CLINICAL

Vascularized Connective Tissue Flap for

Bone Graft Coverage
Alan S. Herford, DDS, MD1*
Todd C. Cooper, DDS1
Carlo Maiorana, DDS, MD2
Marco Cicciù, DDS, PhD2

Alveolar defects are characterized by missing soft and hard tissues. It is often necessary to
combine secondary procedures to address the soft-tissue component. The authors describe a
technique that uses a split-thickness flap design that is placed over the crest of the
remaining ridge and extends in a palatal direction. This allows advancement of the flap with
its exposed connective tissue over the bone graft and provides restoration of both bone and
keratinized tissue. Seventeen patients with defects involving the anterior maxilla who
required grafting procedures were including in this study. All patients had an autogenous
bone graft (n 5 17) combined with osseointegrated implants (n 5 41). A split-thickness flap
design was used at the time of bone graft placement (primary) in 9 patients and at the time
of implant uncovering (secondary) in 8 patients. There were no cases of flap necrosis or
dehiscence with exposure of the bone graft. All patients demonstrated an increase in
keratinized tissue involving the peri-implant area. An apical repositioned split-thickness flap
provides an increased zone of keratinized tissue with improved esthetics and implant
maintenance. This technique can be performed simultaneously with the grafting procedure,
thus avoiding extensive undermining of the adjacent soft tissue.

Key Words: split thickness flap, bone grafting

INTRODUCTION Implant placement in prosthetically ac-

curate positions, especially when alveolar

V
ertical and/or horizontal alveo-
ridge augmentation procedures are per-
lar defects are often associated
formed, often result in emergence of abut-
with missing bone and mucosa.
ments through nonkeratinized and unat-
Many techniques are available
tached mucosa. It is necessary to widely
for reconstructing these areas,
undermine the flap to achieve primary
including both hard- and soft-tissue proce-
closure over the bone graft to avoid placing
dures.1 Bone grafts reliably restore the
tension over the graft. Excess tension can
alveolar ridge but do not address deficient
cause dehiscence and exposure of the graft,
keratinized mucosa.
which may lead to significant resorption or
1
Department of Oral & Maxillofacial Surgery, Loma loss of the graft. Undermining of the flap can
Linda University, Loma Linda, Calif. lead to loss of vestibular height and restrict-
2
Department of Oral Surgery and Implantology, IRCSS–
School of Dentistry, University of Milan Dental Clinic, ed movement of the lip. This flap advance-
Milan, Italy.
* Corresponding author, e-mail: aherford@sd.llu.edu
ment recruits nonkeratinized mucosa to
DOI: 10.1563/AAID-JOI-D-09-00146.1 cover the graft.

Journal of Oral Implantology 279

Vascularized Connective Tissue Flap

FIGURE 1. (a) Diagram showing the location of the split-thickness incisions over the alveolar defect. (b)
Diagram showing the placement of the bone graft and coverage with the split-thickness flap. Arrows
indicate the direction of the flap.

Currently, it is widely accepted that The purpose of this study is to describe a

keratinized mucosa, although not essential
to the existence of a tooth and its attach-
ment apparatus, does enhance the long-
term survival of the tooth. On review of the
literature, it is evident that the presence of
the keratinized mucosa is especially impor-
tant around restorations and prostheses or if
the tooth is in a dentition susceptible to
periodontal breakdown.2–5 However, there
has been considerable discussion as to
whether the extent of keratinized gingiva
adjacent to implants bears the same signif-
icance as to natural teeth.6–9 The structure
and function of the mucosa that surrounds
implants have been examined,10 and it was
observed that the soft-tissue response to
plaque develops in a similar manner around
teeth and dental implants.11,12 Longitudinal
studies definitively establish that although
patient comfort may be enhanced in select-
ed patients with the presence of keratinized
gingiva around implants, its presence is not
necessary for establishment of osseointegra-
tion or for its long-term maintenance.13
Although controversy exists regarding
the need for attached mucosa surrounding
osseointegrated implants, there are many
benefits.10,14–17 In the anterior maxilla, opti-
mal esthetics dictate the need for keratinized
tissue in the peri-implant region. Flap
procedures and grafting techniques have
been described to increase the zone of
attached mucosa.18–27
split-thickness flap technique that increases
the amount of keratinized tissue in conjunc-
tion with bone augmentation and implant
placement, thus providing optimal anterior
esthetics.
PATIENTS AND METHODS
This study comprised 17 patients with
insufficient hard and soft tissue involving
the anterior maxilla. There were 10 vertical
(height) bony defects and 7 horizontal
(width) defects. All defects were grafted with
autogenous bone. The harvest sites included
the iliac crest (vertical defects; n 5 10) and
lateral ramus (horizontal defects; n 5 7). The
size of the graft was related to the bone
defect. The graft ranged in width between
5 cm3 and 30 cm3.
A split-thickness flap technique was used
primarily at the time of grafting in 9 patients
and secondarily when exposing the graft in 8
patients. Rootform implants were placed
simultaneously with the graft procedure in
5 patients and secondarily in 11 patients. A
total of 41 osseointegrated implants were
placed in the anterior maxilla. A subjective
esthetic evaluation of the area included
evaluating the shape, color, form, and
sufficiency of the reconstruction.
Surgical procedure
Stage I surgery technique. A partial-thick-
ness incision (Figure 1) is made with a 15

