Received: 29 August 2020 Revised: 3 October 2020 Accepted: 6 October 2020

DOI: 10.1111/cid.12960

ORIGINAL ARTICLE

Clinical comparison of different flap advancement techniques

to periosteal releasing incision in guided bone regeneration:
A randomized controlled trial

Nada Zazou PhD1,2 | Noha Diab MD3 | Samah Bahaa PhD1 |

Azza Ezz el Arab PhD1 | Omniya Abdel Aziz DDS4 | Hani el Nahass PhD1

1
Faculty of Dentistry, Department of
Periodontology, Cairo University, Cairo, Egypt
2
Faculty of Dentistry, Department of
Periodontology, Modern Sciences and Arts
University, Giza, Egypt
3
Faculty of Dentistry, Department of
Implantology, Cairo University, Cairo, Egypt
4
Faculty of Dentistry, Department of Oral and
Maxillofacial Surgery, Cairo University, Cairo,
Egypt
Correspondence
Nada Zazou, Modern Sciences and Arts
University, Wahat Road, Giza, 12566, Egypt.
Email: drzazou@hotmail.com
Abstract
Objectives: To compare Double Flap Incision (DF), Coronally Advanced Lingual Flap
(CALF), and Modified Periosteal Releasing Incision (MPRI) to Periosteal Releasing
Incision (PRI) in flap advancement, postoperative complications in augmentation
using titanium mesh.
Material and methods: Forty patients with partially edentulous posterior mandibles
were randomly assigned to the four groups. We evaluated: (a) Flap advancement in
mm (Primary outcome). (b) Pain using the Numerical Rating scale (NRS). (c) Swelling
using the Visual Analogue Scale (VAS). (d) Exposure in mm and exposure percentage
at 1 week to 6 months.
Results: The CALF showed the highest mean flap advancement of 19.9 (±5.0) mm
while the PRI showed the lowest; 10.2 (±1.7) mm. The difference between groups
was statistically significant (P value <.0001). MPRI showed the highest pain score of
5.3 (±1.3) while the DF showed the lowest; 2.39 (±1.7). Swelling did not show a sig-
nificant difference between groups. MPRI showed the highest exposure mean;
18.6 mm (±26.3) while CALF showed the lowest; 2.5 mm (±4.0). PRI showed the
highest exposure percentage; 7.4% (±9.3) while CALF showed the lowest; 0.4%
(±0.7). The difference between groups was insignificant.
Conclusions: CALF reported highest advancement, least complications while PRI
reported the highest complications.

KEYWORDS

bone augmentation, clinical trials, flap advancement, guided bone regeneration, titanium mesh

1 | I N T RO DU CT I O N the well-documented incidence of exposure could reach up to 50% of

Sufficient bone volume remains mandatory for implant placement to
allow proper functional and esthetic positioning.1 An array of augmen-
tation procedures have been utilized to correct bone deficiencies
among which is guided bone regeneration (GBR) that is considered to
2
be a reliable method of augmentation. Titanium mesh is one of the
most predictable non-resorbable membranes used for ridge augmen-
3
tation and has the advantage of space maintenance. Nevertheless,
the cases represent a challenge.4-6 The aforementioned exposure is
attributed to the presence of sharp edges which may cause injury to
the surrounding tissues7 and the tendency to revert to their original
shape after being molded to cover the defect. Tension-free primary
closure is mandatory in all augmentation procedures and can be
achieved through sufficient flap advancement.8 Periosteal releasing
incision (PRI) is the gold standard technique for flap advancement.9 It
involves fenestrations at the base of the flap to render it tension free.

