PLONKA ET AL IMPLANT DENTISTRY / VOLUME 26, NUMBER 1 2017 145

Flap Designs for Flap Advancement

During Implant Therapy: A
Systematic Review
Alexandra B. Plonka, DDS,* Rachel A. Sheridan, DDS, MS,* and Hom-Lay Wang, DDS, MS, PhD†

mplant osseointegration is defined Purpose: Guided bone regener- closure during GBR were intro-

I as direct contact between bone and

the implant surface evaluated on
the light microscope level.1–3 Implant
ation (GBR) procedures allow ridge
augmentation before or at time of
implant placement. GBR outcomes
duced. To facilitate case selection
and treatment planning, flap de-
signs have been categorized based
survival may be maximized when the rely on primary passive tension-free on their ability to achieve minor
entire surface is encompassed by suf-
wound closure, which may be (,3 mm), moderate (3–6 mm), and
ficient bone volume.2 To ensure ade-
quate osseous support, bone grafting achieved by a variety of flap designs major ($7 mm) degrees of flap
may be required. This may occur at and surgical procedures. A compre- advancement.
multiple time points: postextraction hensive literature review of flap Conclusions: Techniques such
for socket augmentation, or in a staged design and management is provided, as vertical releasing incisions, peri-
or simultaneous approach with including material types, incision osteal releasing incisions, and split-
implant placement for ridge augmen- design, reflection, releasing, and thickness flaps may be used alone or
tation. Bone grafting procedures suturing techniques. combined to achieve passivity dur-
require flap reflection for access to Materials and Methods: Two ing GBR. GBR complications may
ascertain bone morphology, quantity, reviewers completed a literature be prevented by imaging and
quality, and relevant anatomical search using the PubMed database preoperative planning and careful
structures. A variety of incision de- and a manual search of relevant surgical technique especially
signs and reflection techniques may
journals. Relevant articles from Jan- flap advancement. (Implant Dent
influence flap properties and optimize
the outcomes of regenerative proce- uary 1990 to September 2015 pub- 2017;26:145–152)
dures. This manuscript provides lished in the English language were Key Words: dental implant, guided
a comprehensive literature review of considered. bone regeneration, alveolar ridge
various flap designs proposed for Results: A variety of flap designs augmentation, flap design, passive
bone grafting during implant treat- aim to achieve primary passive tension flap
ment based on amount of grafting
needed. In addition, key surgical prin-
ciples for enhancing regeneration and
the management of flap complications are discussed. The authors have cate- implant applications such as ridge aug-
gorized the flap designs by the mentation, coverage of fenestration,
*Resident, Department of Periodontics and Oral Medicine, amount of desired flap reflection to and/or dehiscences defects at implant
School of Dentistry, University of Michigan, Ann Arbor, MI.
†Professor and Director of Graduate Periodontics, Department provide primary closure of an aug- placement, grafting of the gap sur-
of Periodontics and Oral Medicine, School of Dentistry,
University of Michigan, Ann Arbor, MI. mented ridge volume based on cate- rounding immediate implants, and
gories described by Greenstein et al4 treatment of peri-implantitis.5,6 Like
Reprint requests and correspondence to: Hom-Lay (2009) and provide additional clinical
Wang, DDS, MS, PhD, Department of Periodontics and GTR, membranes or barriers may be
Oral Medicine, School of Dentistry, University of recommendations. used to exclude rapidly proliferating
Michigan, 1011 North University Avenue, Ann Arbor,
MI 48109-1078, Phone: (734-763-3325), Fax: (734) Guided Bone Regeneration epithelial cells to allow more beneficial
936-0374, E-mail: [email protected] slowly-growing osteoblasts to infiltrate
Guided bone regeneration (GBR)
ISSN 1056-6163/17/02601-145 is a strategy to augment hard tissue and promote new bone formation.7
Implant Dentistry
Volume 26  Number 1 around implants before or at the time of GBR may be performed for both
Copyright © 2016 Wolters Kluwer Health, Inc. All rights
reserved. their placement. GBR is a modification horizontal and vertical ridge augmenta-
DOI: 10.1097/ID.0000000000000510 of guided tissue regeneration (GTR) for tion. It is recommended for both staged