280 Vol. XXXVII/No. Two/2011

 Herford et al

FIGURE 2. (a) Anterior alveolar defect with congenitally missing lateral incisor. Note the insufficient
ridge width places the rootform implants in a proper location. (b) Placement of an onlay block
graft harvested from the lateral ramus of the mandible. Note the minimal undermining of the
facial tissue. (c) Coverage of the graft with the split-thickness flap. Note the exposed
connective tissue providing coverage over the graft. (d) Postoperative result prior to implant
placement showing the sufficient amount of attached gingival to obtain optimal anterior
aesthetics.

surgical blade and placed in the keratinized
mucosa approximately 3 mm from the
mucogingival junction. A beaver blade is
then used to undermine the palatal tissue.
The amount of undermining depends on the
desired amount of keratinized tissue to be
gained and the need for sufficient coverage
of the graft. The palatal tissue is retracted,
and a 15 blade is then used to incise the
tissue to bone. At this point, the connective
tissue flap is reflected in a subperiosteal
manner. The alveolar defect is exposed and
grafted with either a block onlay graft or a
particulate graft with a membrane. Implants
may be placed at the time of grafting or at a
second stage. The split-thickness flap is then
positioned apically to cover the graft and
sutured to the palatal flap. A minimum 3-mm
overlap of the 2 flaps was needed to avoid
tissue breakdown at the junction, essential
for reestablishment of vascularity. An area of
exposed connective tissue is visible over the
reconstructed ridge and is left to epithelialize
(Figure 2).
Stage II surgery technique. The develop-
ment of the split-thickness flap (Figure 3) is
made in the same manner as for the stage I
technique. The graft is exposed, and the
entire flap is repositioned apically and
secured into place. The exposed connective
tissue is left to epithelialize with attached
mucosa (Figure 4).
RESULTS
The postoperative course was uneventful for
all patients. There were no patients with
dehiscence or necrosis of the flap. Two
patients complained of slight pain involving
the harvest site for the bone graft. The split-
thickness portion of the flap was epithelial-
ized with keratinized tissue by the third

Journal of Oral Implantology 281

Vascularized Connective Tissue Flap

FIGURES 3 AND 4. FIGURE 3. Diagram showing the location of the split-thickness incisions over the grafted
ridge. FIGURE 4. (a) Diagram showing the new keratinized mucosa around dental implant. (b) Anterior
maxilla after grafting procedure with insufficient keratinized tissue. The area of incision is shown
(black dash) as well as the area of undermining in a split-thickness manner (gray lines). (c) Apical
repositioning of the split-thickness flap and placement of implant healing abutments. (d) Four
weeks postoperatively with an increase in attached gingival along the facial aspect of the peri-
implant region.

week. There was also an increase in vestib- DISCUSSION

ular depth that was not quantified.
Postoperative inconveniences were min-
imal, with postoperative bleeding and dis-
comfort only occasional complications. Hard-
and soft-tissue anatomy was considered
acceptable, and additional bone augmenta-
tion procedures were not performed. Proper
functional and esthetic restorations could be
prepared for all implants 3 weeks after the
surgery (Figures 5 and 6).
Bone grafting and osseointegrated implants
have shown to be a predictable method for
restoring both form and function.1 Unfortu-
nately, the soft-tissue deficiency is not
addressed with this procedure and may
actually be adversely affected by undermin-
ing and disrupting the adjacent anatomy.
Although keratinized tissue is not indis-
pensable for maintenance of peri-implant
tissue health, its presence has many benefits.