Clin Implant Dent Relat Res. 2021;23:107–116. wileyonlinelibrary.com/journal/cid © 2020 Wiley Periodicals LLC 107
108
However, it compromises the blood supply and may increase the
exposure rate and postoperative complications.10
Other techniques were introduced to overcome the drawbacks of
Periosteal releasing incision (PRI) basically by avoiding the excessive
severing of the periosteum. In this article, three flap advancement
techniques are compared to the gold standard, Periosteal Releasing
Incision (PRI): The “Double Flap Incision” (DF) is among those tech-
niques and it involves the splitting of the flap into two layers; an
inner periosteal and an outer mucosal layer that extends coronally
to achieve primary closure.10 The second technique is the
“Coronally Advanced Lingual Flap” (CALF) which involves detach-
ment of the mylohyoid muscle insertion from the lingual flap render-
ing it free to move coronally.11 The “Modified Periosteal Releasing
Incision” (MPRI) is another alternative introduced in 2015 by Hur
et al. and involves a shallow Periosteal releasing incision (PRI) creat-
ing coronal and apical segments that are separated using blunt dis-
section “lateral stretching.” 12
Since those techniques entailed less severing of the periosteum
our hypothesis was that fewer complications would be reported with
such challenging surgical technique compared to Periosteal releasing
incision (PRI). To the best of our knowledge, no clinical trial was con-
ducted to compare those techniques before. Hence, our study aims to
compare DF, CALF, MPRI, and PRI in partially edentulous patients
undergoing guided bone regeneration using titanium mesh in terms of
flap advancement as a primary outcome, postoperative complications,
and mesh exposure as secondary outcomes.
2 | MATERIALS AND METHODS
This study is a prospective, randomized, controlled, multi-arm
parallel-group double-blinded clinical trial conducted in Cairo,
Egypt. The study protocol was approved by the Research Ethics
Committee of the Faculty of Dentistry, Cairo University (Approval
numbers: 15-7-32,15-10-12, and 17-7-7) and the Centre for
Evidence-Based Dentistry, Cairo University. The trial was registered
in clinicaltrials.gov (registration number NCT03787342) and was
prepared based on the CONSORT guidelines for reporting of ran-
13
domized controlled trials.
Forty partially edentulous patients were selected from the outpa-
tient clinic of “The Faculty of Dentistry”, Cairo University, Egypt,
where the trial took place from January 2016 to December 2017. Eli-
gible patients were thoroughly informed of the study protocol (includ-
ing procedures, follow-up assessments, potential risks, and possible
therapeutic alternatives) and signed a written informed consent form
in which all procedures of the study were detailed. Patients approved
the use of their data for research purposes.
2.1 | Eligibility criteria
Patients were enrolled as follow: (a) systemically healthy;
(b) ≥ 21 years of age; (c) partially edentulous in the mandibular
ZAZOU ET AL.
What is known
Recently introduced flap advancement techniques may be
superior to the classical periosteal releasing incision technique
(PRI) in large augmentation procedures. PRI is reported to
result in more postoperative complications and may affect the
flap blood supply. Other alternatives with fewer complications
would be beneficial for patients and clinicians.
What this study adds
Coronally Advanced Lingual Flap (CALF) seemed to be supe-
rior to other techniques in flap advancement and exposure
rates while double flap incision showed lower pain scores.
For large GBR procedures using non-resorbable membranes
in the posterior mandible, the use of CALF is highly
advocated.
posterior region with two or more missing teeth; (d) had insufficient
ridge width (<5 mm), no evidence of vertical loss; (e) adequate soft tis-
sue phenotype (≥2 mm and ≤4 mm of thickness) and a minimum of
2 mm of buccal keratinized tissue, (f) presence of proper inter-arch
space for implant prosthesis placement; and (g) no clinical evidence of
active periodontal disease or oral infections.
Exclusion criteria included: (a) systemic conditions that may
interfere with the results (eg, Diabetes mellitus); (b) local patholog-
ical defects; (c) unmotivated, uncooperative patients with poor
oral hygiene; (d) habits that may jeopardize the implant longevity
(eg, smoking, alcoholism, or para-functional habits); (e) bone asso-
ciated diseases or medication affecting bone metabolism (eg,
bisphosphonates); (f ) history of radiation or chemotherapy;
(g) inflammatory and autoimmune diseases, and (h) Shallow vestib-
ular depth.
2.2 | Pre-surgical phase and treatment allocation
Ridge width was evaluated clinically using bone caliper at 2 and 4 mm
apical from the crest and phenotype was evaluated using a periodon-
tal probe. A Cone Beam CT1 was performed for radiographic evalua-
tion of bone width and postoperative comparison. Upon radiographic
confirmation of the deficient ridge width, patients were enrolled in
the study. All patients received oral hygiene instructions and full
mouth scaling before the surgery.
Simple randomization was performed by a computer-generated
