790 THE DIGITOCLASTIC TECHNIQUE PISTILLI ET AL

Safe New Approach to the Lingual Flap

Management in Mandibular
Augmentation Procedures: The
Digitoclastic Technique
Roberto Pistilli, MD,* Vittorio Checchi, DDS, PhD,† Gilberto Sammartino, MD,‡ Massimo Simion, MD, DDS,§ and
Pietro Felice, MD, DDS, PhD¶

one atrophies in the posterior Purpose: This article describes Results: Coronal flap displace-

B mandible caused by to early

teeth loss are common in
implant therapy, and bone regeneration
is hampered by technical complexities
and anatomical limits.1
Various therapeutic procedures,
such as onlay or inlay bone grafts,
distraction osteogenesis, and guided
bone regeneration (GBR), have been
proposed for vertical bone incrementa-
tion in the posterior mandible, and all
these techniques have yielded reliable
documented results.2,3 The primary
goal of a preprosthetic technique is to
reconstruct both hard and soft tissues
similarly to the prepathologic situation,
with a good long-term stability of the
regenerated bone.4
GBR is a well-established proce-
dure to augment vertical and horizontal
bony deficiencies, using bone graft
materials and membranes. It has been
*Resident, Oral and Maxillofacial Unit, San Camillo Hospital,
Rome, Italy.
†Researcher, Department of Medical Sciences, University of
Trieste, Trieste, Italy.
‡Professor, Department of Dental Sciences, University of Naples
Federico II, Naples, Italy.
§Professor, Department of Biomedical, Surgical and Dental
Sciences, University of Milan, Milan, Italy.
¶Researcher, Department of Periodontology and Implantology,
Dental School, University of Bologna, Bologna, Italy.
Reprint requests and correspondence to: Vittorio
Checchi, DDS, PhD, Department of Medical Sciences,
University of Trieste, Ospedale Maggiore, Piazza
dell’Ospitale 2, 34125 Trieste, Italy, Phone: +39 040
3992168, Fax: +39 040 3992665, E-mail: vchecchi@
units.it
ISSN 1056-6163/17/02605-790
Implant Dentistry
Volume 26  Number 5
Copyright © 2017 Wolters Kluwer Health, Inc. All rights
reserved.
DOI: 10.1097/ID.0000000000000599
the digitoclastic technique, an inno-
vative procedure for coronal dis-
placement of the lingual flap. The
new technique has the potential to
obtain primary flap closure without
surgical risks to the anatomical
structures on the lingual side of the
mandible.
Materials and Methods: Recon-
struction of an atrophic mandible
with guided tissue regeneration
(guided bone regeneration) and
implant placement is described,
using the digitoclastic technique
to displace the lingual flap
coronally.
used with success before implant ther-
apy or at the same time of implant
placement.5 Complications from GBR
are generally related to membrane
exposure, with a negative influence on
the amount of regenerated tissue.6
Although the regenerated bone seems
to be stable over time, once the bone
graft has healed and been incorporated,
remodeling of particulate grafts leads to
some vertical loss during the healing
period.7
Alveolar distraction osteogenesis
avoids bone harvesting and obtains
concomitant regeneration of mature
bone and soft tissues. However, this
technique in the posterior mandible is
prone to a huge number of complications
ment was sufficient to obtain com-
plete passive coverage of the grafted
area. No bleeding or neurosensory
complications were recorded, and no
membrane exposure occurred.
Conclusions: The digitoclastic
technique reduces the risk of damage
to the lingual nerve and minimizes
the amount of bleeding during sur-
gery, allowing progressive and con-
trolled retraction of the flap until the
desired detachment is achieved.
(Implant Dent 2017;26:790–795)
Key Words: bone incrementation,
soft tissues, flap management, flap
closure
and failures. The strong traction exerted
by the mouth floor muscles and occlusal
disturbances may jeopardize the final
result in this anatomical region.8
For block onlay grafting, almost all
grafts show major dimensional changes
postsurgically.9,10 In addition to verti-
cal augmentation of the atrophic poste-
rior mandible, an autologous bone
block graft is suggested, with the need
for a second surgical site.11
None of these techniques are
clearly superior to the others in graft
stability and implant survival and
success.2 A commitment shared by
these procedures is the proper man-
agement of soft tissues. Primary flap
closure is mandatory to prevent

