Surgical Technique

Irrespective of the technique chosen by the clinician, there are some key elements such as flap design, recipient site preparation and flap closure that will define the outcome of the surgery.

The flap design should include vertical, crestal and sulcular incisions such that it has a wide base. This design will maximize blood supply and allow for adequate access and visibility of the defect. In addition, the periosteum may be scored using a blade or scissors in order to further release tension and advance the flap coronally.⁶⁰ The aforementioned techniques will allow for tension free closure over the surgical site.

Recipient Site Preparation and Decortication is done after the flap is elevated in the edentulous site. This involves thorough debridement of all granulation tissue and creating perforations or intra-marrow penetration in the cortical bone using a round bur. There is weak evidence to support the benefit of decortications as most studies are animal studies and there are no randomized controlled trials available; however, it is thought that this will enhance the development of blood clot and trigger the process of angiogenesis and cell migration justified by the regional acceleratory phenomena (RAP). ⁶² The concept of RAP suggests that the tissue response to a noxious stimulus will result in acceleration of normal cellular activity, in this case, increased bone turnover. In addition, decortication allows for mechanical interlocking of bone grafting material and the recipient site.

Primary Closure or re-approximating the wound edges to their original position to allow healing by primary intention, is a fundamental requirement for optimal healing without complications.^60,62 This creates an environment that is undisturbed and unexposed to bacterial or mechanical insults from the surrounding environment.⁶⁰ Passive, tension-free closure of the wound edges allows for better soft tissue healing, less remodeling of the bone, and less post-operative discomfort. This is achieved by use of vertical and periosteal releasing incisions. Non resorbable mono-filamentous sutures are preferred to hold the flap in place during the early healing phase for predictability of primary closure with minimal bacterial wicking.⁶⁰

Figure 6.

A. Vertical, crestal and sulcular incisions.

B. Full thickness flap elevation and adequate access for debridement of the defect.

C. Decortication/intra marrow penetration.

Figure 6.

D. d-PTFE membrane with xenogenous particulate graft.

E. Primary closure achieved using a combination of nylon and PTFE sutures.

F. Primary closure achieved using a combination of nylon and PTFE sutures.