list from a “random.org” website by a colleague (S.N.) who was not
involved in the study. The sequence was generated from the website
and assigned equally to the four treatment groups. The numbers were
kept in sealed opaque envelopes concealed from the investigator and
patients were asked to pick an envelope then were assigned randomly
to one of the four parallel groups in 1:1:1:1 ratio. Due to the nature of
ZAZOU ET AL.
the study, the operator could not be blinded, performing the surgeries,
but the outcome assessor, data analysts, and the participants were
blinded from the allocation. For participants, all surgical procedures
were similarly interpreted and their blinding was possible. For out-
come assessor (H.N.), he was unaware of the group the participant
belonged to during follow-up, and for the data analysts, they were
unaware of the study hypothesis.
The sample size was calculated to detect a minimal clinically sig-
nificant difference in flap advancement of 2 mm with one way
ANOVA power calculation by R statistical package.2 This difference
14
was obtained from a previous similar study by Ogata et al. The
power was set as 0.8 and the Type I error probability (alpha) associ-
ated with this test was 0.05. The results of the test showed that each
of the four groups had n = 6.81. To account for patient loss to follow-
up (attrition) around 25%, a sample size of 40 patients were selected
and divided into four groups, 10 each.
2.3 | Surgical procedures
All surgical procedures were performed under local anesthesia.3
Patients were assigned to one of four groups, all undergoing GBR
4
using Ti-mesh and Xenograft. 5
For all groups, a full-thickness mid-crestal incision was performed
over the edentulous ridge with a small T-shaped cut at the distal end
to avoid laceration during reflection. The following steps differed
according to each technique as follows:
Group A (DF): A split-thickness mesial vertical releasing incision
was performed buccally considering the position of the mental nerve.
Sharp dissection was performed starting at the coronal part of the
vertical incision until the whole flap was reflected in a split-thickness
manner separating the outer (mucosal) layer from the inner (perios-
teal) layer. Full-thickness reflection was then performed for the inner
periosteal layer and the lingual flap while the buccal flap was reflected
as two separate layers (Figure 1).
Group B (CALF): On the buccal aspect, a full-thickness crestal and
mesial vertical incision were performed, a mucoperiosteal flap was
reflected and PRI was performed. On the lingual aspect, a full-
FIGURE 1 DF technique: Buccal flap clearly reflected as two separate layers
109
thickness flap was elevated accessing the mylohyoid muscle, inserted
into the inner part of the lingual flap (about 5 mm apical to the crest).
Using a blunt instrument, the muscle was detached from the inner
part of the lingual flap allowing lingual advancement (Figure 2).11 Flap
advancement was obtained from both the buccal and lingual flaps
until passive primary closure was obtained.
Group C (MPRI): Full-thickness buccal and lingual flaps were
reflected as described earlier then a 0.5 mm deep incision was per-
formed near the base on the periosteal side of the flap creating two
segments (coronal and apical). Lateral stretching of the coronal seg-
ment was achieved by applying pressure with a blunt instrument in a
sweeping motion while the flap pulled laterally in tension (Figure 3).
This motion allows stretching the flap over the submucosa, permitting
the flap to be mobile, and facilitating the advancement of approxi-
mately 3 to 5 mm until the desired advancement is achieved.12
Group D (PRI): Full-thickness buccal and lingual incisions were per-
formed and the flap was reflected using a periosteal elevator. Incremen-
tal incisions of 1 to 3 mm into the periosteum and submucosa were
made perpendicular to the base of the inner surface of the flap
(Figure 4). The flap advancement was evaluated to determine if deeper
incisions into the submucosa were needed to attain more advancement.9
Following flap reflection in each group, cortical perforations
“decortication” on the buccal and crestal aspects of the ridge were
performed using a low-speed surgical round bur and copious irriga-
tion to enhance blood supply to the bone graft site and improve
osteogenesis.15,16
The titanium mesh was supplied as a 20 × 20 cm sheet of 0.2 mm
thickness and 1 mm pore size. A UNC 15 periodontal probe was used
to measure the augmentation area and accordingly the size of the tita-
nium mesh was trimmed from the sheet. Any sharp edges were
smoothened using finishing stones to avoid flap perforation. The mesh
was then shaped according to the desired augmentation volume and
fixed in place, using titanium 7 to 9 mm mini-screws,6 extending buc-
cally and tucked under the lingual flap. The bone graft material,7 parti-
cle size 0.5 to 1, was first soaked in saline then packed to fill the
space created by the mesh. The mesh was sometimes curved in a
dome shape to accommodate the mental bundle in this area and avoid
injury. The mental foramen was located beforehand on the
110 ZAZOU ET AL.