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146 FLAP DESIGNS FOR FLAP ADVANCEMENT PLONKA ET AL

and simultaneous approaches in cases postoperative concerns, primary wound membrane and increased volume of
with at least 3 mm residual buccolin- closure protects the healing graft graft material. Most strategies combine
gual bone width.8 Nevins and Mello- and progenitor cells for maximum flap extension, vertical incisions, and
nig9 described early cases of regeneration. periosteal releasing incisions to
horizontal GBR using ePTFE mem- As previously mentioned, mem- increase mobility and passivity of full-
branes, tenting screws, and autogenous brane exposure is the most common thickness (mucoperiosteal) flaps. Park
grafts and/or FDBA in a staged complication of GBR and often has et al30 found that the addition of one
approach. Buser et al10 found lateral a negative effect on regenerative poten- vertical incision extends the length of
bone gain of 3.6 mm in 40 patients trea- tial. Exposure has been reported in 60% the flap by 1.1 mm, the second vertical
ted with ePTFE membranes and auto- of cases of one-stage GBR, leading to incision extends the flap 1.9 mm from
grafts with a complication rate of 5%. 80% less regeneration due to early baseline, and a periosteal releasing inci-
However, membrane exposure is the membrane removal, absorbable mem- sion extends the flap by 5.5 mm from
most common complication with non- brane dissolution, graft contamination, baseline.
resorbable membranes. Possible mech- failure of graft adaptation, and total graft Greenstein et al proposed strategies
anisms behind flap sloughing include failure.13 Exposure of ePTFE mem- to achieve different strata of flap
lack of blood supply due to the imper- branes during a 3 to 6 months healing advancement: minor (,3 mm), moder-
meable nature of the membrane,11 in period reduced the regeneration rate ate (3–6 mm), and major ($7 mm).
addition to the clinician’s inability to from 96.6% to 46.5%.23 Nonresorbable Minor flap advancement may be
advance the flap without tension. Expo- ePTFE membranes have been reported achieved by extending full-thickness
sure of nonresorbable membranes may to have a higher incidence of wound flap reflection beyond the mucogingival
lead to failure of the graft.12 opening and membrane exposure versus junction (MGJ). For moderate flap
Collagen membranes are often the collagen membranes.20,24 Immediate advancement, 2 vertical releasing inci-
absorbable membrane of choice because implant placement may be associated sions are recommended, with the addi-
of their favorable biological properties, with higher wound opening (80%) than tion of periosteal scoring of 1-mm depth
including lower risk of exposure.6 Park delayed approaches (17%–32%).20 as needed. Major flap advancement
et al13 found more bone gain in absorb- In a meta-analysis, Machtei25 may require deeper periosteal scoring:
able membrane groups versus no mem- found 6 times more bone gain in non- 3 to 5 mm into submucosa. In addition,
brane (1.66 vs 1.08 mm), using exposed compared with exposed sites, split-thickness flaps may be employed
a sandwich simultaneous grafting tech- although only 2 studies were included. to further extend soft tissue coverage.4
nique. Nonetheless, flap advancement In their decision tree, Mellonig and Ne- These categories of flap advance-
with primary tension flap closure re- vins26 recommend treating exposed ment are used in this review to group
mains to be one of the key factors to membranes with increased postopera- flap reflection techniques for varying
ensure a successful outcome.14 tive monitoring, premature removal, degrees of augmentation procedures
Compared to horizontal augmenta- attempting coverage, and a staged with the goal of promoting passive
tion, vertical GBR can be more chal- approach. Depending on the grafting primary wound closure to maximize
lenging.15 The overall complication rate approach, implant components such as GBR success.
for vertical GBR is reported at 0% to cover screws may also be exposed.27
45.5%, compared with 0% to 24% for Early barrier removal often limits
horizontal GBR.16,17 The most com- the amount of regeneration achieved MATERIALS AND METHODS
monly reported complication for both but may still lead to successful A literature search was completed
procedures is membrane exposure, rang- GBR.10,27 Potential mechanisms lead- using the PubMed database to generate
ing from 6.95% to 13.1%.10,16–20 This is ing to graft failure after exposure a comprehensive review of flap design
largely due to the difficulty in advancing include bacterial contamination, pres- strategies proposed for use during ridge
the flap to achieve primary wound clo- ence of foreign bodies, and increased and socket augmentation procedures.
sure as well as maintaining flap closure speed of graft resorption.6,28 The flap designs were grouped by their
during the healing period.21,22 ability to achieve flap extension, based
Flap Reflection on categories proposed by Greenstein
Surgical Principles Wound closure should be achieved et al (2009). Two reviewers (A.P. and
Regardless of membrane type or passively, as flap tension increases risk R.S.) searched the PubMed database
graft material, successful GBR hinges of dehiscence.29 In addition to preven- manually using several search terms
on 4 key properties outlined by the tion of exposure, passive primary clo- and pairs of search terms, including,
“PASS” principle: primary wound clo- sure improves wound healing by but not limited to, the words “flap de-
sure, angiogenesis, stability, and space eliminating wound tension, preventing signs,” “guided bone regeneration,”
maintenance.6 Flap design and releas- loss of blood supply, and subsequent “ridge augmentation,” and “socket aug-
ing techniques may facilitate primary tissue necrosis.6 Incision design and mentation.” In addition, a manual
closure, critical to success of regenera- flap reflection and extension techniques search of the following journals was
tive procedures. In addition to promot- may increase flap mobility, allowing conducted: The International Journal
ing soft tissue healing and easing the flap to rest passively over the of Oral & Maxillofacial Implants,

