JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No.

1 (84 - 87): Soft Tissue Management for Primary Closure in Guided Bone Reg

Soft Tissue Management for Primary Closure in

Guided Bone Regeneration: Surgical Technique and
Case Report
Arthur B. Novaes, Jr, DSc/Arthur B. Novaes, DSc

A surgical technique with the objective of obtaining and maintaining soft tissue closure over
membranes used for guided bone regeneration is described. This procedure achieves primary
closure in extraction sockets or in association with immediate implants without creating
mucogingival problems around adjacent teeth.
(INT J ORAL MAXILLOFAC IMPLANTS 1997;12:84–87)
Key words: Gengiflex membrane, guided bone regeneration, resorbable hydroxyapatite, surgical flap design

G uided bone regeneration (GBR) has been shown to be a successful and predictable procedure in
humans for the regeneration of bone in fresh extraction sockets,1 around immediate implants,2-4 and for
implant dehiscences.5 Some researchers consider it critical to obtain and maintain complete soft tissue
closure over the membrane.6 Warrer et al 7 showed in monkeys that premature exposure of the
membranes hampers complete bone regeneration; Lekholm et al,8 in a dog study, demonstrated that more
bone is formed when the membrane remains covered until second-stage surgery of implants. To the
contrary, Nevins and Mellonig, 1 in a clinical report, showed complete osseous filling in four patients in
whom membranes were prematurely exposed and removed within 4 weeks. However, most clinicians
agree that ideally the membrane should be completely covered by the flap and remain submerged during
the entire healing period.
The extraction of a tooth creates soft tissue management problems because of the difficulties in
obtaining and maintaining complete closure over the barrier membrane, be it for GBR of the alveolus or
over immediate implants. Removal of the tooth prior to the regeneration procedures may be one solution,
but this creates other problems, such as increasing the treatment period, the addition of another surgical
procedure, and, most importantly, postextraction ridge resorption.
The purpose of the present study was to describe a surgical technique that allows complete soft tissue
closure over membranes placed on extraction sockets or immediate implants, without creating
mucogingival problems in adjacent teeth when there are adjacent teeth.
Surgical Technique
The surgical procedure most often used currently involves the placement of vertical releasing incisions at
the distal and mesial line angles of adjacent teeth, and a combination full- and split-thickness flap that is
coronally displaced and sutured over the membrane. Although this procedure relieves the tension on the
flap as much as possible, tension is nonetheless still present and may lead to premature exposure of the
membrane. This exposure creates postoperative control problems that may affect the final result. It may
also lead to future mucogingival problems because the amount of keratinized gingiva is often insufficient
to provide a wide band of keratinized tissue around the implant, which facilitates home care by the
patient and favors a better esthetic result.

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (84 - 87): Soft Tissue Management for Primary Closure in Guided Bone Reg