F I G U R E 2 CALF technique: The mylohyoid muscle insertion into the inner part of the lingual flap and the use of a blunt instrument to detach
the muscle from the flap

F I G U R E 3 MPRI technique: Diagram showing the blunt separation of the coronal and apical segments created after a shallow periosteal
incision was made at the base of the flap

FIGURE 4 PRI technique: Diagram demonstrating Periosteal fenestrations made perpendicular to the base of the inner surface of the flap
ZAZOU ET AL.
preoperative CBCT and wet gauze was placed at the base of the flap
during reflection to protect the bundle.17
For all groups, the flap was sutured by interrupted sutures while
special consideration was given to the suturing of the double flap
where the periosteal layer was sutured first over the titanium mesh
using 6/0 VICRYL resorbable suture,8 then the mucosal layer was
sutured over the periosteal layer achieving primary closure of the flap
using 4/0 silk sutures.9
The patients were prescribed Penicillin10 1 g twice daily and Met-
ronidazole11 500 mg Tid for 10 days after surgery. Analgesic,12 Brufen
600 mg was prescribed according to the patients' needs so as not to
interfere with their pain scores. Patients were instructed not to brush
the area of the surgery and to use chlorhexidine HCL 0.12% mouth
wash13 twice daily for 2 weeks. The sutures were removed 7 to
14 days postoperatively.
2.4 | Criteria for modifying intervention
Mesh exposure: Irrigation with chlorhexidine HCL 0.12% and mouth rinse
for 2 weeks with weekly follow-up to monitor the healing pattern.18
Infection: Defined as any redness, swelling, pain, heat, or pus forma-
tion that required an additional course of antibiotics. Broad-spectrum peni-
cillin was administered for 7 to 10 days. This complication was
encountered in two cases of the PI group accompanied by mesh exposure.
Paresthesia: Defined as altered sensation ranging from a tickling
sensation to numbness. Vit. B12 injection was prescribed and the
numb area was traced and followed-up. This occurred in two cases in
the PI group and improved over time.
F I G U R E 5 Flap extended with minimum tension and the probe
was positioned on the crest of the ridge to measure flap advancement
111
2.5 | Outcome measures
All outcomes were recorded by a single masked examiner who
was not involved in the surgical procedures. All measurements
were repeated three times by the examiner and we recorded the
mean of the three readings to avoid intra-examiner discrepancy.
The Primary outcome was flap advancement measured in mm
using a UNC 15 periodontal probe. The flap was extended with mini-
mum tension while the probe was positioned perpendicular to the
crest of the ridge and kept parallel to the flap direction (Figure 5).19
The readings were taken at the mesial, middle, and distal parts of the
flap, for each part the advancement was measured three times and an
average of the three readings was recorded by a single examiner. In
CALF, MPRI, and PRI groups the flap advancement was measured
before and after scoring then the difference was calculated while for
the DF group the advancement was recorded as the difference of
extension between the two layers of the flap. For the CALF group,
the advancement was calculated as the sum of the buccal and lingual
advancement.
Secondary outcomes include the following:
1. Postoperative Pain was recorded using the Numerical Rating scale
(NRS)20 and postoperative swelling was recorded using the Visual
Analogue Scale (VAS).21 Both scores were recorded for 7 days
postoperatively and were collected from the patients on the suture
removal visit.
Postoperative swelling was scored as follow:
a. None (no swelling).
b. Mild intraoral swelling confined to the surgical zone.
c. Moderate intraoral swelling confined to the surgical zone.
d. Intense (extraoral swelling spreading beyond the surgical zone).
2. Postoperative membrane exposure was recorded at 1, 2, 3, 4,
12, and 24 weeks using a UNC periodontal probe in millime-
ters.14,22 The exposure percentage was calculated as the per-
centage of exposure size in relation to the mesh size measured
using the UNC probe in mm. The augmentation size could be
considered as the size of titanium mesh in mm and was calcu-
lated by dimensions of the trimmed mesh as an area
(length × width).
2.6 | Statistical analysis
2.6.1 | Comparative analysis
Intention to treat analysis was performed. (a) To assess overall dif-
ferences between groups regarding numerical variables, the para-
metric One Way Analysis of Variance (ANOVA) was performed for
normally distributed data; while the nonparametric Kruskal-Wallis
test was performed for the not normally distributed data. (b) To
assess pairwise differences between groups and changes across
follow-ups in each group, the parametric post-hoc test according to
Tukey's test was performed for normally distributed data; while the
112 ZAZOU ET AL.

non-parametric post-hoc test according to Conover's test was per-
formed for the not normally distributed data. (c) Pearson's Chi-
squared test was used to assess differences regarding categorical
data (ie, MCI, and gender).
2.6.2 | Correlation analysis
The difference in flap advancement at the mesial, middle, and dis-
tal aspects in each individual group was not statistically significant
while it was significantly different between groups (Table 1).
When comparing individual techniques the CALF group
showed a statistically significant difference compared to DF, PRI,
and MPRI individually while DF and PRI showed borderline insignif-
icant difference.

(a) To assess the relationship between numerical variables that are nor-
mally distributed, Pearson's Correlation Coefficient was applied. (b) To
assess the relationship between numerical variables that are not nor-
mally distributed, Spearman's Correlation Coefficient was applied.
3 | RESULTS
3.1 | Demographics
Forty participants were enrolled in our study (10 patients in each group),
two patients withdrew from the DF group after randomization due to trav-
eling and one from the MPRI group due to early infection. The mean age of
participants was 42.5 (range 25-65) years with no statistically significant dif-
ference for age or gender distribution among the four groups (P > .05).
3.2 | Flap advancement
The CALF group had the highest mean flap advancement of 19.9
(±5.0) mm while the PRI group had the lowest mean of 10.2 (±1.7)
mm. The mean flap advancement of the DF and MPRI groups was
14.4 (±2.2) and 10.7 (±3.4) mm, respectively (Figure 6). The difference
between groups was statistically significant (P value <.0001).
3.3 | Pain score
The results of our study showed that the MPRI group had the
highest mean pain score of 5.3 (±1.31) while the DF group had the
lowest mean of 2.39 (±1.76). The difference between groups was
statistically significant. Pain scores changes across the 7-day follow-
ups were statistically significant in all treatment groups where the
MPRI group had the most significant improvement while the DF
group had the least.
3.4 | Swelling score
PI group had the highest mean swelling score of 3.01 (±0.54) while
the CALF group has the lowest mean of 2.66 (±0.56). The differ-
ence between groups was statistically insignificant. Changes in
swelling scores across the 7-days of follow-up were statistically sig-
nificant in all treatment groups with the least improvement in the
PRI group.
T A B L E 1 Descriptive analysis of flap advancement at the mesial,
middle, and distal parts of the flap and total advancement of each
group

Flap advancement Mean SD P value*

Mesial PRI 10.5 1.65 <.0001*
DF 15.88 3.36
MPRI 10.3 2.21
CALF 16.9 4.82
Mid PRI 10.45 2.93 <.0001*
DF 15.13 2.90
MPRI 11.05 3.82
CALF 21.65 5.94
Distal PRI 9.7 2.67 <.0001*
DF 12.38 2.62
MPRI 11 4.97
CALF 21.3 6.75
Total PRI 10.22 1.71 <.0001*
DF 14.46 2.23
MPRI 10.78 3.4
CALF 19.95 5.04
FIGURE 6 A box-plot graph showing the mean flap advancement
of all groups Significance level at P value ≤.05.
*
ZAZOU ET AL. 113