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PLONKA ET AL IMPLANT DENTISTRY / VOLUME 26, NUMBER 1 2017 147

Clinical Oral Implants Research, a horizontal incision in keratinized tis- scoring incisions (for additional
Implant Dentistry, Journal of Peri- sue 3 mm apical to the free gingival 2–3 mm advancement).
odontology, and the International Jour- margin, followed by 2 vertical releasing
nal of Periodontics and Restorative incisions extending past the MGJ. Periosteal pocket flap
Dentistry. Relevant articles in English The flap may be performed before Proposed for horizontal augmen-
from January 1990 to September 2015 or after atraumatic extraction of the tation of knife-edge ridges, this flap is
were included. hopeless tooth. After implant place- indicated for staged GBR before
ment, the buccal plate fenestration implant placement.34 It entails splitting
may be grafted, such as with the the buccal flap into mucosal and peri-
RESULTS sandwich bone augmentation (SBA) osteal components to increase flap
technique,37 and an absorbable colla- elasticity and motility for improved
FLAP DESIGNS Based on the Need for primary closure. Mesial and distal ver-
Flap Advancement gen membrane placed. The flap is re-
placed, and suturing of the vertical tical releasing incisions in the mucosal
followed by the horizontal incisions is flap provide additional flap extension.
Mild flap advancement (1–3 mm). performed to minimize tension. Ideally, The periosteal pocket provides both
Mild flap advancement techniques the implant will be immediately tempo- stability and graft containment. A col-
may be employed for GBR limited to rized to maximize support of the soft lagen membrane is used to cover the
a horizontal dimension requiring 1 to tissue profile. coronal portion of the graft. Horizontal
3 mm of advancement (Table 1 and mattress suturing through the lingual
Fig. 1). Mucogingival pouch flap flap is performed in 2 stages to engage
This technique is also performed the buccal periosteal and mucosal
Esthetic buccal flap for grafting a buccal dehiscence or layers separately. In a case series, this
This technique was proposed for fenestration defect at implant place- flap resulted in an average of 4.3 mm
immediate implants in the esthetic zone ment when esthetic concerns horizontal augmentation and 100%
when a buccal plate defect likely to are minimal.33 This flap design uses of implant success rate.34
result in implant fenestration is pres- papilla preservation incisions and MGJ
ent.31,32 This flap is particularly recom- incisions for “soft tissue camouflage.” Lateral incision technique
mended when existing alveolar bone Another advantage of this technique is This procedure supports localized
loss, thin tissue biotype, or a combina- it may be performed in cases of limited horizontal ridge augmentation using
tion of both, may result in recession, soft tissue thickness because it does not a staged approach to GBR.35,36 The
loss of papilla height, and unfavorable require splitting the flap, as is seen in lateral incision is performed from the
esthetics after flap reflection. It is essen- other techniques, to achieve primary palatal/lingual aspect to create a split-
tially a replaced flap requiring minimal closure. After flap reflection and graft- and full-thickness combined flap. The
additional reflection because of limited ing with the SBA technique37 and a col- combined flap design is purported to
extent of augmentation. It entails re- lagen membrane, additional flap reduce soft tissue complications as
flecting a full-thickness flap with extension is achieved by periosteal compared with crestal incisions.