The technique proposed in the present study is similar to the technique reported by Becker and
Becker, 9 but with important modifications. Buccal vertical releasing incisions are placed on the mesial or
distal line angle of the anterior or posterior neighboring tooth. Buccal tissue from the adjacent tooth is
used to obtain primary soft tissue closure over the membrane. At the time of surgery, clinical judgment
will determine whether the tissue will be displaced from the anterior or posterior adjacent tooth.
Case Report
The releasing incision in this situation was placed on the mesial line angle of the first premolar, and the
second premolar was extracted because of a longitudinal root fracture (Fig 1). A second releasing
incision was placed on the line angle of the tooth adjacent to the tooth to be extracted, in this instance on
the mesial of the first molar (Fig 2). A split-thickness flap was made over the first premolar starting at the
releasing incision and continuing distally until reaching the distal line angle of the same tooth. At this
point, a vertical incision was made in the periosteum down to the bone surface and a combination
full-thickness (more coronal portion) and split-thickness (more apical portion) flap was made. Becker
and Becker9 used a full-thickness flap on the buccal portion of the tooth acting as a soft tissue donor. In
the situation in the present report, the first premolar was the tooth involved.
The tooth was gently extracted, all granulation tissue was curetted, and the alveolus was rinsed with
sterile saline. Next, a grafting material is used or a blood clot is allowed to form. For this patient, a
resorbable hydroxyapatite (Bon-Apatite, Bio-Interfaces, San Diego, CA) was used and covered by a
nonresorbable cellulose membrane10 (Gengiflex, Bio Fill Produtos Biotecnologicos, Curitiba, Brazil)
(Fig 3). In this situation, membranes are recommended to impede connective tissue of the inner surface
of the flap from invading the socket, which could hamper complete bone formation. Grafting materials,
as used in this patient, are used to avoid collapse of the membrane into the socket when bone resorption
of one or more walls of the socket has occurred.
The flap was moved distally and coronally and sutured over the membrane to the palatal or lingual
tissue (Fig 4). Just prior to suturing, tension on the flap must be tested, and a small horizontal incision
may be placed on the mesial and most apical portion of the flap to relieve any tension on the flap. A
gingivectomy type of incision was made on the most coronal portion of the palatal or lingual flap to
create a beveled surface of exposed connective tissue on which to lay the border of the buccal flap.11
This connective tissue–to–connective tissue contact is important in the maintenance of the primary soft
tissue closure.
When the flap is displaced distally from the adjacent tooth, as in this situation, some excessive soft
tissue will need to be trimmed on its distal portion to facilitate closure of the distal vertical incision. The
excessive tissue was carefully removed to preserve all the keratinized tissue that was used as a free
gingival graft to cover the exposed periosteum on the buccal surface of the donor tooth, the first premolar
in this patient (Fig 5). The free gingival graft will create an adequate zone of keratinized gingiva on the
donor tooth, avoiding the creation of mucogingival problems (Fig 6).

Becker and Becker9 have recommended a split-thickness flap from the tooth adjacent to the donor
tooth to cover the exposed bone on the donor tooth, or to close the mesial vertical incision the best way
possible and to correct any mucogingival problems at a later date, should they arise. By using the
trimmed keratinized tissue as a free gingival graft, extension of the flap to another tooth is avoided, along
with all of the disadvantages of involving another healthy tooth in the procedure, added trauma, and

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (84 - 87): Soft Tissue Management for Primary Closure in Guided Bone Reg

postoperative discomfort, and the possibility of creating soft tissue problems, since the donor tooth will
have exposed periosteum on its buccal surface.
The patient was placed on 500 mg of amoxicillin every 8 hours for 10 days, starting 24 hours before
the procedure, and was instructed to rinse twice daily with a solution of 0.12% chlorhexidine for 10 days,
when the sutures were removed and the area was examined for membrane exposure. The area was
examined and cleaned weekly for the first month and then monthly until implant placement.
Figure 7 illustrates the clinical result 10 months postoperatively, and Figs 8 and 9 are radiographs of
the region immediately following the procedure and 10 months later. Bone regeneration has been
completed and the site is ready to receive an implant. We recommend that 6 to 9 months of healing be
allowed before implant placement; however, in this situation this period was extended because of the
patient’s personal problems.
Summary
The proposed technique allows for primary soft tissue closure over the barrier membrane and avoids the
creation of mucogingival problems involving the donor tooth. The need to extend the flap to yet another
tooth is circumvented, and a possible mucogingival procedure at a later date may be avoided.

Arthur B. Novaes, Jr

Chairman of Graduate Periodontics, Federal

University of Rio de Janeiro, School of Dentistry,
Rio de Janeiro, Brazil.

Arthur B. Novaes

Chairman, Department of Periodontology,

University of São Paulo at Ribeirao Preto, School
of Dentistry, São Paulo, Brazil.

FIGURES

Footnotes 3
Figure 1

Fig. 1 Vertical incisions on the mesial surface of the maxillary right first premolar and on the
mesial surface of the maxillary right first molar. The combination buccal split-/full-thickness flap
is also shown.

Figure 2

Fig. 2 Occlusal view of the incisions and of the alveolus to be regenerated.