T A B L E 2 Descriptive analysis of exposure (mm2) and exposure Regarding the exposure percentage, the PRI group showed the
percentage and results of the between-group comparison (n = 38) highest percentage of 7.4% (±9.3) while CALF showed the lowest per-
Exposure (mm2) Mean SD P value* centage of 0.4% (±0.7). The difference between groups was statisti-

1 Week PI 6.56 13.03 .0925 cally insignificant (Table 2).

Concerning other postoperative complications, for the PRI group,
DF 2.75 6.32
we had three cases of paresthesia and two cases of infection. For the
MPRI 0 0
DF group, only one case of paresthesia was reported. In the MPRI
CALF 0.38 1.06
group, we encountered two cases of paresthesia and two cases of
2 Weeks PI 6.56 13.03 .0996
infection while for the CALF group only one patient encountered
DF 2.75 6.32
infection.
MPRI 0 0
Vitamin B12 weekly injection was prescribed for paresthesia23
CALF 0.50 1.41 and it resolved after 4 weeks except for one case in the PRI group
3 Weeks PI 9.78 10.41 .0205* who had improved but not completely resolved numbness at
DF 2.75 6.32 6 months. As per the infection cases, one presented with the infection
MPRI 1 3.16 at the time of mesh removal in the PRI group, the mesh was removed
CALF 0.75 2.12 and the implant could be placed successfully. One case was lost from
4 Weeks PI 10.89 12.05 .028* the MPRI group due to early infection. The other infection cases

DF 3 6.41 resolved with antibiotic administration and chlorhexidine mouth wash.

MPRI 1.11 3.33

CALF 0.75 2.12
4 | DI SCU SSION
3 Months PI 13.44 13.92 .2638
DF 7.38 17.34
To the best of our knowledge, this is the first randomized clinical trial
MPRI 8.33 12.66
to compare DF, CALF, MPRI, and PRI advancement techniques for
CALF 1.88 3.56
attaining tension-free primary closure. Our primary outcome is flap
6 Months PI 15.67 17.92 .5311 advancement showing the highest values for the CALF group and low-
DF 10.5 18.99 est values for the PRI group. Advancement was measured separately
MPRI 18.67 26.36 at the mesial, middle, and distal portions, and, as anticipated, the CALF
CALF 2.50 4.07 group recorded higher advancement at the middle and distal sites
Exposure percentage PI 7.46 9.31 .3279 while mesial sites mostly showed more values in the other groups due
DF 3.9 6.89 to the mesial vertical incisions. Ogata et al14 compared DF and PRI

