CLINICAL

Periosteal Releasing Incision for

Successful Coverage of
Augmented Sites. A Technical Note
George E. Romanos, DDS, Dr.med.dent., PhD*

The periosteal releasing incision (PRI) is very common in intraoral surgical procedures,
especially when flap advancement is indicated, that is, when vertical or horizontal
augmentations take place. This technical note describes the surgical skills for sufficient flap
advancement. Complications due to improper PRI are also discussed.

Key Words: flap advancement, periosteum, releasing incision

INTRODUCTION search/analysis of the clinical outcome of

different augmentation procedures showed

T
he periosteal releasing incision
(PRI) is a very common surgical
procedure in daily practice. To
repair or cover oroantral fistulas
and/or augmented sites, the cli-
nician often has to deal with problems, such
as inadequate tissue (flap) length for com-
plete coverage of the bone, the defect, or
the augmented site. In bone grafting proce-
dures, sufficient soft tissue closure is a key
factor for uneventful healing.
Postoperative complications, such as flap
dehiscences and bone graft exposures have
been reported very often in the recent
literature. The incidence of wound dehis-
cence is reported as 2.5%–10%1 especially in
patients who smoke.2 Therefore, resorption
of the graft and an insufficient, unsuccessful
final clinical result may be associated with
flap dehiscence. However, a recent literature
Eastman Institute of Oral Health, University of Roches-
ter, Rochester, NY; Department of Oral Surgery and
Implant Dentistry, Dental School, Frankfurt, Germany.
* Corresponding author, e-mail: Georgios_Romanos@
urmc.rochester.edu
DOI: 10.1563/AAID-JOI-D-09-00068
different clinical results using guided bone
regeneration and/or block grafting proce-
dures and showed higher success using the
guided bone regeneration (GBR) technique.3
Extensive discussion among clinicians
regarding success of augmentations and
the management of complications is typical-
ly related to the osteogenic potential of the
grafting material, the immobilization of the
graft during the surgical procedure, and
issues with sufficient coverage of the recip-
ient site due to flap advancement. There are
important biological and postsurgical con-
siderations, but an insufficient releasing
incision of the periosteum for flap advance-
ment is often the most important criteria for
success or failure. Complete coverage of the
surgical site is important to control the
contamination of the grafted site and to
support the osteogenic potential of the
grafting material.
The exact technique of the PRI is not
precisely described in any current surgical
textbook or scientific journals. The aim of this
report, therefore, is to demonstrate the exact

Journal of Oral Implantology 25

Flap Advancement

FIGURE 1. (a) Flap tension after augmentation before periosteal releasing incision. (b) Periosteal releasing
incision. (c) Muscle release for a better flap advancement. (d) Coverage of the augmented site and
wound closure. (e) Flap suturing.

surgical technique so that sufficient coverage
of the augmentation site may be achieved.
The author, who is fully trained in the field
of periodontology and oral maxillofacial sur-
gery, noticed that there is not enough focus
on this very important surgical procedure in
textbooks. Based on the author’s experience
of PRI to advance flaps and cover augmented
sites, especially after vertical augmentations of
the maxilla or mandible, this technical note
describes the most important steps for
successful results.
Surgical guidelines for successful result:
1. The flap has to be a mucoperiosteal flap
and must be raised sufficiently over the
mucogingival junction in an apical direc-
tion for at least 10 mm.
2. With conventional dental forceps (sur-
gical forceps may lead to flap perfora-
tions) hold (but do not pull) the flap in a
coronal direction to evaluate the tension
during coverage of the augmentation
site.
3. With a new scalpel (blade No. 15 or 15c),
start at the distal part of the flap
perpendicular (or at a 60u angle) to the

26 Vol. XXXVI/No. One/2010

 Romanos

FIGURE 2a–d. (a) Surgical site in the posterior mandible. Observe the mental foramen. (b) Decortication of
the mandible and lingual fixation of a collagen membrane. (c) Augmentation with BioOss and
membrane fixation with tags. (d) Periosteal releasing incision of the buccal flap for flap advancement.

periosteum and, without stopping (that is,
in one shot), cut the periosteum in a
depth of 1–3 mm always moving the
blade in a direction from distal to mesial.
4. The blade should cut the tissue in a level
apical to the mucogingival junction (to
avoid flap perforation, do not cut the area
of keratinized mucosa). To avoid flap
perforation, do not cut the area of the
keratinized mucosa.
5. Pull and evaluate (in a coronal direction)
the flap and check for a tension-free flap
advancement. In case of insufficient
closure, stay at the same area and cut
more deeply in the muscle layer or use a
new PRI in a parallel direction to the
previous one, more apically.
6. Always check the final result in such a way
that the buccal flap margin covers the
lingual or palatal site at least of 3–5 mm. If
this overlapping does not occur, there is a
lot of tension in the flap, which means the
closure is insufficient. Muscle release can
be performed using dissection scissors
(Figures 1 through 3). This is very impor-
tant, especially in vertical or horizontal
augmentations of the alveolar ridge with
corticocancellous bone grafts or ad-
vanced applications of the GBR-technique
to avoid graft exposure.
Intraoperative surgical complications due
to PRI, like advanced bleeding from perfo-
rated blood vessels, should be controlled
before final closure using electro- or laser-
assisted coagulation. If advanced arterial
bleeding occurs, surgical ligation of the
blood vessels should be done. In that way,
postoperative problems such as bleeding
from the surgical site, ecchymosis, or hema-
toma can be controlled. Before starting the
PRI procedure, be aware of certain anatomic
structures, such as parotid duct, in case of
flap advancement in the maxilla. Special
considerations may take place at the lingual
flap advancement, where a PRI may damage
the lingual nerve. This nerve is oriented
parallel to the lingual part of the mandibular

