients accept it..also alloderm is a very beautiful solution but i stopped using it because of swelling..in this way you can keep the original architecture of soft tissues and not to have correct them in a second stage surgery.

Hi Alejandro, good to hear from you yes the periosteum definately the membrane with the BEST blood supply. Maybe the desire from achedemia ( or companies with a vested interest) for excessively extesive evidence is in fact holding us back in providing better solutions ( in many ways) for our patients. In India a week ago it was interesting to see other surgeons getting very impressive outcomes with these techniques and materials ( Easygraft). It is also nice to be able to show all your cases close up after years with no loss of buccal profile. Keeping it localised and simple without has real benefits , but it is not what we did 15 years ago which does not mean that it not a solution Regards Peter

Sorry typos again must slow down .... Peter

In my opinion, regardless of the design you choose, the flap must be closed with absolutely no tension. Take rather large bites with a noncutting needle. Gortex is a great suture with or without a membrane. Metal meshes placed intraorally are a crap shoot at best, but sometimes unavoidable. Two companies have prototypes, that will take the place of the mesh, hopefully. I personally don't like vertical release incisions, unless it's absolutely necessary. Palatal flaps do well in the posterior, and the area from the harvest(transposition) sight will heal secondarily. There is one opinion. Bvinci

Dr. Bvinci, I'm interested, so what's your recomendation on the anterior maxillae, if you dont´t like to do vertical incisions and sliding the palate only in posterior.

Dr OZ , if it's to cover a large block that has been secured with fixation screws and filled with prp/ cancellous bone, I'll do an "envelope burger flap", and use dull side of blade to score the periosteum. I have used alloderm with residents and was pleasantly surprised. I'll use a vertical release as last resort, but several teeth over. I still believe in keeping flap base as wide as possible. Bv

If I'm doing a "burger", I'll go up to piriform apeture and split the flap. When I go this far I always apply tincture of benzoin and 1/4 inch paper tape ( laid on thick) across the upper lip , to help control edema. Bv

Don't know what your problem is with titanium mesh. Of all of the major bone graft cases we have done in the past 5 years, hands down, Ti Mesh has consistently given us the best bone volume, trajectory, and consistency of any of the modalities, including autogenous block grafts. Even when there are small dehisences at later stages of healing, there is no soft tissue invagination into the grafted areas. For me, especially in the aesthetic zone where the facial/incisal line angle position is essential for aesthetic success, the only way I can achieve this predictably is Ti Mesh. One of the ways we decrease problems with this technique is to use PRF membranes over the mesh at closure. This serves to ramp up early angiogenesis, and thickens the biotype of tissue, making it more resistant to incision site opening and dehisence, both early and late. RJM

Agreed Dr Millar it is interesting about pore size correlation to soft tissue cell exclusion and hence the resurgence of Ti mesh usage in Italy . The interesting associated research is by Gutta , Bartolucci , Baker and Louis , J of Oral MaxFax Surg , 67 Pgs 1218- 1225 , 09. Peter

I've even used stainless mesh. Certainly, ti mesh is a much better option, but I also get those breakdowns that tend to work out. Just kind of a hastle. Reference a. Herford et. Al. , he does some good stuff with small plates used over the tops of grafts that maintain space, just as well. The 4 or 5 I've done have never broken down. This is how I'm going currently. Bv

I absolutely have no problem using ti mesh, placed through the neck with an in tact mucosa. Bv

I have shift to a biodegrable membrane which is stable like a titaniumreinforced membrane and works like a titanium mesh. If the disadvantage from a dehiscence appear by cutting from the membrane through the mucosa you can gring it off or cut it. You don't have to remove it and it' s nice to work with when one uses particular grafts because of the puoche one can make before applying the particles. i am axcited to see how it will work with the new grafts since the materials are quite the same

Dutchy, is this the medpore system? Bv

Medpore is not biodegradeable. We were using this together with Infuse on large graft cases last year at the Atlantic Coast Dental Research Clinic as a result of the initial findings by Dr. Spagnoli. While we were able to generate large volumes of bone, at one year we started to see dehisence/sequestration of these membranes with localized imflammatory lesions. As a result of our experiences, we have discontinued use in these types of cases. RJM

Yeh , thank god it's not biodegradable, since we use it as dorsal strut grafts, orbital floor fractures, cheek and chin augmentations. It is however, very biocompatable. Hate to see that the idea has been canned. Spagnoli was supposedly involved with the design. According to medpore, they are a year away from the litho. models. Maybe my rep. Is out of the loop. We use a bunch of their product. I do think something is coming "down the pike" that will replace meshes. Again small midface plates placed over grafts , have worked well for me , and they are a lot easier to remove, in that there is less soft tissue integration. I've also been saying someone is going to replace Erich arch bars and that really hasn't happened either . Bv