MPRI 6.45 9.07
CALF 0.48 0.78
Note: PI (n = 10), DF (n = 8), MPRI (n = 10), and CALF (n = 10).
*
Significance level at P value ≤ .05.
3.5 | Mesh exposure
Our results showed the highest mean of exposure for the PRI group
on the first 4 weeks and at 3 months while at 6 months MPRI
showed the highest exposure mean. MPRI showed the lowest mean
in the first 2 weeks while CALF showed the lowest mean in the third
and fourth week and at 3 and 6 months. The difference between
groups was significant in week 3 and 4 only (Table 2). The augmen-
tation size was measured as the size of the mesh used in each
patient. Only the CALF group showed significantly larger augmenta-
tion size compared to the other three groups (Figure 7).
The overall incidence of mesh exposure in our study was 39.5%
(15 out of 38 cases), distributed as follow: 60% in the PI group, 25%
in the DF group, 40% in the MPRI, and 30% in the CALF group.
techniques and showed a significant difference for flap advancement
and patient discomfort. Our study focused on the same outcomes,
comparing two additional techniques that we thought may result in
remarkable advancement, less morbidity, and possibly a shift for the
gold standard technique. In addition, we measured membrane expo-
sure more precisely.
CALF showed the highest mean of flap advancement (19.9 mm)
which is higher than that reported by Urban et al19 (16.4 mm in some
zones). This could be due to recording the combination of the buccal
and lingual flap advancement. Our finding is similar to that reported
by Ronda and Stacchi24 (21.7 mm) for the brushing technique. For the
DF group, the mean advancement was 14.4 mm and that of the PRI
group was 10.2 mm which is higher than that reported by Ogata
et al14 (9.6 and 7.1 mm, respectively). The difference between DF and
PRI in our study showed borderline significance while Ogata et al14
could prove statistical significance. This could be due to the variation
in the methodology where we measured mean advancement of the
mesial, middle and distal portion of the flap separately while Ogata
et al14 measured the advancement at the middle portion only. How-
ever, PRI mean advancement was comparable to that measured by
Ronda and Stacchi24 (8.4) mm and with Urban et al19 (8.2 to 10.2)
114
FIGURE 7 A box-plot graph showing the mean exposure area of all groups over time
mm. Regarding MPRI, the advancement was similar to that obtained
by PRI and this was similar to the case report conducted by Hur
et al12 reporting around 10 mm of flap advancement. These findings
demonstrate the superiority of CALF and DF advancement techniques
to the gold standard regarding this outcome.
We selected pain and swelling as patient-reported outcomes that
were anticipated to show lower values in DF, MPRI, and CALF than
the gold standard. Concerning pain score, the MPRI group had the
highest pain score which may be attributed to the excessive flap
manipulation when performing lateral stretching. DF showed the low-
est values which may be due to the gentle flap management with
sharp dissection and the absence of periosteal severance. PRI patients
scored less pain than the CALF which could be due to the additional
lingual flap reflection in the latter. Our findings are in accordance with
Ogata et al14 who reported less pain score for the DF group compared
to the PRI group. However, the mean pain for DF in our study (2.3)
14
was higher than that reported by Ogata et al (1.5) while that of the
PRI group (3.3) was lower (3.7) possibly due to the subjective nature
of the outcome.
Differences in swelling scores were not statistically significant
between the four groups. However, PRI showed the highest swelling
scores and CALF showed the least swelling. This can be attributed to
the deep scoring of the periosteum in the PRI group which in mini-
mally performed in CALF. The scores we recorded for the PRI group
14
were similar to those reported by Ogata et al (3.0), (3.2), respec-
tively, while that reported for the DF group was slightly higher (2.7),
(1.9), respectively. The mean swelling reported in MPRI was relatively
ZAZOU ET AL.
high (2.9) which again could be due to the additional manipulation of
the flap performing the blunt dissection.
To the best of our knowledge, our study is the first to calculate
the difference in exposure and exposure percentage between the
four techniques in mm. We focused on measuring the exposure size
as a percentage from the mesh size itself in an attempt to deter-
mine if the percentage of mesh exposed is related to the amount of
flap advancement and if this would affect the final outcome. PRI
reported the highest mean of exposure in all-time points except at
6 months and highest exposure percentage which is in accordance
with the results of Ogata et al.14 This could be attributed to the
tension applied on the flap edges due to reduced flap advancement
or the severing of the periosteum which may compromise the blood
supply to the flap. The fact that CALF reported the least mean
exposure and exposure percentage could be due to the higher com-
bined buccal and lingual flap advancement achieving tension-free
closure.
We could not statistically prove a correlation between flap
advancement and pain scores, swelling scores, mean exposure, or
exposure percentage of any of the groups. However, we could prove
a direct correlation between flap advancement and the mean pain
score in the DF group and between swelling scores and exposure at
6 months in both PRI and MPRI groups. It is worth mentioning that
although we could not prove statistical correlations yet we cannot
overlook the clinical correlation between flap advancement and expo-
sure percentage. CALF with the highest mean of advancement
recorded the least exposure percentage (0.5%) while PRI with the
ZAZOU ET AL. 115