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PISTILLI ET AL
Fig. 1. Clinical view of the posterior right
mandible showing severe atrophy of both
vertical and horizontal bone volumes.
Fig. 2. Panoramic x-ray of the posterior right
mandible showing the vertical atrophy of the
bone that prevents placement of traditional
length implants.
Fig. 3. Anatomical drawing showing the
raised buccal flap: detachment of the buccal
flap shows the neurovascular bundle close to
the mental foramen (drawing by R.P.).
Fig. 4. A–C, Clinical view of the measurements made with a periodontal probe. These were taken distally (A), medially (B), and mesially (C) to
verify the mobility of the lingual flap before flap elevation.
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IMPLANT DENTISTRY / VOLUME 26, NUMBER 5 2017
membrane exposure and bacterial
contamination of the graft and to
ensure a low rate of complications
during the healing period. These goals
can only be achieved when both buc-
cal and lingual flaps are released
enough to obtain complete passive
coverage of the graft.12–14
A variety of techniques have been
proposed for soft tissue management
and coronal displacement of the lingual
flap in the posterior mandible to allow
primary flap closure after a bone aug-
mentation procedure.15–18
This article describes the digito-
clastic technique, an innovative pro-
cedure for coronal displacement of the
lingual flap. The new technique has the
potential to obtain primary flap closure
without surgical risks to the anatomical
structures on the lingual side of the
mandible.
MATERIALS AND METHODS
This case presentation describes
a GBR reconstruction of a left atrophic
mandible with implant placement,
using the digitoclastic technique to
displace the lingual flap coronally.
A male patient with posterior man-
dibular atrophy signed a written
informed consent form to undergo
GBR reconstruction and implant place-
ment. The patient initially underwent
clinical (Fig. 1) and radiographic
(Fig. 2) examination with periapical
and panoramic x-rays. The tenets of the
Declaration of Helsinki were followed.
Surgical Protocol
Under local anesthesia, the pro-
cedure begins with a crestal incision
extending from the edentulous area of
the second molar mesially until the
791
sulcus of the last tooth present, split-
ting the residual amount of attached
gingiva half buccally and half lin-
gually. Mesially, the releasing inci-
sion is performed with a “hockey
stick” design, with preservation of
the papilla between the last and pen-
ultimate teeth. Distally, the releasing
incision is deeper and reaches the
mobile gingiva within 8/10 mm.
The preserved papilla mesial to the
last tooth is deepithelialized as in mu-
cogingival periodontal surgery. Lin-
gually, the sulcular incision is
extended to include 4 teeth.
Buccally, the flap is carefully
raised full thickness to disclose the
neurovascular bundle in the mental
foramen area. Instead, distally to this
area, the flap has to be elevated to
a variable degree. If we mark an
imaginary line that contours the coro-
nal margin of the mental foramen, the
flap has to be raised 6/8 mm to this line
posteriorly and deepened mesially and
distally for 13/15 mm (Fig. 3). Dis-
tally, the flap has to be raised apically
to the fixed part of the flap to reach the
area of the trigone. The lingual flap
has to be raised full thickness with
a Lucas-like periosteal elevator, start-
ing 10/15 mm distally to the last tooth
present (Fig. 4).
With an atraumatic clamp, the
coronal margin of the lingual flap has
to be lightly grasped distally to the
Lucas-like periosteal elevator and,
with a precise movement, raised mesi-
ally to reach the cervical margin of
the last tooth present. Then, the flap
has to be raised distally to achieve
complete detachment of the crestal
part of the lingual flap 10 mm apical
792 THE DIGITOCLASTIC TECHNIQUE PISTILLI ET AL

Fig. 5. A and B, Once the medial surface of the mandible has been raised, the distal fulcrum
of the flap is modified releasing the unmovable part of the flap from the trigone and the fixed Fig. 9. Anatomical drawing showing the
flap in the trigone area is detached with a periosteum elevator. index finger atraumatically detaching the peri-
osteum and the vertical fibers of the accessory
mylohyoid muscle (drawing by R.P.).