Journal of Oral Implantology 27

Flap Advancement

FIGURE 2e–h. (e) Release of the mylohyoid muscle using the finger in the lingual area for sufficient
closure. (f) Tension free closure immediately after augmentation. (g) Radiograph 3 months after
surgery. (h) Clinical situation 3 months after surgery. Complete closure without any complications.

body and close to the periosteum. For
lingual flap advancement, it is of great
importance to raise the lingual flap much
more mesially in full thickness and/or to
release the mylohyoid muscle.
A common surgical error, which typically
takes place 1–4 weeks after surgery when flap
dehiscence occurs, is the closure of the flap
with a new suture with or without cutting the
margin (dependent on the healing stage) of a
flap for a new reepithelization. Premature
exposure of the membranes in augmented
sites is often caused by excessive pressure of
a removable prosthesis.4 To obtain complete
closure of the flap, a new PRI should be
performed with tension-free closure (check
for overlapping). Different suturing tech-
niques, like mattress techniques, may im-
prove the better flap adaptation. An adequate
suction of the blood after incision is manda-
tory to allow a better flap closure without
swelling. I recommend following the surgical
steps reported here and using interrupted silk
or other suture materials for better drainage
of the blood compared with the mattress
suturing techniques. However, healing by
secondary intention would be the best
alternative in such cases of flap dehiscence
until the maturation of the soft tissue is
complete. Certainly, sufficient antibiotic ad-
ministration is of great importance to protect
from bacterial invasion in the augmented site
or underneath the flap. Frequent mouth rinse
with salt water or chlorhexidine solution
irrigations are also recommended for chem-
ical plaque control.
There is no doubt that flap advancement
is associated with insufficient vestibule depth,
which has to be retreated later on, in terms of
a preprosthetic mucogingival surgical proce-
dure. A vestibuloplasty with or without a free
gingival (or skin) grafting procedure (the use

28 Vol. XXXVI/No. One/2010

 Romanos

FIGURE 3. (a) Preoperative situation. (b) Flap elevation and access of the bony defect. (c) Augmentation
with BioOss (big granules and autogenous bone), coverage with a collagen membrane and Gore-Tex
membrane. Fixation with titanium tags. (d) Flap advancement and closure. (e) Lateral aspect of the
advanced flap after suturing. (f) Excellent soft tissue without dehiscence 4 weeks after surgery.

of connective tissue grafts or allografts, such
as Alloderm [Biohorizons, Birmingham, Ala]) is
indicated before or in combination with
implant surgery. Alternative surgical tech-
niques, like the use of laser surgery to increase
the vestibule depth, have also been also
reported.5,6 Moreover, the thickness of the
tissue is important, and this may be reached
by the use of thick free gingival grafts.
ABBREVIATIONS
GBR: guided bone regeneration
PRI: periosteal releasing incision

Journal of Oral Implantology 29

Flap Advancement
REFERENCES
1. Happe A, Khoury F. Complications and risk
factors in bone grafting procedures. In: Khoury F,
Antoun H, Missika P, eds. Bone Augmentation in Oral
Implantology. Berlin: Quintessence; 2007:405–429.
2. Levin L, Heerzberg DE, Schwarz-Arad D. Smoking
and complications of onlay bone grafts and sinus lift
operations. Int J Oral Maxillofac Implants. 2004;19:369–
373.
3. Aghaloo TL, Moy P. Which hard tissue augmen-
tation techniques are the most successful in furnishing
30 Vol. XXXVI/No. One/2010
bony support for implant placement? Int J Oral
Maxillofac Implants. 2007;22(suppl):49–70.
4. Mattout P. Pre- and periimplant guided bone
regeneration. In: Khoury F, Antoun H, Missika P. Bone
Augmentation in Oral Implantology. Berlin: Quintes-
sence; 2007:299–320.
5. Catone GA, Alling CC. Laser Applications in Oral
and Maxillofacial Surgery. Philadelphia, Pa: Saunders;
1997.
6. Romanos GE. Atlas der chirurgischen Laser-
zahnheilkunde. Munich: Urban und Fischer Publ;
1999.