Table 1. Flap Designs for Mild (1–3 mm) Flap Advancement

Required Flap Advancement: Mild (1–3 mm)
Flap Design
Name Indication Incisions Reflection
Esthetic buccal Immediate implant apical buccal Horizontal 3 mm apical to free To expose implant defect
flap31,32 fenestration defect gingival margin
Two divergent vertical incisions
past MGJ
Mucogingival Immediate implant buccal Semilunar crestal incision with Pouch flap reflection 5 mm beyond
pouch flap33 dehiscence or fenestration horizontal extension defect
defect Papilla preservation technique;
one vertical
Periosteal pocket Horizontal ridge deficiency Crestal Create a pocket by reflecting
flap34 Internal vertical periosteum
Lateral incision Horizontal ridge deficiency Horizontal 3 mm lateroapical to Reflect combined split-thickness then
technique35,36 crest full-thickness flap
Diverging releasing incisions
Create periosteal release at base
of buccal flap
This table lists flap designs that may be used to achieve mild flap advancement. The table lists the indication for which the procedure was proposed. The main incision designs and reflection strategies are
outlined in brief.

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148 FLAP DESIGNS FOR FLAP ADVANCEMENT PLONKA ET AL

to augment flap length for primary soft

tissue closure over grafted extraction
sites or deficient ridges.41,42 The spe-
cific buccal flap design includes hori-
zontal incisions of 3 to 4 mm42 up to 6
to 10 mm41 in length at the most apical
extent of the vertical releasing inci-
sions. In a case series, this flap re-
sulted in 98.8% of 173 sites
maintaining soft tissue coverage for
6 months.
Palatal advanced flap
Similar to a lateral pedicle soft
tissue graft, this technique involves
rotating an L-shaped split-thickness
pedicle from the palate for primary
coverage of immediate implants.43
Coronally positioned palatal sliding
flap
This strategy involves creating
split-thickness planes of palatal tissue
from a full-thickness flap to allow for
Fig. 1. Principles for achieving passive flap extension. This figure categorizes the surgical flap sliding and rotation similar to a garage
designs based on the amount of flap advancement that may be achieved by each technique, door to increase the zone of keratinized
shown in the boxes on each axis. The author’s recommendations for each category, based on
tissue and provide primary coverage of
experience, are highlighted in yellow. The center of the triangle lists “Determining Factors,”
which are key principles that determine the degree of flap advancement and success of the barrier membranes during implant
GBR procedure. “Other modifying factors” also may have an effect on flap advancement. placement and simultaneous grafting.44
First, a full-thickness flap with vertical
incisions is raised for implant place-
Tenting screws may be added with the donor for soft tissue coverage over
ment, the flap is split at its edge like
a bone graft and nonresorbable, fixed the membrane through a pedicle38 or
the page of a book into a second plane,
ePTFE membrane for space mainte- free gingival graft approach.39 Any
then at the apical extent of the flap, an
nance. Horizontal mattress and simple excess graft may be used to repair the
additional split-thickness plane is dis-
interrupted sutures are used for donor site.39
sected connecting the vertical incisions
tension-free primary closure. The following techniques involve
which allows sliding of the flap to cover
manipulation of the palatal or lingual
Moderate flap advancement (4–6 mm). the implants with the keratinized tissue.
flaps:
Moderate flap advancement strategies The underlying de-epithelialized pala-
include pedicle flaps for increased graft Vascularized periosteal membrane tal tissue will re-epithelialize like a free
coverage, for primary coverage of This procedure is performed for gingival graft donor site.
extraction sockets or implants, and in primary closure over grafted sockets Major flap advancement (7 mm or
areas of limited keratinized tissue. after flapless, atraumatic extraction.40 greater). Major flap advancement is
Four to 6 mm of advancement can be An absorbable membrane may or may required for vertical bone augmenta-
anticipated (Table 2). not be used. Full-thickness buccal and tion requiring 7 mm or greater of
palatal flaps are raised, and the addi- advancement (Table 3).
Buccal pedicle flap/graft
tional flap extension is achieved by
This technique was proposed “Hockey stick” flap
internally splitting the palatal flap in
using ePTFE membranes and later half from an apical aspect to form a ped- Tinti and Parma-Benfenati45 pro-
converts to absorbable cellulose mem- icle and unfolding it over the graft site. posed this technique to accommodate
branes.38,39 This flap design is used at The buccal flap is replaced over this significant vertical ridge augmentation
socket preservation or immediate extended tissue and sutured with single around implants. The full-thickness
implant placement to allow for soft interrupted sutures. buccal flap has “hockey stick”–shaped
tissue coverage while preventing a dis- apical extensions of the vertical in-
crepancy in the MGJ, loss of vestibule, Lingual pedicle cisions. Another term for these ex-
and limited keratinized tissue, which Like the vascularized periosteal tensions is “cutback” incisions.49 In the
can result from overextension of the membrane, this procedure also in- mandible, the full-thickness lingual
flap. Instead, buccal keratinized gin- volves a rotated split-thickness con- flap is extended to the mesial at least 3
giva from an adjacent tooth is used as nective tissue pedicle from the palate teeth beyond the defect, where it