to the unmovable flap. In the anterior

part of the lingual flap, the lingual
papillae of the anterior teeth have to be avoiding detachment of the insertion of
raised. the mylohyoid muscle.
At this point, the Lucas-like instru- Once the medial surface of the
Fig. 6. Anatomical drawing showing the
ment has to be changed to a medium mandible has been raised, the distal
elasticity of the raised flap after elevation of size Prichard-like periosteal elevator. fulcrum of the flap has to be modified
the trigone area: this posterior extension of This instrument has to be positioned releasing the firm part of the flap from
the raised flap moves more coronally the vertically between the lingual bone and the trigone. With a Prichard-like peri-
fulcrum of the flap (drawing by R.P.). The osteal elevator, the fixed flap in the
arrows indicate the coronal movement of the the flap, and the full-thickness elevation
of the lingual flap of the mandible has to trigone area has to be detached (Fig. 5).
flap after elevation of the trigon area.
be continued until the mylohyoid line, Distally, this posterior extension of the
raised flap moves the fulcrum of the flap
more coronally (Fig. 6).
This extension permits the index
finger to be placed with its fingertip in
contact with the medial surface of the
mandible (Fig. 7, A and B). The finger
moves mesially and distally causing the
progressive atraumatic detachment of
the periosteum and the vertical fibers of
the accessory mylohyoid muscle (digito-
clastic technique of the lingual flap)
(Figs. 8, A and B and 9). Then, hand
Fig. 7. A, Anatomical drawing showing the index finger with its fingertip placed in contact with and finger have to be rotated and the fin-
the medial surface of the mandible (drawing by R.P.). B, Clinical view of the finger with its ger hooks the flap moving it coronally,
fingertip placed in contact with the medial surface of the mandible. with a further tissue-stretching move-
ment (Figs. 10 and 11). Finally, the lin-
gual flap is fully detached, tension-free,
and able to cover the following bone
graft procedure to obtain primary flap
closure with no tensions (Fig. 12).
The vertical bone augmentation
procedure is performed using a micro-
textured titanium-reinforced polytetra-
fluoroethylene membrane (Cytoplast
Ti-250, De Ore, Verona, Italy) in asso-
ciation with a mixture of bone grafts:
a 1:1 mixture of particles of bovine-
derived xenograft (Bio-Oss, Geistlich,
Fig. 8. A and B, Clinical view of the atraumatic detachment obtained with the finger that
Wolhusen, Switzerland) and autogenous
moves mesially and distally causing the progressive and atraumatic detachment of the peri- bone harvested with bone scrapers from
osteum and the vertical fibers of the accessory mylohyoid muscle. the external oblique ridge. Implant sites
are prepared using the dedicated drill