Figures 4
JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (84 - 87): Soft Tissue Management for Primary Closure in Guided Bone Reg

Figure 3

Fig. 3 Alveolus filled with resorbable hydroxyapatite. The cellulose membrane covering the
hydroxyapatite and socket is shown.

Figure 4

Fig. 4 Occlusal view revealing that complete soft tissue closure over the membrane has been
achieved. Free gingival graft on the buccal surface of the first premolar can also be seen.

Figures 5
JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (84 - 87): Soft Tissue Management for Primary Closure in Guided Bone Reg

Figure 5

Fig. 5 Free gingival graft obtained by trimming the distal portion of the flap sutured onto the first
premolar. Note complete closure of the vertical incisions.

Figure 6

Fig. 6 Postoperative view 10 months later showing the quality of keratinized tissue obtained on
the buccal surface of the first premolar and the absence of gingival recession.

Figures 6
JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (84 - 87): Soft Tissue Management for Primary Closure in Guided Bone Reg

Figure 7

Fig. 7 Ten-month postoperative occlusal view demonstrating the good quality tissue that has
formed on the edentulous area and the buccopalatal width of the tissue.

Figure 8

Fig. 8 Radiograph immediately following the surgical procedure. The hydroxyapatite is seen in
the alveolus.

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (84 - 87): Soft Tissue Management for Primary Closure in Guided Bone Reg

Figure 9

Fig. 9 Ten-month postoperative radiograph. Complete regeneration of the alveolus is shown.

The area is ready to receive an implant or any other restorative treatment.

Soft Tissue Management for Primary Closure in Guided Bone Regeneration: S

1. Nevins M, Mellonig JT. Enhancement of the damaged edentulous ridge to receive dental implants: A
combination of allograft and the Gore-Tex membrane. Int J Periodont Rest Dent 1992;12:97–111.
2. Lazzara RJ. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J
Periodont Rest Dent 1989;9:333–343.
3. Novaes AB Jr, Novaes AB. IMZ implants placed into extraction sockets in association with membrane therapy
(Gengiflex) and porous hydroxyapatite: A case report. Int J Oral Maxillofac Implants 1992;7:536–540.
4. Novaes AB Jr, Novaes AB. Bone formation over a Ti-6Al-4V (IMZ) implant placed into an extraction socket in
association with membrane therapy (Gengiflex). Clin Oral Implants Res 1993;4:106–110.
5. Jovanovic SA, Spiekermann H, Richter EJ. Bone regeneration around titanium dental implants in dehisced
defect sites: A clinical study. Int J Oral Maxillofac Implants 1992;7:233–245.
6. Gotfredsen K, Nimb L, Buser D, Hjørting-Hansen E. Evaluation of guided bone regeneration around implants
placed into fresh extraction sockets: An experimental study in dogs. J Oral Maxillofac Surg 1993;51:879–884.
7. Warrer K, Gotfredsen K, Hjørting-Hansen E, Karring T. Guided tissue regeneration ensures osseointegration of
dental implants placed into extraction sockets. An experimental study in monkeys. Clin Oral Implants Res
1991;2:166–171.
8. Lekholm U, Becker W, Dahlin C, Becker B, Donath K, Morrison E. The role of early versus late removal of
GTAM membrane on bone formation at oral implants placed into immediate extraction sockets. An
experimental study in dogs. Clin Oral Implants Res 1993;4:121–129.
9. Becker W, Becker B. Guided tissue regeneration for implants placed into extraction sockets and for implant
dehiscences: Surgical techniques and case reports. Int J Periodont Rest Dent 1990;10:377–391.

References 8
JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (84 - 87):

10. Novaes AB Jr, Novaes AB, Grisi MFM, Soares UN, Gabarra F. Gengiflex. An alkali-cellulose membrane for
GTR. Histologic observations. Braz Dent J 1993 July;4(2):65–71.
11. Buser D, Dula K, Belser U, Hirt H-P, Berthold H. Localized ridge augmentation using guided bone
regeneration. I. Surgical procedure in the maxilla. Int J Periodont Rest Dent 1993;13:29–45.

References 9