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PLONKA ET AL IMPLANT DENTISTRY / VOLUME 26, NUMBER 1 2017 149

Table 2. Flap Designs for Moderate (4–6 mm) Flap Advancement

Required Flap Advancement: Moderate (4–6 mm)
Flap Design
Name Indication Incisions Reflection
Buccal pedicle38,39 Implant dehiscence defect, Horizontal incision on buccal to Full-thickness reflection with partial
immediate implant,6 delineate pedicle graft thickness at buccal pedicle
extraction socket7 Palatal intrasulcular incisions extending
mesial and distal by one tooth
Vertical releasing incisions at buccal
and lingual
Rotate buccal pedicle for primary
closure over implant (trim excess
pedicle as needed)
Vascularized Socket augmentation Circumferential intrasulcular incisions Full-thickness buccal and palatal
periosteal around tooth to be extracted flap, then split-thickness lingual
membrane40 Close socket with palatal split pedicle pedicle
overlaid by buccal flap
Lingual pedicle41,42 GBR 6 extraction or Palatal Partial thickness palatal flap and
implant placement Split tissue near crest with angled full-thickness buccal flap
incision
Vertical incisions
Buccal
Crestal incision
Vertical incisions on mesial and
distal to vestibule
Horizontal incisions at apical end
of vertical incisions
Palatal advanced Immediate implant L-shaped incision with vertical Split-thickness dissection of “L” flap
flap43 incisions extending palatally and rotation to cover implant
Parallel incisions extending distally
forming other leg of “L”
De-epithelialize inner triangle
Coronally positioned GBR around implants Horizontal incision Full-thickness elevation to place
palatal sliding Parallel vertical incisions, 2–3 mm membrane
flap44 longer than planned coronal position
2 mm thick horizontal incision
extending 2 mm coronal to extent of
verticals
Connect vertical incisions apically
External bevel apico-coronal incision to
split tissue
This table details flap designs that may be applied for moderate flap advancement. The original surgical procedure for which the flap was used is listed (“Indication”). The key incisions and reflection
techniques are summarized.

terminates with a vertical incision no implant threads covered with a mem- graft site (compared with 3 mm). Full-
more than 1 mm beyond the MGJ. The brane secured with fixation screws. The thickness flaps are reflected 5 mm
lingual flap reflection involves raising “first line of closure” is achieved with beyond the defect, which includes
the mylohyoid muscle while contain- horizontal mattress “U-stitches” 3 mm reflection beyond the mylohyoid mus-
ing and protecting vital structures in the apart followed by interposing simple cle in the lingual posterior mandible.
floor of the mouth. In the maxilla, interrupted sutures. Periosteal releasing incisions are used
a coronally positioned palatal flap44 is to increase flap mobility. Suturing is
used. The periosteum (along with Remote flap performed with horizontal mattress fol-
muscle fibers in the mandible) is split This flap is a modification of Tinti lowed by simple interrupted sutures.
from the outer, mucosal portion of the and Parma-Benfenati’s45 “Hockey
flaps. The goal is the extension of stick” flap design for horizontal or ver- Double flap
the flap beyond the incisal edges of the tical ridge augmentation.46 Modifica- This flap was derived for vertical
adjacent teeth. Grafting is performed tions include extending the flap in and horizontal GBR in the posterior
with autogenous particles over the edentulous areas 5 mm beyond the mandible.47 A review of anatomical