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PISTILLI ET AL
Fig. 10. Anatomical drawing showing the
index finger that hooks the flap moving it
coronally, performing a further stretching
movement on the tissues (drawing by R.P.).
Fig. 11. Clinical view of the measurements made with a periodontal probe to quantify the coronal displacement of the flap distally (A), medially
(B), and mesially (C) after detachment with the digitoclastic technique.
Fig. 12. The lingual flap fully detached and
tension free is able to cover the following
bone graft procedure and to obtain primary
flap closure with no tensions.
system and implants (AnyRidge, Mega-
gen, Seoul, Korea) are placed supra-
crestally from the initial bone level.
After bone refreshing through sev-
eral perforations of cortical bone in the
recipient site, the graft is positioned and
the membrane adapted and fixed by pins
and miniscrews (Pro-fix Membrane
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IMPLANT DENTISTRY / VOLUME 26, NUMBER 5 2017
Fixation System, Osteogenics Biomed-
ical, TX) both buccally and lingually.
After evaluating the possibility to cover
the whole grafted site with no tension,
the flaps are sutured to achieve primary
wound closure.
A nonsteroidal analgesic (Keto-
profen, Orudis; Aventis Pharma,
Bridgewater, NJ) and amoxicillin
with clavulanic acid (Augmentin;
GlaxoSmithKline, Brentford, UK)
were administered with a loading dose
of 2 g, followed by 2g/d for 10 days.
Postsurgical instructions included a soft
diet for 2 weeks and appropriate oral
hygiene, including twice-daily rinsing
with a 0.2% chlorhexidine digluconate
mouthrinse (Corsodyl; GlaxoSmithKline,
Brentford, UK). Sutures were removed
15 days postoperatively.
Successfully primary closure was
defined as achieved after 6 months of
complete coverage.
Coronal flap displacement was suf-
ficient to obtain complete passive cov-
erage of the grafted area. During the
postsurgical period, no bleeding or
neurosensory complications were re-
corded. No membrane exposure
occurred, and after 6 months after the
grafting procedure, the membrane was
removed to begin the prosthetic proce-
dures over the integrated implants.
DISCUSSION
The digitoclastic technique was
used for the first time in the mid-20th
century by Tôn Thât Tùng, a Vietnam-
ese general surgeon. He used his fingers
793
to separate different areas of the liver to
remove tumors and avoid the risk of
hemorrhage.19 Today, we are using
the same basics doctor Tùng applied
to oral surgery, namely displacement
of the mandibular lingual flap.
Today, all bone incrementation pro-
cedures seem highly predictable in both
horizontal and vertical bone increase and
implant survival.20 However, these are
all very challenging techniques that
require strict observation of the surgical
protocols. One of the basic factors
for success is to achieve and maintain
primary flap closure throughout the
healing period.16,21 These flaps have
to be passive and tension free and
managed with extreme care so as not
to damage the adjacent anatomical
structures.22,23
Various authors have described the
procedure to be used for coronal dis-
placement of the lingual flap.16,17,24 The
technique considers a full-thickness flap
elevation beyond the mylohyoid line and
an incision of the lingual periosteum in
a mesiodistal direction, to free the flap
coronally. In case of incomplete closure,
the suggestion is to cut deeply into the
muscle layer starting from the initial inci-
sion or to perform an additional muscle
release using dissection scissors. This is
a valid procedure, but it is very demand-
ing because there is no direct visual con-
trol of the area and is at risk for the
surrounding anatomical structures.
In 2011, Ronda and Stacchi18 pro-
posed their technique based on separa-
tion of the lingual flap from the
underlying muscular structures in the
794 THE DIGITOCLASTIC TECHNIQUE
mandibular posterior mandibular area.
They claim that the close contact
between the mylohyoid muscle and
the lingual flap in the molar area is an
important limitation for flap displace-
ment. Therefore, they propose using
a blunt instrument, to detach the mylo-
hyoid insertion in the posterior region,
elevating the lingual flap only up to the
mylohyoid line, to protect the underly-
ing anatomical structures.
Recently, other authors have
described in detail the longitudinal
periosteal releasing incision tech-
nique.13,25 After elevation of a full-
thickness flap, the periosteum is cut
with a longitudinal distal to mesial inci-
sion, at a depth of 1 to 3 mm, allowing
coronal displacement of the flap, vari-
able from 5 to 8 mm. If needed, it is
suggested to cut the muscle layers more
deeply. This additional cut raises the
risk of interrupting blood vessels and
nerve fibers, increasing the risks of in-
traoperative and postoperative compli-
cations, such as neurological injuries,
bleeding, hematoma, and edema.
The digitoclastic technique has
many advantages when applied to cor-
onal displacement of the lingual flap in
the posterior atrophic mandible. First of
all, this procedure is easy to perform
and easy to learn and reproduce, mak-
ing it a procedure suited to all clinicians.
Compared with the previously men-
tioned invasive procedures, the digito-
clastic technique is equally able to
displace the lingual flap coronally but
with much less trauma. The lingual
periosteum and blood vessels are
stretched but not damaged because both
have an elasticity that tolerates the
height increase. Moreover, because
the lingual periosteum remains intact
with this technique, the vascularization
on the lingual side is not interrupted, as
it is on the buccal side.
CONCLUSIONS
The selective search for vertical
muscle fibers and their section with
scalpels or scissors is a common pro-
cedure but is subject to the surgeon’s
skills. The use of a scalpel is dangerous
in case of extremely thin flaps that con-
tain few fibers and in severe bone atro-
phy, when there is no residual vertical
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
lingual flap but only the floor of the oral
cavity inserted directly in the alveolar
crest. In these challenging situations, after
detachment of the trigone area, the only
chance to detach the lingual flap is to
resect the mylohyoid fibers, being aware
of the presence of the lingual nerve just
underneath the muscle fibers.
The digitoclastic technique can
drastically reduce all the risks of acci-
dental damage to the lingual nerve
and minimize the amount of bleeding
during surgery, allowing the surgeon to
retract the flap in a progressive and
controlled way until the desired detach-
ment is achieved.
DISCLOSURE
The authors claim to have no
financial interest, either directly or
indirectly, in the products or informa-
tion listed in the article. This study has
been self-supported by the authors.
APPROVAL
Not applicable.
ROLES/CONTRIBUTIONS
BY AUTHORS
R. Pistilli: created the images of the
technique. V. Checchi: wrote the manu-
script. G. Sammartino: corrected and
supervised the article. M. Simion: super-
vised the article and helped with the
translation. P. Felice: clinically performed
the technique and corrected the article.
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