lowest mean of advancement recorded the highest exposure percent- highest mean swelling score and the highest mean of exposure and
age (7.5%) and those numbers are significant to clinicians. exposure percentage. Further studies are required on larger sample
The selection of titanium mesh was due to the recognized space- sizes taking into consideration the vestibular depth, the amount of
making characteristics while the documented high exposure rates keratinized mucosa, and the attempt to prove a correlation between
represented a challenge to assess better flap designs to attain flap advancement and mesh exposure.
tension-free closure. However, mesh exposure did not necessarily
coincide with graft failure which may be due to the smooth surface of CONFLIC T OF INT ER E ST
the mesh that does not act as a niche for bacterial colonization.4,25,26 The authors declare no conflict of interest and declare that the study
The mesh used in our trial was of 0.2 mm thickness and 1 mm pore is self-funded. We acknowledge the statistician Attera Ahmed for
size which allows the penetration of blood supply to the graft mate- doing the statistical analysis of the results and Dr. Baraa Nagy for
27 28
rial. Her et al proposed that larger pore sizes >2 mm may cause doing the artwork illustrations.
excessive soft tissue ingrowth and impair regeneration. Higuchi et al29
reported that a more porous mesh may induce more bone formation AUTHOR CONTRIBU TIONS
than less porous or occlusive ones. Due to this porous nature, we can Hani el Nahass conceived the idea and supervised the surgical part.
assume that the regeneration achieved using titanium mesh is attributed Nada Zazou contributed to conceiving the idea, led the surgical part,
mainly to the space making property rather than the barrier effect.3 data collection, and writing. Samah Bahaa and Noha Diab contributed
The soft tissue growth inside the mesh pores complicated its to the surgical part and collected the data. Azza Ezz el Arab, Omniya
removal due to the thickened connective tissue layer previously Abdel Aziz, and Hani el Nahass revised the writing.
29
described as a periosteum-like layer and could reach up to 2 mm in
humans.30 We observed this layer to be more prominent in the DF DATA AVAILABILITY STAT EMEN T
group. This could be related to the intact inner periosteal layer which The data that support the findings of this study are available from the
may have allowed the periosteum to act as a membrane suggesting corresponding author upon reasonable request.
that the DF group had a double membrane effect; the mesh and the
periosteum overlying.31 The use of Xenograft alone as the bone aug- OR CID
mentation material has been controversial. However, it was recently Nada Zazou https://orcid.org/0000-0002-0896-9313
documented that the addition of autogenous bone to a xenograft Hani el Nahass https://orcid.org/0000-0001-9101-4851
does not seem to influence the resolution of bony dehiscence
defects.32 ENDNOTES
Some of the limitations of our study are the lack of data about 1
OnDemand3D software, Cybermed Inc, Korea (Sordex Machine)
the vestibular depth in each technique before and after flap advance- 2
R core team (2012).R: A language and environment for statistical com-
ment. One of the major advantages of CALF is that advancement is puting. R Foundation for Statistical Computing, Vienna, Austria. WASBN
mainly attained from the lingual flap which may cause less vestibular 3-900 051-07-0, URL http://www.R-project.org/.
3
obliteration that inevitably occurs with the other three techniques. Mepecaine-L, Gamila Bohreid Road, Awayed, Alexandria, Egypt.
4
Furthermore, the amount of buccal keratinized tissue was not calcu- MTAM, Stryker, Michigan, USA.
5
lated even though it could be affected by the coronal advancement in Cerabone- Botiss biomaterials GmbH, Germany.
6
some techniques. Orthomed E, Egypt.
7
Cerabone, Botiss biomaterials GmbH Hauptstr. 2 815 806 Zossen.
8
AssuCryl, Assut sutures, Switzerland.
5 | C O N CL U S I O N S 9
Silk, Assut sutures, Switzerland.
10
Hibiotic 1 g, Amoun pharmaceuticals, El Obour City, Cairo, Egypt.
Within the limits of our study we conclude, the following: (a) CALF 11
Flagyl 500 mg, Sanofi-aventis, Egypt.
reported highest flap advancement, lowest mean swelling scores, low- 12
Brufen 600 mg, Abbott Laboratories, Egypt.
est mean exposure, and exposure percentage hence it is rec- 13
Hexitol mouthwash 100 mL, ADCO, Alexandria, Egypt.
ommended in the posterior mandible especially when large
augmentation procedures are anticipated. Experienced manipulation
RE FE RE NCE S
of the lingual flap and knowledge of anatomy is crucial to avoid inju-
1. Wang H-L, Al-Shammari K. HVC ridge deficiency classification: a ther-
ries to any vital structures in the area. (b) DF attained about 14.5 mm
apeutically oriented classification. Int J Periodontics Restorative Dent.
of flap advancement reporting lowest mean pain score and can be 2002;22:335-343.
used in large augmentations with predictable outcomes when used 2. Retzepi M, Donos N. Guided bone regeneration: biological principle
with thick phenotype subjects (c) MPRI showed highest mean pain and therapeutic applications. Clin Oral Implants Res. 2010;21(6):
567-576.
score and highest mean of exposure at 6 months and hence we rec-
3. Elgali I, Omar O, Dahlin C, Thomsen P. Guided bone regeneration:
ommend further studies to confirm our findings regarding this tech- materials and biological mechanisms revisited. Eur J Oral Sci. 2017;
nique. (d) PRI is the least favorable technique of choice reporting 125(5):315-337.
116
4. Proussaefs P, Lozada J, Kleinman A, Rohrer MD, McMillan PJ. The
use of titanium mesh in conjunction with autogenous bone graft and
inorganic bovine bone mineral (Bio-Oss) for localized alveolar ridge
augmentation: a human study. Int J Periodontics Restorative Dent.
2003;23(2):185-195.
5. Proussaefs P, Lozada J. Use of titanium mesh for staged localized