282 Vol. XXXVII/No. Two/2011


FIGURES 5 AND 6. FIGURE 5. Prosthetic restoration after 3-week soft-tissue healing. FIGURE 6. Three-month
radiographic follow-up.
Keratinized tissue enhances esthetics and is
associated with less gingival recession, easier
plaque control, and protection from bacterial
aggression.10,16 Proper soft-tissue anatomy
around implants provides a healthy soft-
tissue barrier, which facilitates oral hygiene
and gives the prosthetic restoration a more
natural look.18 Block and Kent19 have shown
a correlation between the presence of
keratinized mucosa and the health of soft
and hard tissues around implants.
After second-stage surgery, the zone of
keratinized tissue is frequently inadequate.
Classical uncovering incisions and flap de-
signs often result in compromised esthetic
soft tissue.20 From a clinical standpoint, oral
hygiene techniques are easier to perform
and more comfortable for the patient when
an adequate zone of attached gingival is
present.
Grafts and membranes should be com-
pletely covered and remain submerged
during the entire healing period. Tension-
free closure is important for the success of
the bone-grafting procedure. Undermining
and advancement may lead to extreme
displacement of the mucogingival border
and disruption of the entire soft-tissue
architecture.21 An advantage to using the
split-thickness flap that we describe at the
time of bone grafting (primary) is that it
avoids a decrease in the vestibule caused
from extensive undermining of the buccal
Herford et al
mucosa and lip to achieve primary closure.
This technique allows simultaneous place-
ment of the bone graft and implants, greatly
reducing total treatment time. It can be
combined with guided bone regeneration
procedures using particulate bone grafts as
well as block onlay grafts.
Many surgical techniques have been
described to create or increase the zone
of keratinized tissue around osseointeg-
rated implants, including rotated palatal
flaps,14,17,22 various autografts,23–35 and cor-
onally positioned palatal sliding flaps.14
Landi and Sabatucci26 recently described a
modified technique for uncovering implants
at the time of membrane removal, which can
lead to an increased amount of keratinized
tissue.26 Saadoun and Le Gall27 described an
apical repositioned full-thickness flap proce-
dure, which leaves subsequent bone denu-
dation. Denuded bone not only becomes
susceptible to resorption, infection, and
mechanical irritation but also causes greater
postoperative pain than tissue-covered
bone.36,37 Histologic studies have demon-
strated that exposed bone results in signif-
icant bone resorption.38,39 In 1992, Scharf
and Tarnow32 described a modified roll
technique for localized ridge augmentation.
Their technique involved creating a trapdoor
by preserving a partial-thickness flap overly-
ing the area of connective tissue harvest. The
technique that we describe is similar with
Journal of Oral Implantology 283
Vascularized Connective Tissue Flap
the exception that the connective tissue
portion of the flap remains exposed and is
allowed to epithelialize rather than rolled
beneath the flap. This technique minimizes
the amount of exposed bone.
Moreover, likewise, Zigdon and Machtei40
investigated the association between the
dimensions of keratinized mucosa with
clinical and immunological parameters
around dental implants. It was observed that
a thick mucosa ($1 mm) was associated with
lesser buccal mucosal recession compared
with a thin mucosa (,1 mm). These findings
are of special importance in the esthetic
zone, where narrow and thin keratinized
mucosa may lead to greater mucosal reces-
sion.40
The split-thickness flap procedure aug-
ments the buccal peri-implant keratinized
tissue while avoiding a large zone of
exposed bone. This provides improved bone
protection with acceleration of wound heal-
ing and minimizes the danger of infection.
Split-thickness flap procedures are less trau-
matic than full-thickness flap surgery.38
Split-thickness flaps are broad based,
which maintains their blood supply. This flap
avoids a donor site, which differs from free
connective tissue and gingival grafts.41,42
Leaving connective tissue denuded elicits
keratinized tissue formation.26 As the flap
becomes epithelialized, it blends with the
surrounding keratinized tissue.
This technique is simple and predictable
and consistently provides a wider zone of
keratinized gingiva in the buccal aspect of
the future maxillary implant–supported res-
toration. This is especially important in the
anterior maxilla, where esthetics is of para-
mount importance.
CONCLUSION
Apical repositioning of a split-thickness flap
combined with bone grafting and implants
restores both form and function with opti-
284 Vol. XXXVII/No. Two/2011
mal esthetics. This technique addresses both
hard- and soft-tissue deficiencies and may
eliminate the need for further soft-tissue
grafting. It also avoids disruption of the
adjacent facial soft-tissue anatomy and can
be performed primarily with the bone-
grafting procedure.
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