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150 FLAP DESIGNS FOR FLAP ADVANCEMENT PLONKA ET AL

Table 3. Flap Designs for Major ($7 mm) Flap Advancement

Required Flap Advancement: Major ($7 mm)
Flap Design
Name Indication Incisions Reflection
“Hockey Vertical ridge augmentation Intrasulcular incisions on buccal and Buccal: full-thickness flap
Stick” flap45 around implants lingual extending to mesial line angle
of adjacent teeth
Buccal Lingual
“Hockey stick” vertical incisions on Mandible: full-thickness flap to raise
mesial line angles of adjacent teeth entire floor of mouth
7–8 mm distal to membrane if Maxilla: palatal sliding flap, if
edentulous necessary11
Lingual
Intrasulcular extension incision
mesially 3+ teeth
Two vertical releasing incisions 1 mm
beyond MGJ on the mandible
Periosteal releasing incisions
Remote flap46 Horizontal and/or Midcrestal incision Full-thickness reflection past MGJ and
vertical GBR Divergent verticals 1 tooth (or 5 mm 5 mm beyond defect (past mylohyoid
away from site if edentulous) line in the mandible)
Verticals connected with periosteal
releasing incisions
Double flap47 GBR Crestal incision Partial thickness flap on the buccal and
Vertical releasing incision 2 mm from periosteal flap reflection
terminal tooth
Multilayer GBR, mucogingival C-shaped vertical on buccal Combined full-partial thickness:
approach48 surgery, or periodontal Full-thickness, then partial thickness
plastic surgery 2–3 mm beyond MGJ
Paracrestal incision Reflection of periosteum for 1.5–2 mm
thick inner flap
This table describes flap incision and reflection techniques suggested for major flap advancement. The application for the procedure is given (“Indication”), followed by a brief description of the major
incisions and reflection technique.

considerations led to the design of augmentation procedures; in Flap sloughing may result from an
a midcrestal horizontal incision with response, several authors have pro- interruption of blood supply leading
a single vertical incision at the mesial posed systems for complication clas- to tissue necrosis; thus, proper flap man-
aspect of the flap to preserve blood sup- sification and management.10,16,50 agement is essential by avoiding exces-
ply to the avascular crestal portion of The primary issue associated with bar- sive flap thinning or perforation during
the edentulous ridge while avoiding rier membranes is early exposure, re- periosteal release.50
vital structures. Similar to the periosteal ported as a percent of complications in Other surgical complications
pocket flap,34 the mucosal and perios- one review as 0% to 24% of horizontal include damage to vascular and neuro-
teal flaps are elevated and sutured GBR at implant placement, 11.9% for logic structures.10 Prevention is key by
separately. staged horizontal GBR, 13.1% for way of appropriate presurgical imag-
vertical GBR at implant placement, ing and planning, as well as intraoper-
Multilayer approach and 6.95% for staged vertical ative identification and avoidance of
This technique uses principles of GBR.17 The use of absorbable mem- vital structures. In the mandible, the
plastic and microsurgery to obtain branes has reduced the incidence of lingual and sublingual artery, in addi-
a double partial thickness buccal flap membrane exposure; however, severe tion to other contents of the sublingual
along with the coronally positioned ridge deficiencies may require the use space, must be avoided during inci-
palatal sliding flap.44,48 of nonresorbable membranes so iden- sions and flap reflection. In the maxilla,
tification, diagnosis, and management the greater palatine neurovascular bun-
DISCUSSION of membrane exposure and other com- dle is most susceptible to trauma. Neu-
plications remain essential. Compli- rosensory disturbances can be avoided
Complication Management cations may be grouped into 2 major by respecting the mental nerve, lingual
Complications have been re- categories: those caused by direct sur- nerve, and rarely, the infraorbital
ported in up to 25% of horizontal gical trauma or those that occur during nerve.50 In addition to attention to
and 45.5% of vertical bone healing. clinical detail, the use of imaging is

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PLONKA ET AL IMPLANT DENTISTRY / VOLUME 26, NUMBER 1 2017 151

imperative, including preoperative ra- materials evolve with technology, sur- membranes in dogs. J Periodontol.
diographs and cone beam computed gical procedures, especially designs 1997;68:217–224.
tomography imaging when indicated. for tension-free flap advancement, 12. von Arx T, Kurt B. Implant
placement and simultaneous ridge
must be re-examined. augmentation using autogenous bone
Healing Complications
and a micro titanium mesh: A prospective
Membrane exposure with or with- clinical study with 20 implants. Clin Oral
out bacterial contamination and infec- DISCLOSURE Implants Res. 1999;10:24–33.
tion is not uncommon, especially with The authors claim to have no 13. Park SH, Lee KW, Oh TJ, et al.
nonresorbable membranes.16,17,50 Small financial interest, either directly or
Effect of absorbable membranes on
(,3 mm) asymptomatic exposures may sandwich bone augmentation. Clin Oral
indirectly, in the products or informa- Implants Res. 2008;19:32–41.
be left in place for a maximum of 1 tion listed in the article. 14. Fu JH, Oh TJ, Benavides E, et al.
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disinfection and regular patient follow- the efficacy of the sandwich bone
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