alveolar ridge augmentation: clinical and histologic-
histomorphometric evaluation. J Oral Implantol. 2006;32(5):237-247.
6. Strietzel FP, Reichart PA, Graf H-L. Lateral alveolar ridge augmenta-
tion using a synthetic nano-crystalline hydroxyapatite bone substitu-
tion material (Ostim): preliminary clinical and histological results. Clin
Oral Implants Res. 2007;18(6):743-751.
7. Choi TJ, Burm JS, Yang WY, Kang SY. A wrapping method for
inserting titanium micromesh implants in the reconstruction of blow-
out fractures. Arch Plast Surg. 2016;43(1):84-87.
8. Burkhardt R, Lang NP. Role of flap tension in primary wound closure
of mucoperiosteal flaps: a prospective cohort study. Clin Oral Implants
Res. 2010;21(1):50-54.
9. Romanos GE. Periosteal releasing incision for successful coverage of
augmented sites. A technical note. J Oral Implantol. 2010; 36(1):25–30.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/20218867
10. Hur Y, Tsukiyama T, Yoon T-H, Griffin T. Double flap incision design
for guided bone regeneration: a novel technique and clinical consider-
ations. J Periodontol. 2010;81(6):945-952.
11. Ronda M, Stacchi C. Management of a coronally advanced lingual flap
in regenerative osseous surgery: A case series introducing a novel
technique. Int J Periodontics Restorative Dent. 2011;31(5):505-513.
12. Hur Y, Bui MN, Griffin TJ, Ogata Y. Modified periosteal releasing inci-
sion for flap advancement: a practical technique for tensionless clo-
sure. Clin Adv Periodontics. 2014;5(4):229-234.
13. Moher D, Hopewell S, Schulz KF, et al. Original article consort 2010
explanation and elaboration: updated guidelines for reporting parallel
group randomised trials. J Clin Epidemiol. 2010;63(8):e1-e37.
14. Ogata Y, Griffin TJ, Ko AC, Hur Y. Comparison of double-flap incision
to periosteal releasing incision for flap advancement: a prospective
clinical trial. Int J Oral Maxillofac Implants. 2013;28(2):597-604.
15. de Carvalho PS, Vasconcellos LW, Pi J. Influence of bed preparation
on the incorporation of autogenous bone grafts: a study in dogs. Int J
Oral Maxillofac Implants. 2000;15(4):565-570.
16. Nishimura I, Shimizu Y, Ooya K. Effects of cortical bone perforation
on experimental guided bone regeneration. Clin Oral Implants Res.
2004;15(3):293-300.
17. Greenstein G, Greenstein B, Cavallaro J, Elian N, Tarnow D. Flap
advancement: practical techniques to attain tension-free primary clo-
sure. J Periodontol. 2009;80(1):4-15.
18. Fontana F, Maschera E, Rocchietta I, Simion M. Clinical classification
of complications in guided bone regeneration procedures by means
of a nonresorbable membrane. Int J Periodontics Restorative Dent.
2011;31:265-273.
19. Urban I, Traxler H, Romero-Bustillos M, et al. Effectiveness of two
different lingual flap advancing techniques for vertical bone augmen-
tation in the posterior mandible: a comparative, Split-mouth cadaver
study. Int J Periodontics Restorative Dent. 2018;38(1):35-40.
ZAZOU ET AL.
20. Williamson A, Hoggart B. Pain: a review of three commonly used pain
rating scales. J Clin Nurs. 2005 Aug;14(7):798-804.
21. Penarrocha M, Garcia B, Marti E, Balaguer J. Pain and inflammation
after periapical surgery in 60 patients. J Oral Maxillofac Surg. 2006;64:
429-433.
22. Torres J, Tamimi F, Alkhraisat MH, et al. Platelet-rich plasma may pre-
vent titanium-mesh exposure in alveolar ridge augmentation with
anorganic bovine bone. J Clin Periodontol. 2010;37(10):943-951.
23. Alves FR, Coutinho MS, Gonçalves LS. Endodontic-related facial par-
esthesia: systematic review. J Can Dent Assoc (Tor). 2014;80:e13.
24. Ronda M, Stacchi C. A novel approach for the coronal advancement of
the Buccal flap. Int J Periodontics Restorative Dent. 2015;35(6):795-801.
25. Roccuzzo M, Ramieri G, Spada MC, et al. Vertical alveolar ridge aug-
mentation by means of a titanium mesh and autogenous bone grafts.
Clin Oral Implants Res. 2004;15(1):73-81.
26. Roccuzzo M, Ramieri G, Bunino M, Berrone S. Autogenous bone graft
alone or associated with titanium mesh for vertical alveolar ridge augmen-
tation: a controlled clinical trial. Clin Oral Implants Res. 2007;18(3):286-294.
27. Gutta R, Baker RA, Bartolucci AA, Louis PJ. Barrier membranes used
for ridge augmentation: is there an optimal pore size? J Oral Maxillofac
Surg. 2009;67(6):1218-1225. https://doi.org/10.1016/j.joms.2008.
11.022.
28. Her S, Kang T, Fien MJ. Titanium mesh as an alternative to a membrane
for ridge augmentation. J Oral Maxillofac Surg. 2012;70(4):803-810.
29. Higuchi M, Moroi A, Yoshizawa K, et al. Comparison between various
densities of pore titanium meshes and e-polytetrafluoroethylene
(ePTFE) membrane regarding bone regeneration induced by low
intensity pulsed ultrasound (LIPUS) in rabbit nasal bone. J Cranio-
Maxillofacial Surg. 2016;44(9):1152-1161.
30. Simion M, Jovanovic SA, Trisi P, Scarano A, Piattelli A. Vertical ridge
augmentation around dental implants using a membrane tectinique
and autogenous bone or allografts in humans. Int J Periodontics Restor
Dent. 1998;18(1):8-23.
31. Weng D, Hurzeler MB, Quinones CR, Ohlms A, Caffesse RG. Contri-
bution of the periosteum to bone formation in guided bone regenera-
tion. A study in monkeys. Clin Oral Implants Res. 2000;11(6):546-554.
32. Temmerman A, Cortellini S, van Dessel J, et al. Bovine-derived xeno-
graft in combination with autogenous bone chips versus xenograft
alone for the augmentation of bony dehiscences around oral implants:
a randomized, controlled, split-mouth clinical trial. J Clin Periodontol.
2020;47(1):110-119.
How to cite this article: Zazou N, Diab N, Bahaa S, el Arab AE,
Aziz OA, el Nahass H. Clinical comparison of different flap
advancement techniques to periosteal releasing incision in
guided bone regeneration: A randomized controlled trial. Clin
Implant Dent Relat Res. 2021;23:107–116. https://doi.org/10.
1111/cid.12960
Copyright of Clinical Implant Dentistry & Related Research is the property of Wiley-
Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.